Saturday, January 15, 2011

Production Pressure Versus Safety

by Randy Cadieux

In many organizations an inherent conflict often exists between production pressure and safety. On the one hand, the organizational leadership may be responsible to various stakeholders and may also be responsible for increasing shareholder wealth. To do otherwise might jeopardize the long-term existence of the organization. On the other hand, while numerous employees within the organization depend on the continued existence of the organization, they also want to work in a safe operating environment. At the end of the day, individuals and team or crew members want to go home in the same condition as when they arrived at work. Many employees not only desire, but expect the organization to help provide a safe working environment where hazards are minimized and risk is reduced to a level which is As Low As Reasonably Practicable (ALARP). Sometimes the continued pressure to attain operational goals and increased efficiencies (to reduce costs and increase profits) may lead to a reduction in levels of safety.

While the organization desires employees to be obedient and meet the production goals, employees may use initiative to create their own methods for getting the job done faster. In the face of increased pressure, individuals and teams may either increase their exposure to hazards without realizing it. While the organization pushes to meet internal or external demands for products or services, the increased pressure may push the boundaries of safe operations. Many organizations can function safely with expanded production goals, but only for a limited time. Consider military surges during combat operations; the organization functions effectively and can achieve short term goals, but a surge is not normally intended to sustain increased operations for an indefinite amount of time. When organizations begin increasing production and operations to a point where previous short-term goal expansions become the new norm, the organization may not understand how much their safety margins have eroded and many employees may not comprehend how high the risk has actually risen.

If the organization fails to recognize the potential for increased hazards (either through increased exposure or the introduction of new hazards) during a high operational tempo period, employees may be unnecessarily exposed to increased risk. While it may seem that operations and safety are incongruous, there may be a possibility of achieving increased production goals while maintaining safety goals and values and keeping risk to an ALARP level, but it requires thorough planning, including a comprehensive systems safety hazard analysis. The hazard analysis and risk assessment should include the recommendation and implementation of controls to reduce risks. This process may help organizations accurately recognize their distance from safety boundaries and develop controls which help minimize levels of risk to employees, equipment, and the environment.

Sunday, January 9, 2011

Trust and Integrity

by Randy Cadieux

Trust and integrity are essential traits for leaders in High-Reliability Organizations. To effectively gain the support of followers in any organization, leaders should earn the trust of their subordinate personnel. Leaders should lead by example, and follow through with commitments. Employees seem to have more respect and trust in leaders who are honest, truthful, and lead by demonstrating positive examples. Perhaps this trust will facilitate improved performance by personnel within the organization.

Initiative

by Randy Cadieux

Effective leaders search out ways for training their subordinate employees to become future leaders. In Navy and Marine Corps aviation, pilots and aircrew are trained to operate their aircraft and obey commands, but are also trained in decsionmaking scenarios so that they can provide valuable information during abnormal operations. Creating an organization of followers who do not know how to proactively seek out information to make decisions may solidify failure when that organization faces unexpected challenges. In the Marine Corps, leaders seek out opportunities to "train their replacement" so that if or when the time arises, subordinates can step up and fill the role of their leaders.

Driving the Vision

by Randy Cadieux

Oftentimes organizations have the capability and capacity to become HRO's, but are unable to harness the talent of the individuals to attain that level of operation. By creating a vision which can be explained to top-level leadership and management staff, gaining the buy-in of all personnel, and explaining the long-term goals for an organization, support for HRO initiatives may be more effective. This vision must be championed by top-level leaders, but key mid-level leaders and managers should create the plans which can facilitate the implementation of actionable programs to drive an organization towards the attainment of high reliability operations.

Wednesday, January 5, 2011

Honesty

by David Christenson

We study trust but what role does honesty have in trust? Also, how does honesty contribute to High Reliability?

What do other people say? Honesty and integrity must come from the top down as core values. Honesty is character development and part of building trust. When someone says something, it must be true. There is no attempt as evasion or making things look better. A little lie can ruin your reputation.

Trust, trustworthiness, honesty comes in accident investigations. Ted Putnam refused to sign off on the South Canyon Fire because by not making explicit certain things it was not going to help the investigation.

Sidney Dekker calls this the New View. You look at the environment in which decisions are made the policies, attitudes, events, that are part of the environment. This makes a rich series of stories. This may not be the first story or the headline but the next series of stories. When you do this you generate trust in the community.

From an educational standpoint there is a willingness to discuss closed topics; we are not perfect every day. Some people use liability as a reason not to do something. This may be a lack of honesty if it is meant to dissuade rather than discuss an element of liability.

Honesty is the little bits and pieces we don't think about. Honesty is mentoring instead of assigning tasks. You should explain why (the political atmosphere, etc.). Tell them the things that politically will help them. This gives them a greater understanding of the organization and their role in it. Openness and honesty are difficult and people often avoid them at all costs.

As a leader, you promote psychological safety so people can be honest. For example, the no win situation. Does this dress make me look fat? You create an environment where honesty, integrity, and candor are respected.

Honesty seems to be a top down characteristic of HROs.

For Crew Resource Management (CRM) in aviation I am in the left seat because of longevity, not knowledge. That is honesty. You alert people to each other and make more sensitivity to situations. Leaders may feel they will lose their clout but actually it makes people trust them.

Clarification from a pilot: the issue of CRM ("crew resource management") was brought up as it relates to airline pilots and honesty. It should not be mischaracterized as the Captain being open and forthright with the passengers as it relates to turbulence, etc. CRM actually encourages the crewmembers to be open with each other, not the passengers. One example is a junior first officer being able to voice a concern, no matter how trivial, to a senior captain.

Honesty is a two-way street. The person considered the leader may be willing to be honest but the others may have a hidden agenda.

There is sometimes a question of retribution; if I am honest this will backfire on me.

For a pilot's briefing there is honesty in approaching the unknown. It is the duty to tell people. Honesty and trust are tied together but are situational. The leader opens up his mind to others for his decision making. There is risk and it requires emotional stability. There is the betterment of progress vs. risk of looking down.

It can put you in a position for being attacked.

If team-based, honesty might show weakness but leader must get it out, my knowns, and my unknowns. Pretending you know everything, then people on team may shut down as the leader has it. NRC is open and honest about their policies. They specifically protect from retribution. Web link to the NRC material: http://www.nrc.gov/about-nrc/values.html

Honesty is both a value and a behavior. Honesty is a value and a long-standing value becomes a behavior.

Be open, honest, and humble. A good leader is humble about what he can do vs. what he is relying on from others in the team. It is not bad to show humility and vulnerability, this gives the bottom up honesty.

In healthcare it is less about honesty and more that you cannot speak your mind. Contrary voices are unwelcome so you become a company man. As medicine becomes more corporate, it loses the culture of organizations that emulate HROs from other sectors of the economy; medicine wants being a company man, and criticisms are unwelcome.

Honesty, rather than a value or behavior, it is an insight. If it is an insight then it is a higher level of cognition. I choose to be honest and all the problems that go with honesty.

Retribution organizationally how do you get people to change? From the Commander of the Army Corps of Engineers, you have a permission slip on a business card. It asks Is it good for customers, legal and ethical, and am I willing to be accountable for it?

To address mistrust in an organization, the first thing one person took on was the mistrust against training and safety. Clarify what is punishable and what is not punishable. This helped with trust.

This may have worked because the person knew the organization well. How much do you have to know to pull this off?

It is better to be interested more in what is not said the silence.

You need a prophet who will say things that no one wants you to say and no one wants to hear. HROs are not afraid of the prophet. Those wanting to become an HRO should consider hiring a prophet.

Wildland fire brings in facilitators to help discordant information be brought to the surface.

In a military organization, who is the prophet? The safety officer may have that position as he answers only to the commander. But if he is a prophet too much how effectively can he do his job? Some are mavericks who always tell the truth. How do you keep them viable so they keep doing their job? Who are they in an organization? Where in the organization should they exist?

It is a difficult and hard job to have. Much better is a Just Environment where this is part of the culture.

Honesty is the moose in the room. Incident investigations may be protecting someone. People may not be bold enough to challenge it. One organization takes leaders through a no blame, trust culture.

Class A mishap investigations (loss of aircraft or injuries with total physical disability) now have an outsider to study the mishap to prevent a cover up. It makes it difficult to hide things. This occurred about 25 years ago as it used to be only someone senior to the person involved.

Value Shift

by David Christenson, January 5, 2011

Initiative and Obedience: conflicting, complementary, or dualistic? What is one without the other?

What do others say? There is a group that teaches outcomes engineering that states that, if everybody does what he is told, everybody is motivated, and if he sees everybody as his friend then we will have a fantastic organization. But people are not knowledgeable and cannot be planned. In social engineering people still behave poorly despite good structure, laws, and regulations hence, mindlessness.

You start with background discipline good laws, regulations, and you conform to it. But how do you allow initiative and creativity? It may depend on who presents it first.

Commander's Intent is the context within which you are independent. Who does it first must be technically competent. This is Commander's Intent. Dogma is equivalent to obedience. As with nature vs. nurture it is not one or the other but a balance. The US Navy does not officially present Commander's Intent which is more for land warfare. Commander's Intent is large in the Marine Corps. If it is not presented then the commander may be overwhelmed with circumstances. Subordinates can use Commander's Intent to follow initiative.

Mostly people act poorly because we did not outline expectations and rules of action. If you hear or see something stupid do not act, ask. If it seems wrong it probably is.

There is also shared ethos, values, and experience which results in the Strategic Corporal paper used by the Marine Corps.

There is obedience to the integrity or the technical task. This allows shift form obedience to initiative.

Teams created by shared objective are more likely to use initiative. Commonly, we use teams created by hierarchy.

There is tension between mindfulness and control. For French firefighters, the French culture has a cultural hierarchical organization. In American culture there is Commander's Intent with distributed decision making. When the situation becomes too complex for centralized decision making the French firefighters are forced to make decisions.

Query - What are they doing to change?

Response - Simulations and exercises are used.

When do you let people use initiative? Figure out their level of competency. Mentoring by senior members with evaluation; small tasks initially then evaluate performance; let them make mistakes then debrief them.

On the first day on the job, work with them closest regarding initiative as they will be in over their head at first. When the rookie sees danger what do you want him to do? Communicate is an item of initiative. Safety over-rides initial orders, even by communication. This is in the affective domain of knowledge. How do I teach initiative? Technical competency integrative or adaptive competency may be more important than technical competency.

Action-oriented behavior may be good or bad. How do you teach a person who does not have the characteristics of action oriented behavior? Initiative is a complex decision making tool. As a leader you can empower them or constrain them.

You talk about leader all the way down to middle management. But the most effective mentoring is being careful about lining the new person up with someone who was recently in that situation. For initiative, there is limited interaction from on high; the most effective influence is further down the chain of command.

In the Naval Training Command you take the raw student with minimal flight time in civilian aircraft. Then you expect them to obediently follow the technical tasks to move them to flying alone. You train them to be obedient, give them small tasks, and then move to initiative.

The leader has to set the tone for the employee to take initiative.

You could develop a followership to leadership program. There is a common voice from the beginning. Think of leadership from the follower's position. Develop common values and beliefs so leadership stars on the first day.

What you can do? vs. What you cannot do? as opposing philosophies.

Everything you cannot do is listed, an approach used by the Navy and Marine Corps.

Anything you can do is listed, an approach used by the Air Force.

How does this affect initiative? Initiative is a form of authority migration.

There are standards for compliance you are prohibited from these things; anything within those limits allows flexibility.

Teach in the positive.

The way to make things safe is to limit decision making rules. There are various degrees of right with various consequences so you must choose base on that.

To define the balance between initiative and obedience is more like describing course corrections as you move between too restrictive and too slack. Place emphasis on What are we learning? vs. fault and blame. Course correction then becomes part of maturity.

You have a dynamic balancing and rebalancing between adaptive competency and technical competency.

It is a bad sign if the boss or someone high up is killing initiative. For the new-hire the guy he respects most is the guy he works with; if he is slam-dunked then you kill initiative. How far down do you push this oversight and training? It is a full time job keeping the lines of communication open at all times.

We need continual balance between initiative and obedience; either extreme produces negative consequences. Acknowledge the legitimacy of those who choose rules but say we have gone too far.

Consider the bias for action vs. the bias for inaction.

Another form of initiative: If you have a problem it is your problem until it is solved (this is accountability).

Leadership and Command

by David Christenson

What is the difference? How did we learn them, how do we use them, how do we teach them?

What do others say? There is much discussion in the business literature about leadership. What is missing is a discussion of command. The Department of Defense lexicon defines command. It is discussed in public safety (fire, law enforcement, and EMS).

For one chemical company leadership is coaching; it comes from empowering people to do their best.

Some aspects of leadership can be taught but it is also learned in the hands on and day-to-day work of the organization. In the military command is where the buck stops.* The Commander is responsible for overall performance of the organization and involves some politics as you look up and down the line. Leadership is how you inspire people. Command is from your experience coming up the line. You develop from good and bad examples.

*[For some of our foreign participants: The buck was a type of knife common on Mississippi River gambling boats. It was passed around in a card game to signify the dealer. Where the buck stops is who had responsibility for the deal. Cheating and whether you had a good or bad hand clearly originated from the dealer (at least, in the gambler's mind).]

Leadership is empowering people and is more personal while command is more impersonal.

As parents we start out being in command, then in the teenage years we take on more leadership, finally, we only have leadership. Command is the health and well being of people while leadership is making people strong.

How will you measure your life? If we keep controlling our kids they will never be able to make a decision; we must get them to think for themselves.

There is a counter article to that in the New York Times called The Summoned Self by David Brooks. Read them together for a richer sense of how to teach others to think. There is Freedom of Decision and Freedom of Thinking.

With check list there is enthusiasm and interest to bring that safety tool to the hospital. Now they want the check list to used 100% of the time. There is a sequence of: impose it first then internalize it. There is tension between imposed and internalized. Some people are more self-directed and they internalize better. There is also tension between mindfulness and control. This is not either/or but use them as necessary.

Command - the physical abilities of the people to use their hands and achieve, and tactical.

Leadership - the hearts and minds, their vision, inspires, and strategic.

Leadership in wildland fire the authority to lead is established by law and includes accountability. Commanders can delegate responsibility but not the accountability.

Command is a tool that allows the organization to make a structure. Then there are functional leaders within that structure. The pilot is a commander and the functional leader comes out from that. The designated leader is the commander and appointed by authority to make decisions. The functional leader is the leader for the time-specific event. For example, on a mission the commander may be in different plane and the functional leader is the pilot. At the drop zone the load master becomes the functional leader and takes over from the pilot.

The aircraft commander may not be the pilot depending on the mission of the airplane. The pilot puts the plane where it should be and the commander tells what to do.

Can someone be both commander and leader? In the Aegis Cruiser the Captain is down below working with the missiles while the other person is on the bridge and keeps the ship going. In the movie Crimson Tide there are both aspects of leadership and command. There is the legal command of who is in charge by law and then there is the one who takes leadership.

How does the role transition in command when the functional leader takes over from the commander?

In the KC 130 refueling aircraft the aircraft commander is always in charge as designated leader. If the mission is command and control then the senior officer is the aircraft commander and the pilot gets the plane to where it needs to be so senior officer can act toward command and control, this officer then can function as his role as commander.

But for aerial delivery the KC130 must go to the specific spot to deliver things to the ground. The loadmaster then decides about the aerial delivery. For paratroops it is the Jumpmaster and for equipment it is the Loadmaster.

Leadership is not a position; it is a means of influence. Command is a position. Does the commander have the skill sets of a leader? In the art of leadership they can maneuver in that environment and not micromanage.

In Wildland Fire there is a transition from followership to leadership. The good follower learns tactical implementation. As they grow and mature they gain a greater understanding of strategy.

Wildland Fire has a great gasp of leadership but structure fire does not. Promotion in structural fire is by exam and politics.

A good leader had a clear vision of where they need to go and they inspire others to get there so people will rise to the occasion. If the leader in the command structure does not trust others then the command structure breaks down.

The command structure allows for effective flow of information. Leaders can over ride the people and goes beyond their training and their ability to obey. Managers will micromanage as they are good at the command function but are poor leaders.

With leadership and command is there nature or nurture? In a recent bus accident a young girl calmed the other kids and organized their exit without an adult to assist.

What happens if the commander is not the one with the most information or experience yet is responsible for those under the command?

Situational awareness is a Crew Resource Management (CRM) term. Basically, it is the degree to which one's perception of reality mirrors reality. A good commander builds situational awareness for the team. If this occurs, inevitably, someone on the ground or in the team has the information.

Some things that facilitate cooperation is that you try to keep your crews similar, including in training and action together. Do not overload them too much; improper presentation is part of this.

In CRM there is specifically addressed obedient disobedience for situations when the commander does not have the necessary information. Then the subordinate is obligated to tell the commander this information.

What is the difference between "Breakdown in command" and "Breakdown in leadership?"

Humility - the leader needs to be humble and listen to others and ask for help.

Framing - leadership is focus on the team while command is focus on the situation.

In the nursing home the nurse must have leadership skills to look over all aspects of care; it doesn't matter who has command as the RN is on site and, if not leading, there is a breakdown in command.

An effective leader listens to those around them. There is failure when commands are ignored. There is tension between command and leadership. This could be a good contrast to smoke out a large number of examples of HRO.