Baker - Foundation and Operational Learning.pdf
- 1. Human & Organizational Performance Resilient design Understanding the humans in the system ANDREA (ANDY) BAKER
- 2. HOP Basic Beliefs People Make Mistakes Blame Fixes Nothing Context Drives Behavior Learning & Improving is Vital Leader’s Response Matters
- 3. “Employee (EE) suffered multiple fractures to right leg after collision between injured EE’s vehicle and a forklift. Injured EE was in maintenance cart driving E to W in building 32. Forklift driver was traveling S to N in building 32. Collision occurred in the middle of a 4- way stop. Injured employee states that forklift did not stop at 4-way stop. Both parties state proper PPE was worn.”
- 4. Most common questions… Did you stop? What happened? How is the visibility, lighting, signage, flooring? Have you been trained? What was on your forks? What direction were you driving? Were you distracted? Is something going on at home? Vehicle maintenance records Did you inspect your vehicle? Training records Cameras Drug Test How fast were you going?
- 5. Most common solutions… Retrain the Drivers & Hold a safety stand- down about roads rules: Aware of surroundings, full stop, honk your horn at intersections. Put in speed bumps or aisle cops Send the forklift driver to HR
- 6. Underneath every seemingly obvious, simple story…there is a second deeper story. A more complex story…a story about the system in which people work. (Adapted from Dekker, 2006)
- 7. “Teach me what it takes to get your work done.”
- 8. What we didn’t know...
- 11. Traditional View A significant difference in solution sets... HOP View • Stand down about road rules • Put in speed bumps or aisle cops • Send employee to HR • Change intersection from 4 way stops to 2-way yields (give-way) • Put attention activators in the intersections • Change maintenance cart to allow them to fail safe Questions that lead us to judge quickly Questions that teach us about the “real deal”
- 12. Be curious, not judgmental. -Walt Whitman -Ted Lasso
- 13. Taylorism
- 14. Focused on trying to “fix” the worker Focuses on creating system improvements. Recognizes the worker is not the “problem.” Behavior that upon first glance seems like a “flagrant violation” is almost always a logical adaptation that most other people would make if put in a similar environment. The shift in thinking... Traditional View New View
- 15. Assumption: the person is the problem
- 16. Blame prevents improvement... “...blame is the enemy of understanding.” (Andrew Hopkins)
- 17. Blame is very common, but not helpful
- 18. Blame cycle Be hard on the process, not the person
- 20. To move beyond blame, I needed to learn a bit about what it means to be human...
- 21. We are all the same amount of “lazy”
- 24. We drift towards “short-cuts” (efficiency gains)... ...because we are hard wired for energy conservation (Baker)
- 25. Complacency is not a choice
- 27. Risk Perception is very difficult to change
- 30. We want to shift the focus from the conditions we strive tirelessly to control (but can’t) to the elements of our system we can control and manage. HOP shifts us away from the incorrect belief that we can “cure” the human condition (the inevitability of error, the influence of context, the drift towards efficiency) Departure from this flawed thinking relieves us from a subset of pervasive operational inefficiencies we have all been laboring under and refocuses that energy on sustainable change.... (Baker)
- 31. Ordered Systems vs Complex Adaptive Systems
- 32. Ordered Systems (David Snowden) A Sense Making Model for Systems (The Cynefin Framework) Complex Simple Chaotic Complicated
- 33. Ordered Systems Simple Complex Adaptive Systems • Cause and effect is fixed, known and predictable • Events have a root cause or causal factors • The system can be fully understood (often needing various SMEs) • Cause and effect is NOT fixed. Outcomes are not predictable, but patterns can be understood • Events are combinations of normal variability • Success is often due to human adaptation • Change is the only constant
- 34. “What is happening when nothing is happening?” - Dr. Erik Hollnagel Operational Learning
- 35. (Conklin / Edwards / Baker) Work as Planned vs Work in Practice
- 36. Normally Successful! (Conklin / Edwards / Baker) “Masters of the blue line” Work as Planned vs. Work in Practice
- 37. If one person makes an error or breaks a rule, the probability is high that other people, given the same environment and information, would do the same. (Baker)
- 38. Error: I did NOT intend my action I did NOT intend something bad to happen Mistake: I DID intend my action I did NOT intend something bad to happen Person Problem: I DID intend my action I DID intend something bad to happen (violation) (rule breaking) (deviation) (drift) (adaptation) Accountability…?
- 40. Great performance is not the absence of errors (or poor decisions)... ...it’s the presence of capacity to fail safely (Conklin, 2018)
- 42. http://www.newgeography.com/content/004892-is-suburbia-crashing-suburban-traffic-myths-refuted US vehicle miles travels and proportionate fatality rates
- 43. “You cannot manage what you do not understand.” (E. Jacques) Designing to fail safely requires a different level of detail…
- 45. Singular focus on prevention of failure Recognition that although we prevent what we can, not all failure can be predicted, and therefore not prevented. We work toward allowing people to fail safely. One mistake or bad decision should not be life altering – that is the sign of a brittle system The shift in thinking... Traditional View HOP View
- 46. What we cannot control: We cannot change human nature What we can control: We can learn about normal work (the blue line). Once we learn, we can improve by: • Making the “right” way the “easy” way • Increasing system transparency • Filling knowledge gaps • Removing goal conflicts • Removing error traps • Adding controls that allow humans to fail safely (make mistakes and errors without leading to serious consequence)
- 47. Assumption: We need to hold people accountable
- 49. • Not punishment • Not retribution • Not something you can “do” to a person or “extract” from a person Accountability is not something that management can demand, or dictate, or punish people into compliance with. Accountability is the willingness to accept responsibility, or to account for ones actions. What is accountability? tell the story of We have confused the ideas of accountability, culpability, and discipline – Merriam-Webster dictionary -Tim Autrey
- 51. ... disciplinary action does not create accountability… We want and need accountability. But…
- 52. Sought to create accountability through disciplinary action Recognizes that disciplinary action is used to fairly remove a person problem. Disciplinary action is not a good mechanism for creating accountability, or solving a system problem. The shift in thinking... Traditional View HOP View
- 54. Compliance mentality: behavior is changed only when we are monitored and fearful of what happens if we are “caught” Continuous monitoring is expensive, often impractical, and creates an “us versus them” mentality which makes it difficult to learn and improve A compliance mentality may be necessary in the short term, but it is not a long term solution
- 55. We rarely have quality, safety or people issues… ...we have operational struggles. (Edwards/Baker)
- 56. In some circumstances people “should know better” Recognizes our perception can be heavily influenced by biases. Seeks to learn the context from the point of view of those closest to the work in order to understand the local rationale. The shift in thinking... Traditional View HOP View
- 57. Our Goal . . . . . . is to become less surprised by human error and failure . . . . . . and instead, become a lot more interested in and a lot better at operational learning! (Edwards)
- 58. errors are choices – if you try hard enough you won’t make them Assumption:
- 59. Is error a choice?
- 61. Billy and the dock plate
- 62. How many times does the letter “f” appear in the following sentence? Finished files are the result of years of scientific study combined with the experience of many years How many did you find? Finished files are the result of years of scientific study combined with the experience of many years Error likely situations are predictable…
- 63. “Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.” - Dr. Edward de Bono
- 64. Assumption : “not following procedure” is the reason why something went wrong
- 65. Procedures are important... But they are not sufficient enough to create safety or quality Our organizations have become complex-webs of procedures that are incomplete and difficult. (Conklin)
- 66. Truth: Variation from a procedure (or any pre-defined plan) is normal, and often necessary for success
- 67. Normally Successful! (Conklin / Edwards) “Masters of the blue line” Work as Planned vs Work in Practice
- 68. Normally Successful! (Conklin / Edwards) Work as imagined vs Work in practice
- 69. (Conklin, 2017) Saying an event was caused by error or not following procedure is like saying an object fell due to gravity: it’s always true, it just doesn’t tell us anything.
- 70. (Conklin / Edwards / Baker) Work as imagined vs Work in practice Focusing on the gap between the black and blue lines is too narrow a view point; it is normal to have this gap, even when no event occurs It is much more beneficial to focus on learning about the blue line: how normal work is done.
- 71. Sought to constrain behavior to a procedure to remain safe Recognizes workers complete/fill-in procedures to meet the variable conditions in real world and adaptations from written instruction are often necessary for success The shift in thinking... Traditional View New View
- 74. We can move our culture in only one of these two directions: Option 1: Blame and Get Even Option 2: Learn and Get Better -Adapted from Conklin
- 75. There is a root cause Assumption:
- 76. 1 2 3 4 5 Event Root Cause? Some tools lead us to a linear understanding of an event…
- 77. Start back in process and move towards the event Latent Conditions System Weaknesses Near Misses Local Factors Normal Variability Errors Hazards & Risks Flawed processes Poor communication Production pressure Resource constraints Change in plans Fear of reporting System Strengths Design shortcomings (Conklin/Edwards/Baker/Howe) Incomplete Procedures Weak Signals Personal Factors Surprises Data Past Success Unclear Signals Tradeoffs Goal Conflict Adaptation Failure looks more like... Event Incompatibilities ...in operational learning, we don’t ask about these categories…we ask about normal work. In that discussion, elements in categories LIKE these are brought forward.
- 78. Latent Conditions System Weaknesses Near Misses Local Factors Normal Variability Errors Hazards & Risks Flawed processes Poor communication Production pressure Resource constraints Change in plans Fear of reporting System Strengths Design shortcomings (Conklin/Edwards/Baker/Howe) Incomplete Procedures Weak Signals Personal Factors Surprises Data Past Success Unclear Signals Tradeoffs Goal Conflict Adaptation Success is similar Success Incompatibilities
- 79. Failure is a combination of normal variability (Hollnagel, Baker, Edwards)
- 80. Failure is a combination of normal variability (Hollnagel, 2018) Success
- 81. If we wait for an event to learn, we miss out on 99% of our learning opportunities
- 82. Ordered Systems Where I am… (David Snowden) 1 2 3 4 5 Event Root Cause? Fail Safe Experiments A Sense Making Model for Systems (The Cynefin Framework) Best Practices Complex Simple Fail Safe Design Chaotic Listening Faster Fail Safe Design Good Practices Complicated Novel Practices
- 83. Sought to learn from events by finding root cause Recognizes failure is a combination of normal variability and there is no one root cause unless a system is purely mechanical Recognizes we can learn before events occur to understand system weaknesses The shift in thinking... Traditional View HOP View
- 84. Operational Learning & Learning Team structure ANDY BAKER MATT FLORIO
- 85. programs, practices, rituals HOP Principles Proactive and Reactive Learning Teams Traditional investigations What changes first… shared beliefs, values and assumptions
- 86. programs, practices, rituals HOP Principles Operational Learning – seeking struggle Traditional audits What changes first… shared beliefs, values and assumptions
- 87. 1. Mistakes are not intentional…? (J. Reason). 2. Mistakes and errors are consequences of the environment/system (adapted from Conklin). 3. Blame is common, because it is easier to blame than improve 4. Blame hurts our organization 5. You have two strategies after an event: blame and retrain, or learn and improve – and they are opposing strategies (Conklin) 6. Accountability and discipline are different 7. True accountability is akin to ownership 8. An environment of accountability can (and should) be created without meeting pain with pain (bottom of the iceberg) Key Concepts
- 90. Question Difference Investigation Learning Questions are designed to test a theory, check a cause, or hunt for an explanation Questions are designed to encourage people to teach us the good, bad and ugly of their work world
- 91. (Baker/Edwards) • Asking to learn, not to teach • Asking about how work is done • Reflective listening: genuine curiosity • Beyond Open-ended: my next question comes from what I’m learning Being teachable
- 92. Logistics Tips (Baker/Edwards) • Where we talk • Leader kick off • Who we talk with: • Multiple perspectives • Mindful of authority figures • How we take notes Conditions for Candor
- 93. What makes a Learning Team …a learning team? Being teachable Valuing Soak Time Learning First (Baker/Edwards) Defining the problems Conditions for Candor Trystorm
- 94. What makes Operational Learning…Operational Learning? Being teachable Valuing Soak Time Learning First (Baker/Edwards) Defining the problems Conditions for Candor Trystorm
- 95. Share operational intelligence Define the problems and brainstorm (some) improvement ideas Learn Soak Review Define (Baker) Improve “I’d do the same...” “How do we ever do this successfully?” Are we missing anyone? Want to go see? Set the stage
- 97. The supervisor’s take… using a traditional approach: Why did the employee get propane exposure? There was a propane leak and the employee was not wearing gloves Why was there a propane leak? The connection between the hose and the tank valve was cross-threaded Why was the employee not wearing gloves? Complacency Corrective actions • Re-train employee on importance of wearing gloves • Disciplinary action Why was the connection cross threaded? The employee did not double check connection before opening the value Corrective actions • Add checking for cross-thread to pre-use inspection Why was the employee complacent? She had successfully completed the task without gloves before
- 98. Sue – Sweeper driver Joe – used to drive sweeper, now drives forklift Bill – newer forklift driver Aaron – material handling supervisor
- 99. Communicate & Take Action Help free up the resources Set the tone: give permission to speak freely Anticipate complexity and “bad news” Protect soak time Support additional learning sessions as needed “Combat breathe” Let the team try-storm Remove roadblocks Remember there is real value in the information alone Tell the story Pass on the operational intelligence Use it to inform decisions Leader’s Role Define Improve Learn Soak Review Are we missing anyone? Want to go see? Set the stage
- 100. Learn Soak Time Gain Understanding Take Action Define Areas for Action & Prioritize Test changes Try-Storm Ideas Sustain & Monitor Determine Need & Establish Team (Edwards, Baker, Conklin) Feedback loops Soak Review Manager kick-off Brainstorm The Learning Cycle The Improvement Cycle Tell the Story The HOP Learning Team Cycle
- 101. Operational Learning Cycle Problem statements: Draft, define, redefine Learn Cycle: Learn, soak, tell the story, learn some more Improvement Cycle: Brainstorm, trystorm, test, feedback, improve (Baker/Edwards) Understanding: “I’m surprised we are successful most of the time” Masters of the blue line agree: “huh…yeah…that’s about right” Helps address the problem statement
- 102. What is the output of a Learning Team? Problem statements Understanding Team’s improvement ideas (Baker/Edwards)
- 105. Hierarchy of controls is the most important indicator of whether a defense is strong or not Assumption:
- 106. Hierarchy of Controls... • Elimination • Substitution • Engineering Controls • Administrative Controls • PPE More focused on ownership and effectiveness
- 108. Resources Todd Conklin, PhD Sidney Dekker, PhD Jerry Muller Edgar Schein, PhD www.hophub.org Weick & Sutcliffe Chris Clearfield Andras Tilcsik Don Norman Bob Edwards Andrea Baker