Joe Estey started in a nuclear control room and spent four decades studying why capable people get hurt doing work they know well. His new book argues the answer lies less in attitude than in biology, and in who owns the risk before the job starts.
Joe Estey began his career as a chemical operator and lead control room operator in nuclear processing, then spent more than 40 years training and consulting with frontline workers, supervisors, and executives on human performance. His first book, The Tomorrow Tapestry: Life Woven on the Fabric of Change (2003), was about owning your career. His new book, Humans at Work: Lessons in Performance, co-written with his daughter Bethany Estey, features a brain on the cover and argues that our biology and neurology shape performance more than our psychology does. In this conversation with SafetyDifferently.com editor Chris McCullough, Joe talks about the grey zone between what’s written and what’s done, why accountability must be defined before work starts rather than after it goes wrong, and a four-question end-of-shift review one crew came to rely on.
The Grey Zone Nobody Talks About
Chris McCullough: Early in your career, you were a chemical operator and a lead control room operator in nuclear processing. That sounds heavy. What does a control room operator know about error that most safety managers never learn?
Joe Estey: Well, that’s excellent. Mainly, the system has to account for the errors that will be made in the process. Even though an organization spends countless hours and money designing a quote-unquote perfect system, we all know the designer always leaves something out that someone like me has to fill in. The way they see it working isn’t how it’s actually going to work when chaotic moments occur.
So the control room operator has to know exactly what their responsibilities are within their limits and training, what they can respond to, and what falls outside their responsibility and requires help. It’s about the defined accountability in our training, where they tell us, “You have this much discretion here, and you have no discretion in that area.” But then there’s an area they don’t think about: the grey zone, the area nobody addressed when they wrote those two definitions. That’s where a control room operator has to use their discretion.
Chris: So here’s the blue line, here’s the black line, and here’s what’s in between.
Joe: That’s right. Exactly. And curiously, we talk about the blue line, but we don’t talk about who created the black line. The black line has an origin. That’s one of the discoveries I’ve made recently in my work. We don’t talk about certain things that are undiscussable, like who owns the risk and who accepts it. Are we building greater controls? Are we trying to build greater capacity? People are afraid to talk about how much control is too much control, how much compliance is too much compliance, how much discretion is too much discretion. Until something happens, we don’t really address those issues.
Chris: I like it. Your bio lists the title “disaster reclamation specialist.” I like that. What was that work, and what did it leave you with?
Joe: Well, ultimately, I got my job as a nuclear chemical operator because we were restoring the house of the person who ended up hiring me, after a fire. We would get called in immediately after a disaster, sometimes even before the first responders showed up, to board up windows, barricade doors, and secure the property. Then, along with the insurance adjusters, if there were one, we would assess the extent of the damage, and I would have to personally consider how much effort it would take to restore the property to wholeness. In my particular situation, it wasn’t the structure. It was the personal artifacts: the oil paintings, the Persian rugs, the furniture, whatever it was. People wanted their property back.
From Psychology to Biology
Chris: Interesting. Thank you. Your first book, and I told you we’d get to this, was The Tomorrow Tapestry, back in 2003. This one carries the neuroscience of people on its cover. What changed in your thinking between them?
Joe: That’s a great question. I wrote The Tomorrow Tapestry: Life Woven on the Fabric of Change from a personal account of owning your career rather than having the organization dictate your career. When I was with Westinghouse Electric Corporation, I went from a first-line supervisor to director of certain operations in a fairly short time because I believed I could find holes in the organization people weren’t aware of and fill them. They didn’t know they needed someone doing that. They didn’t realize they had an issue there. So I created about five job titles that didn’t exist in HR and helped fill those roles as I left the organization.
It wasn’t enough for me to plug the hole. If I created a dependency and not a legacy, I wasn’t doing them a favour. The goal was to find the hole, fill it, grow somebody into it, and then leave. So The Tomorrow Tapestry is about being an entrepreneurial employee who owns your position and doesn’t let the company dictate it. The rules for success and mobility were in there. A lot of psychology, a lot of motivation, a lot of inspiration.
That changed when I started realizing how much hard physical science goes into our performance. Through my studies of the bioelectric chemistry of neuroscience, how our brains function, and how our senses dictate what we do, I began to realize it’s less about psychology and more about biology and neurology.
We give far too much credit to how our heart feels instead of how our brain thinks. When a safety person sees somebody do something, they usually go with attitude and motivation first. They default to “they must not have cared enough,” or “they need to care about it differently.” The reality is, whatever they were doing at the time, their senses spoke to them, and the senses don’t come from the heart. They come from the head. The reason the brain is on the cover is that I’ve turned a new leaf. I believe our biology, more than our psychology, gets us into trouble and lets us succeed.
Chris: Interesting. It reminds me of something somebody once told me about the difference between skepticism and cynicism. Skepticism is questioning the information and the reality around it. Cynicism is just questioning everybody else’s motivations, and it’s usually rather pejorative.
Joe: Interesting. I like that. I appreciate that.
Pit Nine: Everyone Could Have Thrown the Flag
Chris: The book opens with Pit Nine, and you said you were asked to evaluate it afterwards. Did that event change how you look at work, or were you already there?
Joe: I was there already. I was looking into a variety of things preventatively to help them align their processes, from policies to procedures to the practices they teach in training. So they had a consistent philosophical approach. The bottom line is that when you say you believe in something as an organization, there has to be a practice you teach people that supports it. You can’t just have a declared value up on a poster and then no practice out in the field.
Chris: You’re saying that posters aren’t necessarily an effective behaviour modification technique.
Joe: There could be evidence that says otherwise.
Chris: Hey, I’m just asking.
Joe: I know. So, if you walked in this organization’s front door and read their values and guiding principles, you’d think this is a robust, actively caring organization. They must do a lot to keep their people out of harm.
So, Pit Nine. This was a milestone-driven project where everybody, from the people at the end of the shovel to the people up on the observation deck, wanted it to succeed.
Chris: Sorry, I didn’t mean to interrupt, but just for our readers: what was Pit Nine? What kind of operation was this? I didn’t clarify, and I didn’t ask you to. Sorry.
Joe: I appreciate that. There are non-disclosure agreements, so I can’t get into the specifics, but I can give you the generalities. It’s a waste site. For years, we buried things until we could get back to them. That’s fairly typical in the nuclear processing world. We may not have the science right now to figure out what to do with something, so we put it in safe storage; when we do, we come back and do something with it.
They did a great job keeping this material contained, and then the day came when we had to get rid of it. It was a monumental task involving science, engineering and operations, and they sent a crew out there. Right away, nothing went to plan. The plan was to hold the pre-job meeting the day before. You’d show up the next day and hit it hard around 7:30 in the morning, and you’d be done around 3:30 in the afternoon, having removed an item, taken care of it, and shipped it safely to its final home. That was the goal: get it out of the dirt, put it in something, and ship it to its final home.
Well, when they got to work that morning, and safety people won’t be surprised by this, they found out they had caught three people the week before not wearing their seat belts around campus, even though 999 others were wearing theirs. Because three people weren’t, they shut down all activities and held an all-hands meeting from 7:30 to 9:00 about how important it is to wear seat belts.
When the crew got back to their trailers to talk about the job, they were an hour and a half behind schedule. They asked everybody, “Hey, do you guys want to keep going?” And they said, “Yeah, we’re here for a reason. Let’s keep going. We can get this done.” So they skipped some breaks and even went through lunch. Every time they did something right when they faced a challenge, they believed they could do the next thing right. So they kept going. Nobody stopped when they were unsure. Nobody paused.
When I say nobody, I mean the crew, the supervisor, the support staff, the safety person, and the C-suite executives who were there observing. In my interviews with them, everyone talked about why someone else didn’t raise the red flag, but everyone I interviewed had the opportunity to do so. It all came down to one person, the person in charge or the foreperson, who really should have had that responsibility. But of course, they were looking at the people watching them, wondering why they weren’t saying anything. That’s when I realized nobody had clearly defined who owns the risk, who manages it, and who has the right to declare it unacceptable.
Editor’s note: After reviewing this interview, Joe added a detail he had left out. The real incident at Pit Nine was a heat stroke that shut the job down late in the afternoon. Everyone agreed afterward that the work should have been stopped along the way, once the late start and the time pressure had squeezed the safety margins. He sees that, more than the deteriorated end caps, as the event that mattered.
Chris: So if it’s everybody’s responsibility, it’s nobody’s responsibility.
Joe: That’s a hundred percent right. Especially when you’re surrounded by people you believe are responsible.
Chris: The bystander effect. To follow up on that, the procedure said to stop work if the cap was, for example, deteriorated. But “deteriorated” had never been defined. So who owns that gap?
Joe: That’s exactly it, and that’s the secret: nobody discusses that. At what point is something just something we need to be aware of, versus something we need to react to? I find that happens a lot before an incident. The lines of action aren’t clearly drawn because people are sloganeering about what we ought to do: “Pay attention, and if you believe this is too risky, don’t do it.” Well, that’s a nice slogan. What’s the practice that would support it?
Chris: On that, the all-hands meeting for the seat belts. Did the workforce perceive that as more performative safety than real safety?
Joe: Oh, yeah. There’s no question. If you talk to people in the field, they’ll say, “You had three people not wearing their seat belts. Talk with those three people. I wear my seat belt every day. Why am I listening to an hour-and-a-half talk about why I should be doing something I’m already doing?”
Chris: Interesting. Also, they paid an award fee for starting on time, not for finishing.
Joe: That’s fairly typical. Much of the work this organization and others do is first-time, one-of-a-kind work. The goal is to perfect your performance and operation before you start, knowing you’ll pivot and adjust along the way and get better. The way you approach the job the first time probably isn’t the way you’re going to keep doing it. You do a proof of concept, a proof in practice, and later you say, “Well, you know what? There’s probably a better way.” It’s hard to reward adjustment with a deadline. You’re more likely to be able to do it with a start time.
Accountability Comes Before the Work
Chris: You’re right. Not to excuse poor decisions, and not to eliminate accountability: where is accountability in Pit Nine? The decision that came back was “proceed with caution.” Does someone actually have to answer for that?
Joe: Oh, that’s an excellent point. In my opinion, the risk owner ultimately has to answer for that. And answering for it means defining what it looks like before you start. For me, accountability isn’t something you do after the fact. It needs to be expressed and understood beforehand.
Chris: We’ve got Joe Estey’s bumper sticker.
Joe: I love it. For me, the guided adaptability somebody has on the job, as some folks call it, means you should have the adaptive ability, flexibility, and discretion you’ve been trained to use to make decisions. Because not everything will go according to Hoyle, and we can’t always stop and go back to the book to see what it says we can and can’t do. So there’s some adaptability, but it has to be guided. It has to be within a certain boundary, and I have to know that boundary before I start.
The Convenient Reason
Chris: A good reason, a convenient reason and the real reason. You list “the current issue helps justify our budget” as a convenient one. What’s the most common convenient reason you hear now?
Joe: “We’ve already been working on that. We have a budget and a subcommittee looking into that.” Let’s say something happens operationally, and you’ve got a safety team or a quality team that’s been funded to look at how to fix that kind of thing. Just about every problem that happens will then fit into it. They’ll force-fit it into the most convenient fix with current resources.
Chris: I like that. Sorry, go on, Joe. This is awesome.
Joe: And I wish I had thought of that. Richard Feynman, when he was called in to work with the Rogers Commission on the Challenger, faced exactly that. He came in open-minded and just wanted to know what happened. But the folks he talked to on the very first day had already closed their minds. They said, “We already know what happened. The engine turbines had some cracks, and we’ve had a group studying that, so we already have budget for fixing those kinds of cracks. There’s really no reason for you to be here.” That was a convenient reason, because they already had funding.
Chris: It’s kind of like when the root cause is a lack of training. We determined on Wednesday that the problem is a lack of training, and, what do you know, we’ve got training booked on Thursday anyway.
Joe: You got it. That’s convenient. Very convenient. Or another good one: “Well, the person who had the problem already left. We got rid of him last week.” That was convenient.
Put the Checklist Aside
Chris: Oh, absolutely. To go in another direction, you say that the observation card teaches leaders to audit instead of learn. I like that. So what replaces it?
Joe: Now, that’s an excellent question. That is the number one error I see organizations make. They turn their managers into people who proctor and examine the field, when the field should teach them how the work gets done. So they go out and ask very academic questions: “Do you know the scope of work? Do you understand your hazards? What are your control points?” When they should be asking, “What about the work is making it more difficult to do? What can I learn from you that I don’t know about the work you do?”
A leader needs the heart of a learner, especially in safety. They’ve got to put the checklist aside and pick up the learning mantle. They’ve got to be the most curious person there, and willing to understand that the preferences people have for doing the work may not match their own preferences for how the work should be done. They have to be open to opinions that may contradict the training.
Just in Time, Not Just in Case
Chris: I like that. The control paradox: compliance replaced cognition. I like that. Give me a control that you watched get removed, and what happened to the work afterward.
Joe: Oh, excellent. There are so many examples. I worked with an organization that trained people during the readiness review, well ahead of when the actual job would take place. Eight months earlier, they tried to build muscle memory for what you’d do in that room when you started work. The room required very limited exposure to hazards, so you were going to be dressed to the hilt. Your dexterity and your peripheral vision were going to be very limited by the kind of PPE you were wearing.
But the training was based on somebody who wasn’t in that PPE and didn’t have those limits on dexterity and peripheral vision. So the mechanics of what you’d do in that room weren’t supported by the PPE that was eventually assigned when people got there. That happened because the training organization, which taught what you do when, never integrated its work with the safety organization, which ultimately prescribed the PPE.
So when people got into the room, it was a unique world they hadn’t been trained for. They immediately backed out and said, “Hey, this isn’t working. What can we do instead?” And the answer was, “Rather than relying on that training credit, let’s start doing mini pre-job meetings every time we do an evolution of work. Instead of relying on eight-month-old training, let’s get your mind where it needs to be just before you go into the room. Do something. Come back out. Let’s do it again. Let’s not act like everything you got trained in is enough for you to remember everything you need to do.” And that worked out very well. The craft and safety folks came up with it.
Chris: So just in time rather than just in case.
Joe: A great way to say it. Great way to say it. But you know, just in case was convenient. That’s why they did it.
Chris: We had training scheduled on Thursday.
Joe: Maybe they thought the jobs were going to go sooner than they did.
Chris: They always do. It doesn’t matter the industry. They always think it’s starting next week.
Joe: That’s right. And it’s eight months later.
When Safety Starts to Surveil
Chris: Yes. You use Air France 447 and the 737 MAX as examples of the control paradox. Automation has saved many lives. How does a leader know when capacity is keeping pace with the controls they’re adding?
Joe: You know, I wish I had the silver bullet answer for that. Sometimes you can see the challenge, but how do you help resolve it? In that case, for instance, somebody had to decide, even before any of this happened, who has the ultimate authority to call the shot. Do we listen to the onboard automation system, or the human on the ground? Do we trust our own intuition? Maybe both of those are wrong, and we’re right. In certain dynamic climates, it’s very difficult to learn which voice I should listen to now, because my indicators tell me one thing, and indicators are based on science, and human beings are based on intuition.
I think the big dilemma, control paradox-wise, right now, the one people struggle with most, in my experience, is that we know distractions and self-interruptions are today’s greatest challenge. We live in a world where we’re constantly distracted and called away from our attentive work, thinking about what just came in on our phone, or what’s going on at home, or what we have to say at the next meeting. So goal interference is our greatest challenge. I have something to do, and I’ll get distracted. I’m going to self-interrupt.
So a lot of companies are investing in new tech to see what your brain is doing when it’s doing it: biometric sensors, Muse headbands, smart bands, drivers who have to wear headbands so they pay careful attention to the roadway and can’t think about anything else. From a safety perspective, it’s great to automate the paying-attention process so people can focus on what they’re doing. From a human standpoint, it’s causing a great deal of difficulty, because what was meant to keep you from being distracted is now what distracts you most. Now you’re worried about being surveilled. We’ve gone from a world where safety supported us to one where safety surveils us.
That’s with drones and digital JSAs and sentry dogs. All kinds of good-intentioned devices are being made. The problem is that not everybody who’s going to benefit from them sees them as good intentions.
Chris: What would we say about paving and roads?
Joe: I’d love to hear that one. I’d love to hear that.
Chris: The road to hell is paved with good intentions.
Joe: That’s it. That’s right. That’s right.
The Brain Runs on a Budget
Chris: We’ve got some assumptions in the book about how the brain works: the brain is a prediction engine, teachers over learners, fires together, wires together. What is one neuroscience claim in this book that you’d defend in front of a neuroscientist, and what does it change on the job site?
Joe: Oh, that’s an excellent one. We have an energy budget; the brain can only do so much at once. We have to stay in tune with what we predict and the limits of our senses. We can only see so much, hear so much, feel so much, calculate so much. The brain runs on about twenty watts, which is roughly twenty percent of the body’s total energy.
That means the energy is very limited, so we have to use it in a focused, beneficial way. We can’t let it compensate for the imperfections of a system that didn’t account for a person’s limited energy. Given the limits of our human energy budget, we have to plan the work in a way that addresses that rather than ignores it.
Giving somebody too much to do all at one time, for instance. I know that alarm flooding, as a control room operator, wasn’t the engineers’ concern. It’s a concern of the control room operators. Thirty-three alarms going off on a panel of a hundred and one doesn’t concern the people who built the system, because that’s what it’s supposed to do. But it concerns me when I look up at thirty-three alarms and don’t know which one I should respond to right now.
If you accept the fact that I’m human, and that neurologically I have a limited capacity, you’re going to colour-code certain alarms so that I know exactly which ones need to be addressed right away, rather than just saying, “Well, use your discretion and attend to the alarm you think is most important right now.”
Chris: Don’t we have a lot of history of aviation disasters where a crew was tapping a light in the cockpit, not knowing what it was?
Joe: That’s right. That’s right.
Chris: Oh my goodness. So, in your 2025 CHOLearning workshop, you talked about one universal human performance principle that all the others come from. What is it?
Joe: I believe what I was referring to is that, as biological creatures, we seek to conserve energy. Everything we do is the conservation of energy. When you look at all the other principles, they tie into how we use energy, when we misuse it, and when we don’t apply it properly.
So, error is normal, but consequences are by design. That means that, given my limited energy, I won’t see everything I need to see, and I won’t be able to react to everything I predicted. So we build error-tolerant systems that account for the limitations of a limited energy budget.
Blame fixes nothing because it explains nothing. What explains it is the context I’m working in. My performance is influenced by a variety of things, like distractions, self-interruptions, the predictions I’m making, and the reality I’m facing. So learning about those before I walk into them is vital. How the organization or its leaders respond will tell me how to react, respond, and predict next time. But it all comes back to this: I have limited capacity, and systems have to be designed with that in mind.
From Root Cause to Learning
Chris: Staying with CHOLearning: it used to be called HPRCT, Human Performance, Root Cause and Trending. Now “root cause” is gone from the name. Was that a statement? And what does the community still get wrong?
Joe: No. Okay, excellent. About a third of our members practise root cause, either as analysts or root cause consultants, and they teach us a lot. In fact, I spend a lot of time in causal analysis, but I spend just as much time in learning teams.
We changed because we used to be mainly nuclear about thirty-something years ago. Then it became nuclear and manufacturing. Then all of a sudden we had healthcare, and we had a regulatory agency. We have a broad range of folks interested in these topics. It felt too narrow to talk about human performance and root cause when it was actually a community wanting to learn.
So the decision was made on the board: “Hey, this is about learning.” Whether that comes from an analysis perspective, a learning team perspective, or a preventative perspective, it’s about what we know up front and what we can incorporate into our practices. Healthcare especially helps us with that, because you can’t always wait for a cause evaluation to determine why an operation went the wrong way. You have to have a system in place that tries to prevent as many of those as possible. That’s really why we changed the name: to broaden the audience.
The System as Designed Versus the System as Experienced
Chris: Okay, I like that. All right, on to the process of writing the book. The book ends with two lessons to apply. Ten chapters, two lessons. How did you get there, and what nearly made it as a third?
Joe: You know, I went immediately from writing the book to writing a visual graphic library. I’m a visual learner, so words on a page don’t speak to me nearly as much as the infographics we created to support the book. The visual graphic library covers science, system practice, case studies, and then what the future looks like. There are five volumes. So, to be honest, I’d have to go back and look at the last chapter to remember the two. There are a lot of lessons. Can you recall which two?
Chris: No, you’re calling me out, and I can’t remember either.
Joe: I can go back and re-brief them, but there’s been a lot of thought and study since then. The book took a while to write and a while to publish. If I were to summarize it, I’m fairly certain one of them was this. We’ve been working with the “work as planned” versus “work as performed” viewpoint for a long time: the black line and the blue line. But what we need to do is step back and ask about the system as designed versus the system as experienced.
In the book, we talk a great deal about incidents where it wasn’t necessarily the person at the controls, or the person making that immediate decision, who was in the blue line. The black line was written in a way that forced the blue line to be followed. The black line didn’t look at grey zones and performance-influencing factors.
One thing that clicked for me was when I was teaching about the anatomy of an event in a workshop one day, and the latent organizational weaknesses, from James Reason and other folks. Take a train derailment, for example. Somebody asked me, “Well, where do the latent organizational weaknesses come from?” Well, they come from what’s written in your policies, your goals, your processes. “Yeah, but where do those come from?” Well, I don’t know. They come from someone. Somebody wrote a policy. Somebody wrote a set of goals. Somebody decided what the metrics would be.
So I started pulling the string and looking at a variety of case studies. I realized we tend to start with what was missing organizationally, then talk about the individual actions influenced by it. But we don’t talk about the influences on those organizational issues. That’s what we named the performance-influencing factors.
That means that, as an organization, you and I will focus a lot on two of the nine PIFs. The PIFs include neurological, biological, psychophysiological, and psychosocial factors, all the way down to technical and motivational issues. When something happens, we look at the individual’s motivation and their technical capability and capacity. Was their equipment working? Did they understand how to use it? But we don’t look at the rest. We don’t look at the circadian rhythm of their shift operations. We don’t look at the biological limitations people have in actually performing that work. Even the colour of the room influences the senses if it’s a visual or acuity-type activity. But we don’t consider that.
So I think the lesson was that somebody in the organization, usually somebody who helps design the system, needs to be aware of where the grey zones are and where the PIFs are, and needs to account for them and give credit for them, so that latent conditions are less likely to happen.
Where Do You Draw the Line?
Chris: You have a bold line at the end of chapter seven: “Error is normal; consequences are by design.” Was that there from the first draft, or did it arrive after you’d written the control paradox examples? How did you come to it? Because that is bumper sticker gold.
Joe: Yeah, I appreciate that. I’ll never forget this. Three former Navy officers attended a workshop I was giving as I was writing the book. They had just come out of the Navy, and they believed their individual vigilance, and the way the Navy trained them, kept them from many of the problems they were now seeing as managers at the site. They couldn’t believe people at the site were operating that way, because they would never do that in the nuclear Navy. That’s what they told me.
And one of them said, “Where do we have to draw the line between how much we do to support our people and how much we just hold them accountable?” That struck me as odd. I thought, okay, so there’s a line you want to draw. We’ll give you this much support, but we’re not going to give you that much. So I asked him to clarify.
He said, “Well, for instance, why do we even have to separate certain containers? People should be forced to read the label. We have areas where we put alkalis in one colour and acids in another. It’s their responsibility to read the label. Why should we have to do that for them?” Which again caught me by surprise. I realized they had no understanding of error tolerance or the limits of our neurological condition.
So I said, “So in the Navy, was it all up to the person at the helm to make all the decisions?”
“Well, yeah. That person is responsible.”
“So they never got any training, help or support from the Pentagon, who helped the admirals, who helped the people?”
“Well, yeah. There’s a whole hierarchy of controls put in place. So the person at the helm really doesn’t make all those decisions. Billions of taxpayer dollars have gone into a system to train people, and that helps eliminate some of the errors that can be made along the way.”
The line is drawn with what the organization is willing to do. If they’re not willing to support those things, then the line has to be drawn with the individuals. So the bottom line is errors. “Would you admit errors are going to happen?”
“Oh, yeah.”
“So if errors happen, how much of a consequence do you want to endure? Does the Navy, for instance, build in defence in depth, so a single mistake doesn’t sink a ship?”
“Oh, yeah, yeah. We’ve got that.”
“See, that’s what we’re talking about. A person at the helm can make a mistake. So you design for the mistakes we’re willing to live with versus the ones we’re unwilling to live with, and that’s consequence being there by design.” Then they got it. They understood.
The First Story Is Almost Always Wrong
Chris: Back to the book. Chapter six says the first story is almost always wrong. So tell me about that, but also tell me what your first story was about this book, and how it was wrong.
Joe: Oh, okay, excellent. Very good. That’s very good. Nice. I like it.
Well, the first story is almost always wrong because, in the cause evaluations I do, or in what we used to call lessons learned teams and now call learning teams, we’re there to learn something about what happened, the conditions and the influences. Initially, people will state a conclusion rather than a condition. They’ll say something like, “Well, if so-and-so had been paying attention,” or “if we had used the tool this way.” Then when you start pulling the string, you realize that was just one of many conditions. It wasn’t the conclusive condition. Other things were also influencing the process. So the first story you hear is almost always wrong, and when you start to clarify it, you suddenly realize, wait, there’s a lot more going on.
For instance, in one of our workshops, we have an activity where people are given tokens, each representing a certain percentage of why an event happened. Your job is to throw them into the various cups (the individual, the organization, supervision, regulatory) based on where you think the greatest weight was. Not the accountability, but where you think the greatest weight was in influencing the event.
So, in a train derailment, a rail engineer was doing 80 miles an hour around a 30-mile-an-hour curve. The train derailed, and three people were killed. Where do you think the greatest weight was? Of course, the first story is that the guy was going 80 miles an hour, and he should have been going slower. Then you give them another piece. The sign for that curve was placed to the regulation for straight-line track, a mile away from the curve. But this was a high-speed train that required the sign to be three miles farther up the line so the operator could see it in time, except the FRA grandfathered that clause until after the train ran, when they could put the signs back where they belong. So does the weight shift, now that the sign wasn’t in the proper place? Every time you add another line of conditions from the story, it clarifies why that first story may not have been as accurate, or as important to the event, as you thought.
Chris: So what was your first story when you wrote your book, and what was wrong about it?
Joe: God, that’s a great question. And I know there was one. I know because I wrote it, rewrote it, and until my daughter got involved, it probably wouldn’t have been written. I’m just telling you right now. She was the taskmaster who said, “You’ve got to quit telling so many stories and changing them. You’ve got to go with the ones you’ve got.” I think the first story… I know there was one, or a couple. There were probably a couple. Oh boy, I’m telling you, that may have been the hardest question I’ve ever been asked. What was the first story?
Chris: Can you remember the young, naive Joe you were when you started writing this book?
Joe: Oh, man. Well, if I hadn’t written the first book, I think I would have been more naive. The first book gave me a twenty-three-year lull to really learn some lessons.
One thing Bethany helped me see is that the book was too heavily laden with science and not enough storytelling. And it still could be that way. When I first started, it was almost an encyclopedia of what I had learned over the past 12 or 13 years studying various sciences, integrating their thinking and trying to make some sense of it. So rather than separate thought bubbles coming from psychophysiology and neurology and neuroscience, it would all come together, like string theory. I was really trying to look at it academically.
Bethany came to me early on and said, “Dad, people need stories. They want your stories because they bring the science to life. They don’t really need the science.” What they need is a better understanding of who they are and how what you’re talking about applies to them. That really did change the nature of the book. I went from being more theoretical to, I hope, more storytelling.
Monday Morning
Chris: All right, so we’re going to get less theoretical now and look at how this can help practitioners in the field. A safety advisor reads this on a Friday. Monday morning, what’s the first thing they can do differently?
Joe: See themselves as a learner in every capacity. When they’re asked to review a work document, when they’re asked to do an observation and feedback, when they’re asked to participate in an incident evaluation, don’t go in there with your auditing book and your clipboard. Go in curious to understand why this may have happened, even if it doesn’t make sense to you. The logic doesn’t line up. So try to be less technical in your approach with people.
They may have violated the procedure by going too fast. It’s obvious they, quote-unquote, weren’t paying attention. But what were they paying attention to? What was capturing their mind at the time? It’s a neurological fallacy that people don’t pay attention. People pay attention 100 percent of the time. They just aren’t paying attention to what they need to pay attention to right now. The brain never shuts off its attention. The brain is always paying attention. What you’ve got to do is figure out what was capturing their attention at the time. You can’t do that if you expect them to pay attention to what you covered at the pre-job meeting, with no excuse. So you’ve got to go in as a learner.
The second is: don’t treat the error or near miss that just happened as a signal that something is flawed in your system. Look at it with gratefulness that something was revealed without a consequence. When somebody does something and it doesn’t cost you anything, don’t see it as dodging a bullet or as being lucky enough to get away with it. Study it to figure out how that could happen, given the process we built. Where in our process is it flawed? And don’t wait for an incident to make you create a corrective action that should have been preventative in the first place.
So those two things: be a learner, and figure out what that near miss or error is telling you as an outcome, not as a cause.
Study the Residue
Chris: You say don’t only read the policy; also study the residue. What do you mean by that, and how can a practitioner turn it into an exercise they can run in a week without anyone’s permission?
Joe: Oh, wow, that is excellent. That dovetails into what I did, and I think I mentioned it in the book, with schools and with organizations. Who we are as a culture depends on what our policy says and what we agree to. But the residue, the trash and the artifacts are all the things we say we care about but throw away.
So the residue is this: our policy might say we will always do these things, but the practices in the field show that we don’t always do them. In fact, we do some different things. The continuity of thought comes from when I once worked with the Department of Energy on a garbage study to see what our landfill waste tells us about our culture. If you ask people about our culture, they say one thing. But if you go out and see what we throw away, our trash tells us something entirely different.
So, as a safety person, your policy says this is what we’re going to measure: lost workday cases, DRs, IRs, DART, et cetera. If that’s true, then we’d spend our resources and management’s vision on trying to manage those things, reduce the numbers and improve performance. But then we go out and start to see that the residue really is that we aren’t doing that. We’re still practising “as long as the job gets done and we have a positive outcome, it must have been done the right way.” That’s really not what the policy said. The policy says you have a process for doing the job, and that process is how you do it the right way.
So if I were a safety person, I’d be looking at what the policy says about doing this work. Then I’d go out and study the treasure and the residue. What are we actually doing with the work? That’s connecting what the policy is generating to what the policy said. Either tell us the policy is good, and we should follow it, or that it’s not good because we can’t follow it.
Chris: It reminds me of Annie Duke’s book Thinking in Bets, where we all too often judge decisions by the outcome rather than by how good the reasoning was, given the information they had.
Joe: Excellent. Great. You said that better than I did.
Chris: Oh, well, I get lucky every once in a while.
Four Questions at the End of the Shift
Chris: You wrote about an Oregon operator who had four end-of-shift questions and a pre-job form at the end of the work package. For our readers, what were the four questions? And the main thing: why don’t ideas like this spread on their own, and what actually makes them stick?
Joe: Excellent. Great. I wish they would spread. I think it’s one of the most transformative practices there is. It can really change the current culture into a learning culture, one that not only learns but wants to learn.
Well, the four questions were these. I was there on a day when they were putting a transformer in place on a pad that had been laid previously, and I was surprised they were doing it. I didn’t know it would happen. I knew that every afternoon they did an end-of-task review, but I thought they just got together and said, “Okay, what went right? What went wrong?”
Instead, the lead control room operator, not the manager, asked the crew and the folks in the control room these questions.
“Today, when we did the work, what went as expected? Did we get what we wanted?” And everybody talked about it, and some people said, “Yeah, that went good, and that went good.”
Then: “When we did it, did anything happen that we didn’t expect?” “Well, yeah, we ran long through lunch, and we didn’t have anybody to cover somebody. We didn’t see that coming. We had a subcontractor who we thought was familiar with the area. He was familiar with a different area and got confused. There were some things we could have done better before we started.”
“Great. Now, if we do this job tomorrow in the same way, what would we change?” And they started talking about, “Well, we’d do this differently, and this.”
And then: “If we do it again tomorrow under the same conditions, what would we keep the same?” And they started talking about who was in what position, and that they wouldn’t change it.
And I thought, man, that’s one of the best post-job reviews I’ve seen, because it was a learning moment, and people were actually sharing information. When I walked out of the control room with a guy named Bider, their lead control room operator, he said, “We started doing this because we didn’t really have many events happening, and our plant manager, Josh, said, ‘We’re going to have something happen if we don’t learn when things aren’t happening.'”
Josh was sharp and understood the regulator paradox without ever having read about it. When you regulate your system down to zero but only learn when something goes wrong, you learn nothing at zero. They have a pretty regulated environment where things usually go right, so they forced themselves to learn by coming up with these four questions.
Bider said at first nobody wanted to do it, because it was just additional work. But after about the third day, people started opening up and realizing they needed to talk about things in that eight-to-nine-minute window. It wasn’t venting. It wasn’t a safety meeting where people laid out their issues. It directly reflected the work. They started realizing they could actually fix things, that this could really be the way to change things. He said, “When we started, we did this as a have-to. Now if we don’t do it, even on overtime, it doesn’t feel right. It’s become such a habit that we don’t feel right if we haven’t done it at the end of the day.”
Now, how do you get people to do this? I think, number one, somebody has to take the initiative to say, “It would be a great thing if we started doing this. How do you folks think we ought to do it?”
I’ve worked with a lot of safety folks, from linemen to central safety committees. They’ll propose an idea: “Our challenge is we’re having issues. Do you think we ought to go out and do something like a safety observation program?” That gives people permission not to. As a result, nobody’s going to come on board, because it’s always easier not to do something than to start.
The folks I’ve seen with the greatest success are line leaders who say, “I’ve looked into this, and doing this type of thing, or using this type of equipment, is a great thing. How do you folks think we ought to do it?” It blends leadership with consensus. When people have taken that approach, I’ve seen people get on board. When you tell people, “We’re going to start doing an observation program,” I’ve seen them not want to get on board.
Stop Asking Why
Chris: I love that. So what’s one question a safety professional should stop asking after an event, and what’s one they should start with?
Joe: Oh, that’s very good. Very good. “Why do you think that happened?” I think that’s the one they’ve got to stop asking, because “why” is always about intent. It’s about somebody’s actions and motivation. Instead: “How do you think that happened? What was going on at the time?” Bad questions include, “What didn’t you see that you wish you had seen?” Those are the kinds of questions nobody can answer anyway. So I’d ask fewer whys, and more hows and whats.
Chris: “If we continue to explain events as simply human error, we will continue to produce them.” A wonderful quote from you. What do you want a practitioner to carry out of the room with that?
Joe: Excellent. Error is a sign and an outcome. It is not a cause. It’s the thing telling you it’s possible for something to happen, because it just happened. So I’m going to use it as a neon sign that something is going on in the system, and I want to be willing to pull the string to figure out how we got to that point in the first place.
It wasn’t always motivation, and it wasn’t attitude, and it usually isn’t because somebody wanted to do it that way. It’s that there was something about the physical nature of the work, the way the work was designed and set up, the equipment, the way the system wanted a perfect person to do the job when perfect people weren’t going to start the job. So as a safety person, I’d want to use the outcome of an error to tell me what caused it. I’d want to go back, pull the string, and get back to where the issue really began.
Chris: Not what the error caused, but what caused the error.
Joe: Excellent. That’s exactly right.
The Rule Everybody Breaks
Chris: So is there anything we didn’t get to?
Joe: Wow, you did so many. I’ll tell you what, I appreciate the great line of questions, and I appreciate you digging into them. I had to dust off some things because we keep adding to our stories, and there have been many others since I finished the book. Once in a while, I go back and go, “Okay, I forgot about that one.” No, I think you covered the bases. For me, I’d hope people would start examining their system, not acting as if it’s perfect, but questioning it to see where it leads. Not address the imperfection of people.
I’ll share something with you. I was studying a case this morning, and maybe you can help me with it from your perspective. I was called in to look at an issue where everybody was surprised that a qualified individual walked into an area carrying an article he wasn’t allowed to carry without a safety review first. I can’t get into the details, but you’ve got a person holding something, and he comes into the room. For about two days, nobody in the room questioned it. Then someone asked about it, and everybody questioned him. Two days went by, and nobody’s radar went off. It’s fine. Then something triggered people to say, “Well, wait, does that even meet the definition of what’s allowed in this room?” Their managers and coworkers and everybody had put up with it and tolerated it for two days. Then, when somebody started asking, it became an issue.
So they asked me to come in and take a look. On the way to their site, I was driving the dutiful five miles over the speed limit. I’ll admit it. Maybe I was between 45 and 50, because the sign says 45. Everybody going to that site at start time was doing 65 to 75. No one was doing under 65. In my experience, 20 miles over the speed limit may be normal in certain parts of the country, but it’s not the norm everywhere. So I was wondering why everybody was comfortable doing 75 miles an hour. That’s incredibly over the speed limit.
I got to the site, and they told me I had to use a certain computer to access their information. When I logged on with my name, it said I was delinquent in nine training courses. And I said, “Am I really delinquent in nine training courses?” They said, “Yeah, you are, but we don’t really care about that kind of stuff.” I said, “Well, what do you mean you don’t care about that kind of stuff?” “Well, people put training requirements in, and when we don’t take them, it tells you you’re delinquent. But it’s not a necessary part of your job.”
So you have requirements that really aren’t requirements. “Well, they are requirements. You’ll see them in our requirements.” And I was thinking, the speed limit’s a requirement, the training requirement’s a requirement, but they’re all focused on this one individual who didn’t meet a requirement. Why? They live in a culture that constantly lets requirements go unheeded.
So here’s my thought from this morning. I took umbrage at people driving 65 to 75 miles an hour. Yet when I drove the road, I didn’t feel 45 was a realistic speed limit. Instead of questioning the people doing 65 to 75, I started to wonder. Maybe they’re doing 65 to 75 to get to work because 45 was somebody else’s requirement, and never really a good one. So I looked it up, and you can’t count the number of accidents on that roadway. There aren’t enough to even measure. Other roadways probably need a 45-mile-an-hour speed limit. Somebody arbitrarily, at some point, said 45. But every day people are demonstrating that 65 isn’t an allowable speed limit, but a livable one, because they aren’t having accidents.
It made me pause and think: Is this a realistic rule, and are people expected to violate it because it’s unrealistic? What’s to do? If I asked you that, what would you think about the situation?
Chris: Well, I’d always talk about what we call the second orientation. A new worker goes through their orientation. They’re in the classroom, they fill out the forms, they do everything they need to do. After that, they collect whatever equipment or PPE they need and head out into the workplace, where they meet people who’ve been there for quite some time. Maybe in the smoking area, maybe in the lunch area. And then it comes down to, “What is this really like?” That’s the second orientation. As somebody really wise once told me, the first story isn’t always right. It’s the second story.
The other thing it reminds me of… I was fiddling on my iPad, so once again, I’m paying attention, but always to something. It reminds me of one of my favourite books from many decades ago, The Greatest Management Principle in the World by Michael LeBoeuf, PhD. It comes down to this: whatever gets rewarded gets done.
Joe: Oh, that’s so true, man.
Chris: And if it’s rewarded by achieving some special status in the work group, or by some special attention, usually non-monetary, or even just by being left alone, those are the things that are going to get done. That’s what it reminds me of.
All right, Joe. I enjoyed this conversation very much. It was great hearing your stories, the first and the second, and it was great to hear about your book. Thank you very, very much for your time.
Joe: Thank you very much. It’s been a pleasure talking to you and getting to know you. I appreciate the effort you put into understanding the book before you spoke with me.
Chris: Well, “understanding” is a strong word, but I did enjoy it. Thank you for all you do.
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