ROLE OVERLAP IN CRISIS
Everyone steps in, and the same thing gets done twice.
01 DEFINITION
Condition in which the division of work that holds under ordinary conditions loosens under pressure, so more than one person acts on the same thing while something else is left because each took it to belong to another.
02 CONDITIONS
UNCERTAINTY
MISSING
Who has taken what is not stated while everyone is taking things.
TIME PRESSURE
HIGH
The pressure is what loosens the division; without it the division holds.
ERROR ASYMMETRY
ASYMMETRIC
Two people on one thing and nobody on another are failures of different size.
OPERATOR STATE
CONCURRENT
Everyone is acting and nobody is keeping the account of who is acting.
03 WHERE IT APPEARS
MEDICALUnder pressure everyone present acts, and two people give the same thing while another is missed.
ENERGYControl room roles loosen during an event and coverage becomes a matter of who moved.
CONSTRUCTIONAfter an incident everyone helps, and the tasks nobody claimed are the ones left.
LOGISTICSDuring disruption controllers act outside their sectors and duplicate one another.
PUBLIC SERVICEIn a surge, case ownership blurs and some cases are held by two people and some by none.
MANUFACTURINGA line stoppage draws several people to the same point and away from the rest.
04 WHERE THIS IS SURFACING
This surfaces wherever the roles are clear and the pressure is real. People step outside them because it is faster, and the surface goes on describing the division as though it held.
What stays unresolved is whether a surface should hold a division that people are abandoning for a reason — enforcing it blocks whoever is nearest and able, and abandoning it leaves nobody able to say what is unattended.