Lessons organisations need to learn about dealing with failure

How organisations deal with errors, mistakes and failures predict a range of organisational attributes like how well (and how fast) the organisation learns, changes and adapts to change. 

In this podcast David Interviews Gareth Lock, the author of the recently published book ‘Under pressure: Diving deeper into human factors‘ about blame and just cultures, how people and organisations deal with mistakes, errors and failure as well as what organisations can and should be learning from the aviation, medicine and diving sectors.

Interview with Gareth Lock – Error, mistake and failure handling

Gareths LinkedIn page: https://www.linkedin.com/in/garethlock/?originalSubdomain=uk

Website: https://www.thehumandiver.com

 

The Book – Under pressure: Diving deeper into human factors

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Transcript

– Welcome back, I’m David Wilkinson, the editor of the “Oxford Review.” And today with us, we’ve got Gareth Lock, who’s written a book called, “Under pressure: Diving deeper into human factors.” And before you can log out thinking, diving, not into diving, I think you need to listen to this. He’s got a lot of really interesting lessons for people in organizations, but also dealing with kind of errors and things like that. Welcome, Gareth.

– Thanks so much, David, for inviting me along. Since meeting we had five years ago, I think I should remember when we met.

– There’s been some time isn’t it? Yes, yes, it’s been some time. Do you just wanna introduce yourself and kinda tell us what you do and something about your own interest, your work and your research?

– Yeah, sure. So my sort of what shaped where I am, it’s been 25 years in the Royal Air Force and I left it February 2015. I was flight crew and an Acura instructor on Hercules Transport Aircraft. I then went into systems engineering, requirements management, research and development. And that just really gave me a big, I must say a systems view of the world trying to look at things rather than silos about how stuff goes together? People, organization’s culture, are all of us sort of human factors, stuff that makes stuff happen really. And then I say in February 2015, I left the Air Force and I set up my own company, starts to work in the oil and gas sector, teaching, we call sort of soft skills, but better term is critical decision-making, teamwork, leadership, situational awareness, communications, and understanding this impact of things called performance-shaping factors on how do we make decisions as effectively as possible? Now that carried on for a little bit, and then the bottom fell out the oil market and training is the first thing to go. But that sort of got me going into where my real passion was about, which is improving the safety and performance of divers, sports divers, military divers, commercial divers, and taking those same non technical skills from the aviation industry and applying it into another domain so that we can operate more safely. And that’s been pretty successful. I’ve taught literally all around the world, sort of Seattle, Los Angeles, through the States, Europe, Middle East, Australia and New Zealand and was in sort of Barley earlier this year, there are some downsides to the travel. You get to get to some nice places, all the people go, “Great, you get to go to and see a certain place.” So it’s like, yeah, but I’m normally delivering a class and it’s normally to a consumer level. So they’re not gonna pay for me to hang around. So I don’t get to see places very often. And then you sort of alluded to the sort of book and that was March last year, ’cause it had sort of inklings of trying to condense all of the teachings that I do into a book that people could then use. And it is quite a meaty too, it’s sort of 110,000 words in it. But it gets this topic out there using lots of different stories. And in hindsight, you go, “That was obvious, that was gonna happen.” And what I do is pick it apart in the context of human factors and non technical skills, so that everybody can learn. And that is the biggest challenge.

– Really interesting stories.

– And then to try and bring more of that to life, last November, filmed a documentary in Hawaii, and the reason it was in Hawaii, it wasn’t ’cause it was a nice place, it’s because there’s a fatality happened 18 months prior to that, and I was working with the widow to tell a very context-rich, emotional, powerful story about how that accident happened, which as normal human behavior, we would just focus on the last sort of five or 10 minutes of what happened and we’d normally go, “Stupid, why didn’t you make sure “that your oxygen cylinder was turned on?” When actually we’ll look at the whole story coming up to that, and realize that this was just the final straw that breaks the camel’s back. And there were loads of social and technical issues, cultural issues, that made it really hard not to get off the… To be able to say, stop, this isn’t the right thing to be doing, I’m telling that story both from the emotional context of the people involved, but also with me, giving a sort of science and the theory behind why they made the decisions they did.

– Yeah, that’s really interesting, I used to be a police officer, I was an accident investigator years ago on traffic. So some of the fatal accidents particularly, we used to go right back in history to see what kind of what are the antecedents? What are the things that have led to this, that we could learn from? Particularly, kind of large scale accidents?

– Definitely interesting.

– And unfortunate, I think part of the problem is that, we want an immediate simple answer and accidents don’t happen because of simple things, they happen as deviations from normal behaviors. When people are often involved in really high risk complicated tasks, they will spend a lot of time making sure they manage those risks. Is normal work, normal behavior that we end up drifting away from?

– Yes, and then there are a whole series of factors that lead to those drifts, I suppose. Yes, probably. Okay, so you’ve recently published “Under Pressure: Diving deeper into human factors.” Can you just give a kind of a brief overview before We dive deeper into a couple of issues that you raise. Kinda what’s the book about? And why did you end up writing it?

– Yeah, I suppose as a high-level summary, it looks at human behavior as part of a system, a wider set of cultural technical system. And that looks that peer pressure, it looks at the training system, it looks at the environment that the people are operating in the equipment they’re using, and really is to look at a sport which is a high risk sport, because the consequences can easily be fatal, being underwater. Fortunately, the probabilities are quite small. So what I was looking at, was actually can we tell stories from survivors, from those who’ve had near misses and close calls and get them to tell that context-rich story and the book is broken down into different chapters that look at specific elements. So things like systems thinking, having, how does a system operate? And not just hardware technical, which is what people normally think of as a system, but a social technical system, how people operate as part of the training, as how they interact their equipment, as a team, as individuals, as the peer pressures they’re under there. Then we’ll look at concepts of just culture and psychological safety. How do we create an environment where people are able to proactively prevent something from going on? And then adjust culture is reactively looking back and saying, we’re all fallible? How do we make those mistakes? And can we learn from them, and not throw the metaphorical rocks at others for being stupid, when actually it must have made sense? And then going through the non technical skills themselves of situational awareness, decision-making, communications, teamwork, leadership and followership, performance-shaping factors and then a little bit on incident reporting. Each of the chapters is standalone. So if you want to learn about decision-making or teamwork and leadership, you can go into those specific chapters. But actually, the whole book runs from start to end that tells stories that later chapters refer to stuff that was was earlier on. Because these things, these skills, these traits, behaviors don’t exist in isolation. And it’s like, well, we’re gonna develop leadership. Well, to be an effective leader, you’ve got to understand how to communicate, you’ve got to understand how a team works, how it develops, you’ve got to understand how you pick up information, situational awareness, and decision-making and the biases that we have. And I wrote it because there isn’t anything out there. There are technical books in the, I would say, the traditional safety industries, oil and gas, health care, aviation, those books exist. Nothing including all the programs that I teach exist in the space of diving.

– I didn’t know that? Interesting?

– A niche of one is me.

– Be sure, that’s a good one. It’s the best niche to be in, hopefully-

– Well, it just means you’ve got a big education process to do to start with, to understand and that’s really what the book was about. And the hard part is people go to, “I already know that. “What do I need to read a book about teamwork “or or decision-making, I don’t make decisions.” I was like, “Yeah, we do.” And everybody who reads it and does the training with me goes, “Oh, there’s a lot more to it than this.” And once seen, it’s very difficult to unsee and people start looking at the world differently, which is really what my goal is about, is trying to influence attitudes and behaviors towards human error and the violations that we make.

– Yeah, and it’s those lessons that move us out of, they’re kinda diving context into organizations, into just a human context kind of life and things and it’s those things I’d really like to explore. But before we do, kind of the title of the book is, “Under pressure: Diving deeper into human factors.” What do you actually mean by human factors? What does that mean?

– It’s a huge topic, but it’s simplified as or made simple as making it easy to do the right thing and hard to do the wrong thing. And I use the analogy of Homer in his nuclear power station, he’s got a terrible physical interface that he’s got to work with, which is very similar to what the so the old nuclear power stations look like, dial those buttons, everything going on. He’s got his own physiological needs, doughnuts and coffee, to stay alert. And he’s got the social pressures and the cultural pressures of Mr. Burns sitting there, either physically or metaphorically, on his shoulder going, “Keep the power on, “keep the power on.” And he manages all of these things in real-time, he creates safety and performance dynamically with what he’s presented. But then it’s five minutes to the hour when his blood sugar level is going down, it all kicks off. And the displays don’t make sense. He can’t understand what’s going on. And so he’s just pressing buttons, ’cause he hasn’t been taught how to deal with it. So he’s not had those high pressure situations. And he’s still got Mr. Burns going, “Keep the power on, keep the power on,” because otherwise he’s gonna be fired. So it’s how people sit within systems, not just factors of the human, which is what people normally think about, it’s human factors, i.e our internal decision-making. Well, it’s just being a human. Actually, it’s how we sit in the system of the hardware, the documentation of the people, and under sort of physical and cultural environments.

– Yeah, it’s those kinds of things that are critical. And particularly in the moment when the training fails, when the situation goes beyond something that you’ve actually been trained in. So I spent a long time doing Disaster Management at Cranfield and things like that. And everything’s fine whilst it’s in the system, the system that you’ve prepared for, that you’ve trained for you understand how it all works. It’s the moment that doesn’t happen, there’s a disaster happens or there’s something else happens, is how do people then actually go beyond that and still perform in a way that actually doesn’t have kind of drastic consequences for people?

– That’s what we used to explain with the oil and gas workers was, non technical skills, these sort of crew resource management is another term. They have benefit in normal operations because the goal of these is to create as an accurate as possible shared mental model within the team, so that people know what’s happening now, why it’s happening and what likely to happen in the future? So that they have benefit in normal operations. But they become critical, as you just talked about when you step outside of normal operations, abnormal operations and you have to understand, how do we create a system that has the capacity to fail safely? We’ve got to be able to think outside the box, we’re not being taught this stuff. So now we are second guessing, we are trying to pattern-match as best we can, as to what’s gonna happen in the future? And recognize that how do I look beyond my immediate decision, so that I don’t add metaphorically, more fuel to the fire when it goes wrong?

– Make the situation worse, and that’s not an infrequent thing, particularly disaster situations, when people are actually taken out of their immediate experience and understanding. So you referred to this concept of non technical skills. What does that mean?

– So in sort of late 60s, aviation industry was suffering with pilots flying aircraft into the ground. It was pilot error. And they were just walking around, got professionals here. And so they started to look at why is this happening? And that was when cockpit voice recorders were coming in and flight data recorders were coming in. And they started to realize that actually, there were people on the flight, they knew that it was going wrong, but they were unable to share that information with the captain or whoever was flying the aircraft for a whole bunch of reasons. So they came up with a training program, which started off as cockpit resource management. And it was this bit that says how do we increase the assertiveness and shared mental model within the team? And then we had events like Manchester with the Airtours fire, we had Kegworth where the back end crew, the cabin crew knew that something wasn’t quite right, and so hang on a minute, the cabin crew are part of this team. And there was literally a cabin was that there’s the back end and here’s our sky guards at the front and we don’t talk to each other. So they went well hang on a minute, “We need to have the crew resource management.” And so they started to develop this in the aviation industry. And then healthcare recognize that, “Hang on a minute there’s value to this, “because our surgeons are in a similar situation. “They’ve been trained for excellence in technical skills “of how to do an operation, “but they’re operating with a team of anesthetist, “scrub nurses, nurses, all these other people, “this or what not a crew “so that that crew resource management “doesn’t necessarily help us.” Because labeling is as you know from your research, labeling has a huge impact on whether or not it’s applicable to me. While I’m not a crew, therefore it doesn’t apply to me. So with work up in Aberdeen and Edinburgh, they came up with a non technical skills for Surgeons program knots. And then there was also an aesthetics non technical skills. And I brought non technical skills into the diving environment, because when we don’t operate as crews we have these, but then people go, “Oh, technical, non technical!” And exactly the question you’ve just said, “What relevance is that?” And I try to break it down and say in the context of diving, it would be about buoyancy control, it would be about propulsion in the water, it would be taking photos or surveying a wreck. Those are technical skills. The non technical skills are the bits that basically make that work effectively. And in the non diving environment that could be making widgets, it could be about drugs and quality control, it could be actually in a business software programming and in fact, we’ve always involved in a project last year in Portugal, developing teams, where they talk about Agile and Scrum, they didn’t know what these non technical skills were, nobody taught them how to be part of a team, how to communicate, how to lead, how to debrief. And it’s like, well, there you go, you’re now a team, you’re a bunch of people working together, you’re a team. We go, “No, actually, this is what it’s about.” And there was some big light bulb moments of, “Oh, so that’s what a team is about then.”

– Yeah, it’s all those interconnectors isn’t it? That makes the whole system work and it’s not one person. The example that you gave is a really, really good one about surgeons, in the operating theater. And the old traditional model was really, the surgeon was God, whatever the surgeon said, went. But what happens you’ve got this team of people around you or this group of people around you, you’ve got all these eyes and ears who are all noticing things. Do they have the legitimacy for saying, “Hang on a minute, “there’s a problem here “that you’re not noticing.” And I know in the aviation industry, they call it this cockpit gradient, there’s-

– Cockpit gradient, yeah exactly, gradient for aeronautical.

– The what gradient?

– Authority gradient-

– Authority, yeah.

– Yeah or cross cockpit is the aviation term, yeah there’s hierarchy. In fact, that was one of the motivators for the documentary I put was a documentary called, “Just a routine operation” by Martin Bromley, whose wife died in a routine operation. And it’s about an eight to nine-minute clip that talks about that situation. The missed a test where he’d sedated his wife, but they couldn’t intubate her, they couldn’t ventilate her. And after I think about 20 minutes, they realized that this wasn’t gonna work, and they needed to put it back into recovery. But in the meantime, that had been nurses coming in, and just saying, “Look, do you need a hand? “We’ve got an ICU bed sorted.” And then they were just dismissive. And so Martin leads the Clinical Human Factors Group in the UK, and his work has been instrumental in changing how human factors and non technical skills is developed in the healthcare industry? It’s fantastic work.

– Yeah, it is, I’ve seen some of it. And certainly we’ve done quite a lot of this in kind of disaster management, some of the work that I’ve done with teams over the years, these kinds of areas. Things like the importance of proper debriefing, after incidents, but also regular debriefing, in order so that people can understand the non technical side of things, as well as the technical side of things, how did this work where you’re listening, all of those kinds of things. And they’re there kinds of skills that you get in things like the military, the RF use it a lot, the military use it a lot, the police use it a lot, but once you get into organizations, there’s this kind of, the speed of things of them actually being able to just sit back and do a debrief. And they think, “Well, what’s the point? “It’s done.”

– And it’s often this piece that said, “We only need to debrief when something went wrong.” And well, it didn’t go wrong, therefore, let’s move on. And I used to think about it, no, it’s about how does normal work work? What are the shortcuts that people will take? You’ve got a bunch of rules and regulations processes, as that’s how we’re gonna do stuff. And then you give it to the worker, you go, “I need their work.” And off they go. And so you lose that organizational learning, that corporate knowledge. And so, when I go and treat work in sort of, say, traditional business environments and I’m working with project managers and things, so, do you build a debrief time, a reflection time into your project? Oh, yeah, but it’s often one of the first things that gets been when we’re running late. As because actually, we’re not very good. Well, hang on a minute, if you’re running late on every project, surely there’s some learning to be had at that stage to understand what those pressures are, and build that into your next plan. So try and make that debrief time sacred, because that’s where the learning is. And, you sort of intimated about aviation and military aviation. A sortie wasn’t over until we finished the debrief. We’d land, we had the aircraft back to the engineers, we taxi back, we get the bus back to the squadron, then we’d have the debrief, and then we go home. And that would be the end of it, or there’ll be some carry-ons from from lessons learned. But even if we just done say, a 16-hour day, and it was just a normal route flying as opposed to a tactical low level mission, we would have time in the bus, where we’d grab 10 to 15 minutes, while the engineer was handing the books back and things like that, we’d sit there and go, okay, lessons learned. What did we do well? What do we need to do more often? What are we gonna do less or next time? And that’s when you need, it gets the mindset that says, “We are a continuously learning organization, “team, whatever, since we can get better.”

– Yeah, I used to do that with my shifts in the police, they were a bit startled at first. But actually, what I got out of that was I started to learn an awful lot about what I wasn’t doing and what I wasn’t listening to, once they got over the shock of like a senior officer asking them, and they realized that I wasn’t actually gonna beat them up for telling me, but I needed that information. I didn’t know ’cause quite often, we don’t see our own failures.

– Oh, big time.

– And it becomes crucial.

– And there’s two parts that becomes really difficult to try and bring that into business. Is a, for the leadership and senior leadership to find the time to go right and recognize the value, but once they recognize the value or they’ll find a time, the other side of it is, as you’ve just intimated, is this bit that the boss is here, what have we done wrong? Why is the senior officer come into the office? Or to the tea-boy just to have a chat? And you’re right, the first couple of times, it’s like, okay, there’s a spy in the count, we’re not gonna say anything. And then you realize, actually, and there are ways of accelerating that engagement process by talking about your own fallibility and showing your own vulnerability as a leader, to say, “You know what? “I make mistakes, I don’t know everything. “You are the experts at the front line. “I was in the front line, 20 years ago, “things have changed.” Two simple questions I get, trying to get leaders to ask is, what works and what sucks? Because you can get a conversation going from that, once you’ve opened it, then you can disappear down those sort of really important pieces, but importantly, do something with it. There’s nothing worse than than telling the boss, all of the stuff that’s going wrong, and they go, “Okay, thanks very much.” And then nothing happens. Because you sit there go, “Well, that was a waste of time. “I’m not gonna bother doing anything now. “I’ll just tell you what you want to hear and move on.”

– Yeah, I agree. One of the first times that I came into this, the kind of feedback culture with this thing, so when I went on to traffic as a police officer. So I went off into the advanced driving course, came back full of beans, having passed, and then went on to the traffic unit. And the first day I was double crewed. The guy I was working with sat in the passenger’s and said, “Come on, we’ll go.” And for the next half hour, he just critiqued me. And I felt about like two inches bigger and I thought, I thought I was good at this, I’m absolutely not… And he pulled over and he said, “Right, okay, I think you need to learn some things. “Like we’re professionals here. “And when you’re in the passenger seat, “you do the same to me, because that’s how we learn.” And the speeds that we travel at, particularly during chases, an inch or two inches on the line, can make the hugest difference and can make the difference between life and death. So we’re forever trying to improve and you’re gonna have to get used to getting this feedback ’cause that’s what we do. I was like, and I remember, God, I’m thinking, I can drive. So and then years later, when I was at Cranfield, I went and did some work with the Red Arrows. And I watched one of their debriefs, and I was like, whoa! I thought we were tough on each other, flip it back. And they were doing, like, millimeters out.

– Yeah, and what’s really, been involved in that sort of situation is you leave the person and the ego at the door on the way in, and that sort of ceremonial bit of there’s the helmets got my name on it, I am now that formation position. I’m not John, Billy, Garrett, whatever it is. And the difference between critical feedback and criticism is people go well, it’s the same thing, you are, no it’s not, and it’s also teaching people, we teach people how to give feedback. Often we don’t teach people how to receive feedback, which is to sit there and go, thank you.

– Yeah, ’cause this is about performance, this isn’t about you. Everybody’s getting it. And it’s just exactly what you’re saying, it’s learning to deal with your own ego. And I must admit, when I first came across it, it was it was a bit of a shock. That as I say, years later, when I watched the Red Arrows doing it, I thought, actually, these are professionals, it’s a difficulty.

– Yeah, definitely.

– Cool, great. Anyway, .

– That was a great statement there, I must say.

– One of the things that you talked about in the book that really caught my eye was that this idea of the sharp end and the blunt end, can you explain this a little bit more.

– Yeah, and it comes, a lot of the stuff that’s in that book comes from the safety industry, and this concept that we have sharpened workers, they’re the people who are doing stuff. And in the safety industry that could be the rest of us on the rig, or it could be that the guys doing the sheet metal work or it could be pouring the iron on the workforce, as at the coalface, the sharp end of a business, and they’re the guys that are having to adjust and adapt to the sort of the operational tempo, the old equipment they’re having to deal with, new tasks, the pressures and everything that are going on. So this is the sharp end of the business and when things go wrong, often we focus on the sharp end, those people who didn’t do what they were supposed to do, and that the hindsight bias that allows us to go, “That was obvious, that was gonna happen.” And you sit there go, “Well, they’ve done it loads and loads of times before “and they haven’t had an issue, what’s changed?” So the sharp end is that bit. The blunt end is management, leadership, HR, legal, regulator. All of the people weigh up in the system. And the perverse situation is that when things go wrong, we often focus on the sharp end because they’re the people that done it. And what we’ll do is we’ll fix the sharp end worker, because it won’t happen again. Well, actually, unless, you understand systems thinking and that sort of stuff, unless you change the blunt end, and you change that, that actually these people just inherit a system. And they do the best they can. And in trying to get across to the leadership, the management teams, they have a huge effect, influence over people. And there’s a term that use him in one of the organizations I work for, Paradigm, be mindful of the shadow you cast. And from this, the taller you are, the longer the shadow is.

– I see.

– Yes.

– I like that.

– Getting people to realize that you’re precious and we use Wells Fargo as an example of a CEO who led to huge fraud within the business, but the headlines were 5,300 managers fired for fraud. And you just sit there and go, “Hang on a minute, they were having to make a choice. “Do I commit fraud, which somebody might find out about, “or do I not meet my targets, and I will get fired?” So looking at that context of that manager, that operator at the sharp end, and the decisions they’ve got to make are influenced by way of leadership. And I think that there isn’t this recognition at that level that says, I have a direct impact on what goes on down there by what I say and what I do.

– Yeah, definitely. And it just goes back to what you were saying before about systems thinking. Every action, all of the thinking and everything that goes on in any organization is not in isolation, it’s actually also responding to the whole system and it’s working out what in that system is affecting this, that’s creating the conditions for these things to happen. And quite often we end up into an you’ve mentioned, a just culture, you end up in a blame culture, where we just poke fingers and say, “Yeah, it was their fault.” And therefore we get rid of them, yeah, definitely.

– Touching on that, and the ability to get that conversation back up, was reading Simon Sinek Infinite game, where he talks about Mulally CEO of Ford, who when he took over and trying to get his senior managers, his senior leaders to say, there must be something wrong going on, tell me what it is. ‘Cause when he got the progress reports every week or fortnight, whatever it was, it was all green cards, and traffic light scheme of green, amber and red, everything was green. And he said, “I don’t believe you, “that there’s got to be something there.” And eventually, somebody, after a number of weeks, put up a yellow card and said, “Look, actually, it’s not quite right, “because the previous boss, the previous CEO, “basically if you didn’t have greens, you’re fired.” So guess what, everybody’s gonna show a green card, even though they know that they were wasting millions of dollars, because they weren’t doing what they should have done. And by his changing at the CEO level, getting to say, “We are going to be a learning organization, “we need to understand what is really going on.” As you talked about with your policeman, finding out what was going on. That’s the only way that senior leaders can really understand the impact that they’re having on their workers and what is happening at the sharp end, essentially.

– What they’re having to contend with, how they’re thinking, how they’re solving problems, because all that information kinda feeds back and allows you to support their work, which is what leadership’s about, quite a lot of leadership anyway. And I’ve got to say, I love your slogan about counter errorizm. I think that’s fantastic. Do you just wanna explain what that means?

– Yeah, so it’s always a play on words on counter terrorism. And in fact, when I first put it as a little tag line on LinkedIn, I’ve got a number of people who sent me a private message you said, “I think there’s a typo in your thing.” I went, “No, no, it’s it is about counter errorizm.” It’s about the fact that we are fallible. And what we can do is, errors are predictable, preventable, manageable, because we understand human behavior. There’s a huge body of evidence that says, “This is how people operate. “These are more, error-likely situations, “error-producing conditions.” So let’s look at the conditions which is again, going back to the business intelligence and safety intelligence from your workers. And you’re saying, “Okay, so if we’re going to counter “the errors that are there, “that’s really what it means about us, “is saying, look…” And it’s to grab people’s attention ’cause they go, “oh, counter errorizm.” And I do have a bit of a… ’cause I’ve got a sort of publisher, I’ve got at the moment, but I have shirts with a big thing, big sort of logo on the back, I have a bit conscious I was, I’m not so much now, but I was very conscious when I first started traveling in the States with the whole TSA security bit of counter errorizm. And that’s how I started using the error-producing conditions. And when we do make an error, building it ’till we’ve got the capacity to fail safely. Because we will make mistakes. How do we build resilience within a system, so that we’ve got some stretchability rather than somebody described, a ball coming down on an a fragile system, the ball just goes through this sheet of glass, what we want is to build a system that’s like a big balloon that goes oh! And comes back up again. And then we can recover, and we may end up going off on a different trajectory. But what we haven’t done is shattered the system and had a catastrophic failure. And it’s trying to predict and prevent that and then manage them when when things do go wrong.

– It’s the kinda resilience and talib’s kind of anti fragility. I think there’s also this problem of just like, organizations have this habit of assigning things to human error. And, which is all part of that blame culture, whether you want to just tell us something, ’cause one of the things that I found interesting in the book, is this difference between errors and violations. And I found that really interesting. Do you jus wanna talk about that?

– Yeah, sure, yeah. When we talk about human error, 70 to 80% of aviation accidents are caused by human error. Okay, that’s not particularly useful. That’s like saying that the reason why this book fell off the table is because of gravity. It’s like, okay, thanks, that’s really helpful. It’s a bucket that says, it something that’s worth looking at. But and this is something I put out to the organizations, if you’ve ever got a report that comes back and says the cause of this accident is human error, you stop looking, because you either run out of time or you run out of money, or you didn’t wanna go looking, because it was easy to blame that. So we have these sort of buckets, that human error, right, there we go, there’s a problem. And then we can break that into two sorts of streams. One is honest errors, slips, lapses and mistakes, something that I didn’t intend to do. So here’s a question for you, David, can you tell me something that’s gonna go wrong tomorrow that you don’t intend to do?

– Well, no.

– People say, “Well, hang on a minute.” So blaming somebody for something that they didn’t intend to do is of no value at all. But we can sort of talk about, we can accept that, because that’s an honest mistake. Then we get into another bucket called violations. And the violation is quite an emotive word. Because it’s about rule-breaking, it’s about choice, you chose to break the rules. And because you broke the rules, the accident happened. And then you sit there and go, okay. And there are buckets within the violation. So you’ve got situational violation. I was unable to do my job if I didn’t, if I followed the rules, because the rules you’ve written to me, means that I can’t actually do it, but you’re rewarding me for productivity. So I’m going to break the rules ’cause that’s what I’m being rewarded for. It could be routine violation. And as the next traffic cop, the example I use all the time is speeding on the motorway. And the average speed that I see is probably 75 to 80. Unless there is a police car there who’s doing sort of 68 and everybody’s cued up, going, is sneaking by, because there’s a consequence. But we are socially conformal creatures, we like to be part of the herd. And if everybody is breaking the rules, it’s easier to break the rule than conform to it. And it takes a lot of mental courage to put your hand up and say, “No, I am not gonna break the rules. “I’m going to follow what’s there” And then we get to recklessness, which is the bit where we talk about no thought or care for the consequence. And that’s something that potentially should be punished, is the bit and but they make such a fraction of the accidents that are out there. From research we’ve got, we’re talking a fraction of a fraction of a percent, or accidents are caused by genuine negligence, sabotage, or violations for personal gain. When people are violating for organizational gain, why would you punish them? Because actually, they’re helping your organization, either innovate get productivity. So there’s a bunch of those violations that we as an organization, Paradigm, call organizational drift. And that’s situational and routine violations, that’s where you can find out your business and your safety intelligence, by going down to the frontline and saying, “Okay, tell me what you do. “What are the pressures that we place on you “to get the job done? “What works and what sucks?” And so you will understand this gap between work as imagined, which is all this stuff that’s written in rules and process guidelines, regulations, inductions, PPE, all of those things that create safety or create performance. And then work is done, which is what really happens at the sharp end. And those workers are managing that gap between imagined and as done dynamically, they are creating safety all the time until they run out of or the system runs out of capacity. And that could be productivity, it could be time, it could be cognitive capacity. And when that happens, we have an accident. So it’s this bit that says, “How do we build capacity or resilience “within the individual, within the team, “within the organization that allows us to deal “with that dynamic variation that happens all the time.” So errors are this honest mistake, violations are the dishonest mistake. And you sit there going, really, that it’s not as simple as that, and we need to dig deeper. So human error, it’s a great bucket to throw stuff in, it is a useless term when it comes to organizational learning or personal learning.

– Yes, definitely, and certainly from an uncertainty point of view, one of the things that really helps organizations is looking for these emergent kind of properties, these patterns in the violations, to say actually, maybe we should be changing things here. Because if lots of people are doing this or an individual’s doing this frequently, either we need to get them back on line, or there’s a reason why they’re doing this because they’re having to make it work. And kind of the simplest example I came across in psychology was the pathways-

– Psychology is with the paths.

– Yeah, so with the gardener, who just planted the whole thing, puff! And there we go, “Well, where’s the path?” He said, “Well, I’m not doing the path “until I see where people walk.” And we then waited for the the bare patches, the lines, the bare patches, and that’s where they put the paths down, which is a nice analogy for what organizations quite often don’t do, is they organize things nice and neatly. Somebody with a neat brain says, “This is why you’re gonna work.” And then they find people cutting across the grass, and they put up signs of saying, keep off the grass. So we’ll create a violation, actually, asks, what’s the point of that? Yeah, but it’s a really nice analogy for what goes on in organizations and the way that they create violations when actually they should be creating pathways.

– Yeah, which goes back to that bit about human factors is making it easy to do the right thing and hard to do the wrong thing. So look at health care and labeling of drugs, is making it obvious that you’ve got two very different drugs, even though they’ve got similar names. And the difficulty there is organizations want to have their own branding across all of their packaging, and they will have a name that they will change slightly, but the meaning might, its effect might be slightly different. So there’s always a conflict that happens. And that’s again, work, ’cause imagine work is done, it’s not necessarily sharp end people that have got the issue, it’s also the decision makers, just saying, “And how do we manage branding “and how do we manage reputation, those sorts of things.” So this is what human factors is about. It’s taking that systems view and saying, how do people operate within a complex adaptive system and make it easy to do the right thing, which in cutting across the grass, it doesn’t really matter if they get it wrong to start with, because that’s what experimentation and innovation is about. But you don’t want to be doing that with paralyzing drugs versus healthy drugs. Just in what there is.

– And yet there is.

– Yeah, but there is so much intelligence out there from the incident reporting that’s captured. Well, it’s the stupid human. If they just paid more attention than they would pick the right drug up, and we wouldn’t have these issues in the right place. We fire that person, but we don’t change the system. Everybody broadly plays the same way. So why do you think the next person’s not gonna make those mistakes? Because I’ve told him not to, right.

– Yeah, which is one of the reasons why we kinda promote evidence-based decision-making and taking evidence from a series of places, but that’s a discussion for another day. I’ve got a whole load of questions here, but we’re running out of time here. So can we just kind of, I’m gonna cut it short a little bit. And well, I’ll get you on again, because I think there’s a lot more that you and I can talk about. So, and this is a horrible thing to do and I apologize for this. But if you had to boil all this down to kind of three main practical takeaways for people in organizations, what would they be?

– Be curious, we have a natural tendency to be judgmental. And so be curious. Ask the question, how did it make sense for them to do what they did? Nobody goes to work and most people don’t go to work to cause an injury or fatality or damage your mistakes, they’re doing the best they can with the resources they’ve got. Be mindful of the shadow you cast. And that doesn’t mean that at the lower levels, you can’t influence upwards, but actually, it’s a bit when you’re in the leadership positions you have an influence way below you. And I would also say, as a leader you create… It’s again linked with that shadow, being mindful of the shadow your cast. But try to create an environment where people come to you with the information. Don’t expect them to be brave to speak up, you influence them. that is a big turn at the moment psychological safety, you as a leader, create that environment, allow people to feel included, allow people to make mistakes, but allow them to fail safely and we can learn from it. Allow them to contribute, and most importantly, encourage them to challenge you. And for that to happen, you’ve got to provide top cover for them. Because if they’re coming to you, it’s because they’re not doing it through malice, they’re doing it because they want to improve the team or the organization. Don’t shoot them down in flames, because if you do, you will just lose all of that.

– Yes, creating a learning culture and a learning orientation within an organization requires some finesse, and quite a lot of empathy and the ability to be able to kind of I suppose, particularly into being almost, because it’s kind of a progressive process that is based on psychological safety. So if people can actually feel safe to kinda speak up, to give feedback, but also to put the hands up and say, “Actually, we’ve got a problem, or I’ve got a problem “or this has happened, or I’ve just done this.” And it’s that kind of error reporting that we see a lot in the aviation industry, we’re seeing a lot more in the medical industries. And I suppose this is what you’re doing now for diving safety as well, that’s brilliant. Thank you so much, Gareth. How can people find you or contact you?

– Easiest way is to go visit the website, humandiver.com and contact details are in there. There’s also gareth.lockathumaninasystem.co.uk. I used to run a sort of another company called Human in a System, which looked at all of human factors stuff, but I now really predominantly focus on the diving elements. So humandiver.com.

– Yeah, I love that idea of human in the system. I thought that was brilliant. When I first saw your email, I thought, that was fantastic. And I’ll put a link through to the book. Really, if you’re interested in errors and organizational performance, it’s a really good book for that. That’s fantastic, thank you so much for your time, Gareth. I really appreciate it.

– [Gareth] Thank you, David. And we’ll catch up with you soon, take care.

– Yeah, you take care, bye.

– Bye.