Once an incident investigation is complete, the goal is to use the lessons learned to develop and implement a solution that reduces the risk of the issue reoccurring. It’s a straight forward concept, but even with seemingly simple solutions, things don’t always go according to plan.
Have you heard of the cobra effect? It’s a term that was popularized by a German Economist Horst Siebert that refers to an attempt to curb a cobra problem in Delhi, the capital of then colonial India, that resulted in some rather ironic unintended consequences. There were complaints about the number of cobras in the city and British officials decided that the best way to reduce the cobra population was to pay a bounty for cobra skins. Create an incentive to kill the cobras, resulting in a reduction of the cobra population and the problem should be solved! Simple enough…right?
Well, things didn’t work out exactly as intended. The bounty initially seemed to be working and the number of snakes reported in the city decreased. But rather than the number of bounties being claimed tampering off as might be expected as the cobra population was reduced, the number of snake skins being turned in steadily increased.
The catch is that the bounty was paid for cobra skins, but there was no way of knowing if those skins came from cobras that had been caught in the city. Some brave and enterprising souls found that it was easier to bred cobras than to catch them. The British officials found that what they had actually incentivized was cobra farming.
Too many cobra skins were being turned in and the bounty was canceled. Cobra farmers found themselves with a product that no longer had a market and they released the snakes. The end result was a much larger cobra population than was initially present.
A more modern example of unintended consequences is the recent Wells Fargo scandal where up to 2 million unauthorized accounts were created. The company had an incentive-compensation program combined with aggressive sales goals that were difficult, if not impossible, for many employees to meet. So some employees got creative and found a way to meet the sales goals…by secretly opening unauthorized accounts. Wells Fargo intended the compensation structure to encourage employees to sell more products and increase profits, but the end result was a $185 million fine, massive negative publicity and ongoing investigations and lawsuits.
Our case study about Macquarie Island is another great example of unintended consequences. It is an interesting example of the many things that can go wrong when an ecosystem is tampered with and how difficult it can be to see the many different impacts from implementing a solution. You can read our write-up and view a Cause Map of what happened when feral cats were removed from the island here.
So how do you prepare for and deal with unintended consequences? The first step is to understand an issue as thoroughly as possible. The more you know about how a system works prior to making any changes, the less likely you are to be surprised. It’s also good practice to involve the people closest to the work when developing solutions that change work processes. People will know the details of the work and have important insight into possible ripple effects from any changes being made. And then the impact of an implemented solution should be monitored to ensure that it is having the intended effect, also known as gathering evidence about your solutions.