Drift and weak signals are first precursors to failure. People are our best asset to detect them so I’m going to continue making the case to consciously invest in creating the conditions for people to speak up. It doesn’t happen by itself because people don’t usually voice disagreement when everyone else seems to agree with what is happening. That’s why leaders have to invest in communications training and make sure safety team members, supervisors and leads spend time on the floor talking to people forming the relationships to create a communication network. For more background on why people don’t speak up you may view my previous post.
Drift and Weak Signals
Scott Snook coined the term “practical drift” in his analysis of the friendly fire shoot down of two US Blackhawk helicopters in Iraq to identify the natural human tendency to drift from procedure when the connection to their value and purpose is lost. Karl Weick introduced “weak signals” into the safety vocabulary as a useful way to talk about the little signs like stress and body language that pick up the precursors to system failures. People are our best sensors to detect drift and weak signals.
There was a great story in the NY Times about how everyone knew something was wrong in the Macondo Well before the Gulf of Mexico explosion because Mr. Revette in the drill shack always rubbed his head in a certain way when he was under a lot of pressure from the “company.” If only the people that felt uneasy had been able to stop the process. People did express concerns, but the collective urgency to complete the well was much louder. Reading the article I felt people’s focus on getting the well in on time blinding everyone to the warning signals. Of course the warnings are all clear in hind sight, but in the moment breaking out of the group think trance was apparently impossible.
Can regulations and rules alone avert these tragedies?
A lot of people think that laws and regulations can prevent the types of disasters we’ve experienced in recent years such as the BP Gulf of Mexico explosion or the 2008 financial meltdown . We have very little evidence to support that. In fact tightening the rules often makes little difference such as the famous tax disincentive to put a cap on CEO salaries that the US passed in 1992. Salaries are higher than ever. BP put more than a hundred new procedures in place after the Texas Refinery explosion in 2005, only to re-experience disaster in 2010.
So doesn’t it make sense to enlist every member of the organization as a danger sensor? Doesn’t it make sense to educate every leader–person of influence in a potentially dangerous situation– to effectively solicit bad news? To ask, “What am I missing? What could go wrong?”
I am painfully aware that I am not mindful of my surroundings 24/7. I am ever so grateful when my car passenger’s warning helps me avoid a collision. As human nature would have it, however, we are not likely to take warnings about drift from procedure or weak signals from people we don’t know or whose competence we do not trust. That’s why I wrote the blog on how our beliefs in human nature affect safety performance. Our beliefs about someone determine whether or not we listen to them. A leader who does not trust himself and his or her people will not ask those questions. If they did it is doubtful they would listen. That’s what happened at the Fukushima Nuclear Power Plant in Japan.
Are you thinking we could procedurelize or demand that leaders ask these questions?
The nuclear industry has strict auditing and regulations surrounding listening to and addressing employee concerns. In fact, one of the worst findings a nuclear related facility can get is that management has created a “chilled work environment,” which means they are suppressing information about potential hazards. This and other heavily regulated processes have prevented disasters since the Chernobyl incident. That is until Fukushima, but that was an entirely different set of circumstances. Or was it? Apparently it was very similar to the Challenger incident. TEPCO Engineers told management the historical data on tsunamis indicated that the wall protecting the Fukushima plant was not high enough. They were ignored, and the rest is history. In fact their sister plant, Daini, did listen to their engineers and was built on higher ground. It also had a higher wall to address the tsunami issues and survived surprisingly well.
Rules and regulations will not suffice, we need to build relationships in our organizations
Especially in high hazard environments we cannot justify the continued lack of education we give our managers in communication and relationship-building skills. With what we know about a leader’s influence in shaping the culture there is no way to justify the continued one sided emphasis on financials and control mechanisms. This doesn’t just apply to safety, it applies to every aspect of the business including innovation and operational agility.
If I could wave a magic wand I would have every manager connect in a significant way with every member of their staff and so on down the line. Connecting means to truly get to know someone. Why? As our neuroscience research has shown, when people feel excluded, disrespected or unvalued they either go into high stress mode or withdraw from engagement altogether. This fear of exclusion relates of a study conducted by Google where they discovered that the most common predictor of team success was that team members were not exposed to ridicule. It takes courage to voice innovative ideas just as it does to voice weak signals and drift. Will people listen? What happens if you are wrong? Will people call you Chicken Little or a crackpot?
The fear of ridicule or ostracism is reduced in correlation with how well you know others and how well they know you. There is an excellent study documenting that people do not speak up when they do not feel know or accepted. I have seen this at work in my team building sessions. We do lifeline exercises where people reveal their happiest and most difficult life experiences. We do in depth resumes of experience where people can reveal the background for many of their perspectives and mental models. These exercises get the highest evaluation ratings because people feel connected and even admiring of what each team member brings to the table. After that the team members minimize teasing that can turn into ridicule and protect each other’s right to disagree.
This level of teamwork is not attainable by policy, rule or law. It is achieved through the leader’s willingness to reveal him or herself and create an environment where others can reveal themselves safely as well. The latter takes an investment in time and educational experiences.
Drift warning sign at a gravel road
