A very temporary operating instruction: uncovering emergence and adaptation in air traffic control

The introduction of temporary instructions to amend standard operating procedures, to address emerging safety risks, is an example of the well-intentioned decision-making that occurs every day in organisations that manage safety. These organisations typically assess these changes for potential risks; however, even simple changes can have unpredictable and emergent effects in complex sociotechnical systems. A case study of a procedural change in UK air traffic control, to address the risk from unintentional flight level deviations, is explored through the use of a model of adaptation to understand the unexpected and unpredicted effects of the change and uncover the adaptations that already existed within normal work that were a source of safety. Recommendations on the need for systemic safety methodologies that can identify and enhance the features of sociotechnical systems that support this adaptive capacity are identified with reference to this model for adaptation in complex sociotechnical systems.