In the nuclear industry, most decisions are at least arguably “hard,” i.e., decision makers can agree on the facts and identify areas where there is risk or uncertainty. A recent New Yorker article* on making an indisputably “soft” decision got us wondering if the methods and philosophy described in the article might provide some insight into qualitative personal decisions in the nuclear space.
Author Joshua Rothman’s interest in decision making was piqued by the impending birth of his first child. When exactly did he decide that he wanted children (after not wanting them) and then participate with his wife to make it happen? As he says, “If I made a decision, it wasn’t a very decisive one.” Thus began his research into decision making methods and philosophy.
Rothman opens with a quick review of several decision making techniques. He describes Benjamin Franklin’s “prudential algebra,” Charles Darwin’s lists of pros and cons, Leo Tolstoy’s expositions in War and Peace (where it appears the biggest decisions basically make themselves), and modern decision science processes that develop decisions through iterative activities performed by groups, scenario planning and war games.
Eventually the author gets to decision theory, which holds that sound decisions flow from values. Decision makers ask what they value and then seek to maximize it. But what if “we’re unsure what we care about, or when we anticipate that what we care about might shift”? What if we opt to change our values?
The focus on values leads to philosophy. Rothman draws heavily on the work of Agnes Callard, a philosopher at the University of Chicago, who believes that life-altering decisions are not made suddenly but through a more gradual process: “Old Person aspires to become New Person.” Callard emphasizes that aspiration is different from ambition. Ambitious people know exactly why they’re doing something, e.g., taking a class to get a good grade or modeling different behavior to satisfy regulatory scrutiny. Aspirants, on the other hand, have a harder time because they have a less clear sense of their current activities’ value and can only hope their future selves can understand and appreciate it. “To aspire, Callard writes, is to judge one’s present-day self by the standards of a future self who doesn’t yet exist.”
Our Perspective
We can consider the change of an organization’s culture as the integration over time of the changes in all its members’ behaviors and values. We know that values underlie culture and significant cultural change requires shifting the actual (as opposed to the espoused) values of the organization. This is not easy. The organization’s more ambitious members will find it easier to get with the program; they know change is essential and are willing to adapt to keep their jobs or improve their standing. The merely aspiring will have a harder time. Because they lack a clear picture of the future organizational culture, they may be troubled by unexplored options, i.e., some different path or future that might be equally good or even better. They may learn that no matter how deeply they study the experience of others, they still don’t really know what they’re getting into. They don’t understand what the change experience will be like and how it will affect them. They may be frustrated to discover that modeling desired new behaviors does not help because they still feel like the same people in the old culture. Since personal change is not instantaneous, they may even get stuck somewhere between the old culture and the new culture.
Bottom line: Cultural change is harder for some people than others. This article is an easy read that offers an introduction to the personal dynamics associated with changing one’s outlook or values.
This book* is about biases that prevent us from making fact-based decisions. It is based on the author’s world-wide work as a doctor and public health researcher. We saw it on Bill Gates’ 2018 summer reading list.
Rosling discusses ten instincts (or reasons) why our individual worldviews (or mental models) are systematically wrong and prevent us from seeing situations are they truly are and making fact-based decisions about them.
Rosling mostly addresses global issues but the same instincts can affect our approach to work-related decision making from the enterprise level down to the individual. We briefly discuss each instinct and highlight how it may hinder us from making good decisions during everyday work and one-off investigations.
The gap instinct
This is “that irresistible temptation we have to divide all kinds of things into two distinct and often conflicting groups, with an imagined gap—a huge chasm of injustice—in between.” (p. 26) This is reinforced by our “strong dramatic instinct toward binary thinking . . .” (p. 42) The gap instinct can apply to our thinking about safety, e.g., in the Safety I mental model there is acceptable performance and intolerable performance, with no middle ground and no normal transitions back and forth. Rosling notes that usually there is no clear cleavage between two groups, even if it seems like that from the averages. We saw this in Dekker's analysis of health provider data (reviewed Oct. 29, 2018) where both favorable and unfavorable patient outcomes exhibited the same negative work process traits.
The negativity instinct
This is “our tendency to notice the bad more than the good.” (p. 51) We do not perceive improvements that are “too slow, too fragmented, or too small one-by-one to ever qualify as news.” (p. 54) “There are three things going on here: the misremembering of the past [erroneously glorifying the “good old days”]; selective reporting by journalists and activists; and the feeling that as long as things are bad it’s heartless to say they are getting better.” (p. 70) To tell the truth, we don’t see this instinct inside the nuclear world where facilities with long-standing cultural problems (i.e., bad) are constantly reporting progress (i.e., getting better) while their cultural conditions still remain unacceptable.
The straight line instinct
This is the expectation that a line of data will continue straight into the future. Most of you have technical training or exposure and know that accurate extrapolations can take many shapes including straight, s-bends, asymptotes, humps or exponential growth.
The fear instinct
“[F]ears are hardwired deep in our brains for obvious evolutionary reasons.” (p. 105) “The media cannot resist tapping into our fear instinct. It is such an easy way to grab our attention.” (p. 106) Rosling observes that hundreds of elderly people who fled Fukushima to escape radiation ended up dying “because of the mental and physical stresses of the evacuation itself or of life in evacuation shelters.” (p. 114) In other words, they fled something frightening (a perceived risk) and ended up in danger (a real risk). How often does fear, e.g., fear of bad press, enter into your organization’s decision making?
The size instinct
We overweight things that look big to us. “It is instinctive to look at a lonely number and misjudge its importance. It is also instinctive . . . to misjudge the importance of a single instance or an identifiable victim.” (p. 125) Does the nuclear industry overreact to some single instances?
The generalization instinct
“[T]he generalization instinct makes “us” think of “them” as all the same.” (p. 140) At the macro level, this is where the bad “isms” exist: racism, sexism, ageism, classism, etc. But your coworkers may practice generalization on a more subtle, micro level. How many people do you work with who think the root cause of most incidents is human error? Or somewhat more generously, human error, inadequate procedures and/or equipment malfunctions— but not the larger socio-technical system? Do people jump to conclusions based on an inadequate or incorrect categorization of a problem? Are categories, rather than facts, used as explanations? Are vivid examples used to over-glamorize alleged progress or over-dramatize poor outcomes?
The destiny instinct
“The destiny instinct is the idea that innate characteristics determine the destinies of people, countries, religions, or cultures.” (p. 158) Culture includes deep-seated beliefs, where feelings can be disguised as facts. Does your work culture assume that some people are naturally bad apples?
The single perspective instinct
This is preference for single causes and single solutions. It is the fundamental weakness of Safety I where the underlying attitude is that problems arise from individuals who need to be better controlled. Rosling advises us to “Beware of simple ideas and simple solutions. . . . Welcome complexity.” (p. 189) We agree.
The blame instinct
“The blame instinct is the instinct to find a clear, simple reason for why something bad has happened. . . . when things go wrong, it must be because of some bad individual with bad intentions. . . . This undermines our ability to solve the problem, or prevent it from happening again, . . . To understand most of the world’s significant problems we have to look beyond a guilty individual and to the system.” (p. 192) “Look for causes, not villains. When something goes wrong don’t look for an individual or a group to blame. Accept that bad things can happen without anyone intending them to. Instead spend your energy on understanding the multiple interacting causes, or system, that created the situation. Look for systems, not heroes.” (p. 204) We totally agree with Rosling’s endorsement of a systems approach.
The urgency instinct
“The call to action makes you think less critically, decide more quickly, and act now.” (p. 209) In a true emergency, people will fall back on their training (if any) and hope for the best. However, in most situations, you should seek more information. Beware of data that is relevant but inaccurate, or accurate but irrelevant. Be wary of predictions that fail to acknowledge that the future is uncertain.
Our Perspective
The series of decisions an organization makes is a visible artifact of its culture and its decision making process internalizes culture. Because of this linkage, we have long been interested in how organizations and individuals can make better decisions, where “better” means fact- and reality-based and consistent with the organization’s mission and espoused values.
We have reviewed many works that deal with decision making. This book adds value because it is based on the author’s research and observations around the world; it is not based on controlled studies in a laboratory or observations in a single organization. It uses very good graphics to illustrate various data sets, including changes, e.g., progress, over time.
Rosling believed “it has never been easier or more important for business leaders and employees to act on a fact-based worldview.” (p. 228) His book is engagingly written and easy to read. It is Rosling’s swan song; he died in 2017.
Bottom line: Rosling advocates for robust decision making, accurate mental models, and a systems approach. We like it.
* H. Rosling, O. Rosling and A.R. Rönnlund, Factfulness, 1st ed. ebook (New York: Flatiron, 2018).
Turn the Ship Around!* was written by a U.S. Navy officer who was assigned to command a submarine with a poor performance history. He adopted a management approach that was radically different from the traditional top-down, leader-follower, “I say, you do” Navy model for controlling people. The new captain’s primary method was to push decision making down to the lowest practical organizational levels; he supported his crew’s new authorities (and maintained control of the overall situation) with strategies to increase their competence and provide clarity on the organization’s purpose and goals.
Specific management practices were implemented or enhanced to support the overall approach. For example, decision making guidelines were developed and disseminated. Attaining goals was stressed over unconsciously following procedures. Crew members were instructed to “think out loud” before initiating action; this practice communicated intent and increased organizational resilience because it created opportunities for others to identify potential errors before they could occur and propagate. Pre-job briefs were changed from the supervisor reciting the procedure to asking participants questions about their roles and preparation.
As a result, several organizational characteristics that we have long promoted became more evident, including deferring to expertise (getting the most informed, capable people involved with a decision), increased trust, and a shared mental model of vision, purpose and organizational functioning.
As you can surmise, his approach worked. (If it hadn’t, Marquet would have had a foreshortened career and there would be no book.) All significant operational and personnel metrics improved under his command. His subordinates and other crew members became highly promotable. Importantly, the boat’s performance continued at a high level after he completed his tour; in other words, he established a system for success that could live on without his personal involvement.
Our Perspective
This book provides a sharp contrast to nuclear industry folklore that promotes strong, omniscient leadership as the answer to every problem situation. Marquet did not act out the role of the lone hero, instead he built a management system that created superior performance while he was in command and after he moved on. There can be valuable lessons here for nuclear managers but one has to appreciate the particular requirements for undertaking this type of approach.
The manager’s attitude
You have to be willing to share some (maybe a lot) of your authority with your subordinates, their subordinates and so forth on down the line while still being held to account by your bosses for your unit’s performance. Not everyone can do this. It requires faith in the new system and your people and a certain detachment from short-term concerns about your own career. You also need to have sufficient self-awareness to learn from mistakes as you move forward and recognize when you are failing to walk the talk with your subordinates.
In Marquet’s case, there were two important precursors to his grand experiment. First, he had seen on previous assignments how demoralizing top-down micromanagement could be vs. how liberating and motivating it was for him (as a subordinate officer) to actually be allowed to make decisions. Second, he had been training for a year on how to command a sub of a design different from the boat to which he was eventually assigned; he couldn’t go in and micromanage everyone from the get-go, he didn’t have sufficient technical knowledge.
The work environment
Marquet had one tremendous advantage: from a social perspective, a submarine is largely a self-contained world. He did not have to worry about what people in the department next door were doing; he only had to get his remote boss to go along with his plan. If you’re a nuclear plant department head and you want to adopt this approach but the rest of the organization runs top-down, it may be rough sledding unless you do lots of prep work to educate your superiors and get them to support you, perhaps for a pilot or trial project.
The book is easy reading, with short chapters, lots of illustrative examples (including some interesting information on how the Navy and nuclear submarines work), sufficient how-to lists, and discussion questions at the end of chapters. Marquet did not invent his approach or techniques out of thin air. As an example, some of his ideas and prescriptions, including rejecting the traditional Navy top-down leadership model, setting clear goals, providing principles for guiding decision making, enforcing reflection after making mistakes, giving people tools and advantages but holding them accountable, and culling people who can’t get with the program** are similar to points in Ray Dalio’s Principles, which we reviewed on April 17, 2018. This is not surprising. Effective, self-aware leaders should share some common managerial insights.
Bottom line: Read this book to see a real-world example of how authentic employee empowerment can work.
* L.D. Marquet, Turn the Ship Around! (New York: Penguin, 2012). This book was recommended to us by a Safetymatters reader. Please contact us if you have any material you would like us to review.
** People have different levels of appetite for empowerment or other forms of participatory management. Not everyone wants to be fully empowered, highly self-motivated or expected to show lots of initiative. You may end up with employees who never buy into your new program and, in the worst case, you won’t be allowed to get rid of them.
Sidney Dekker recently revisited* some interesting research he led at a large health care authority. The authority’s track record was not atypical for health care: 1 out of 13 (7%) patients was hurt in the process of receiving care. The authority investigated the problem cases and identified a familiar cluster of negative factors, including workarounds, shortcuts, violations, guidelines not followed, errors and miscalculations—the list goes on. The interventions will also be familiar to you—identify who did what wrong, add more rules, try harder and get rid of bad apples—but were not reducing the adverse event rate.
Dekker’s team took a different perspective and looked at the 93% of patients who were not harmed. What was going on in their cases? To their surprise, the team found the same factors: workarounds, shortcuts, violations, guidelines not followed, errors and miscalculations, etc.**
Dekker uses this research to highlight a key difference between the traditional view of safety management, Safety I, and the more contemporary view, Safety II. At its heart, Safety I believes the source of problems lies with the individual so interventions focus on ways to make the individual’s work behavior more reliable, i.e., less likely to deviate from the idealized form specified by work designers. Safety I ignores the fact that the same imperfections exist in work with both successful and problematic outcomes.
In contrast, Safety II sees the source of problems in the system, the dynamic combination of technology, environmental factors, organizational aspects, and individual cognition and choices. Referencing the work of Diane Vaughan, Dekker says “the interior life of organizations is always messy, only partially well-coordinated and full of adaptations, nuances, sacrifices and work that is done in ways that is quite different from any idealized image of it.”
Revisiting the data revealed that the work with good outcomes was different. This work had more positive characteristics, including diversity of professional opinion and the possibility to voice dissent, keeping the discussion on risk alive and not taking past success as a guarantee for safety, deference to proven expertise, widely held authority to say “stop,” and pride of workmanship. As you know, these are important characteristics of a strong safety culture.
Our Perspective
Dekker’s essay is a good introduction to the differences between Safety I and Safety II thinking, most importantly their differing mental models of the way work is actually performed in organizations. In Safety I, the root cause of imperfect results is the individual and constant efforts are necessary (e.g., training, monitoring, leadership, discipline) to create and maintain the individual’s compliance with work as designed. In Safety II, normal system functioning leads to mostly good and occasionally bad results. The focus of Safety II interventions should be on activities that increase individual capacity to affect system performance and/or increase system robustness, i.e., error tolerance and an increased chance of recovery when errors occur.
If one applies Safety I thinking to a “bad” outcome then the most likely result from an effective intervention is that the exact same problem will not happen again. This thinking sustains a robust cottage industry in root-cause analysis because new problems will always arise and no changes are made to the system itself.
We like Dekker’s (and Vaughan’s) work and have reported on it several times in Safetymatters (click on the Dekker and Vaughan labels to bring up related posts). We have been emphasizing some of the same points, especially the need for a systems view, since we started Safetymatters almost ten years ago.
Individual Exercise: Again drawing on Vaughan, Dekker says “there is often no discernable difference between the organization that is about to have an accident or adverse event, and the one that won’t, or the one that just had one.” Look around your organization and review your career experience; is that true?
* S. Dekker, “Why Do Things Go Right?,” SafetyDifferently website (Sept. 28, 2018). Retrieved Oct. 25, 2018.
** This is actually rational. People operate on feedback and if the shortcuts, workarounds and disregarding the guidelines did not lead to acceptable (or at least tolerable) results most of the time, folks would stop using them.
