Every day the bulk of the human population wakes up and spends a large portion of their waking hours going to work. Some of us are privileged to do work that we want to do, that provides meaning to us. As psychologist Barry Schwartz points out, not everyone is so lucky. In a fairly recent TED talk and subsequent book he offers a blistering critique of how we think about work, particularly in capitalistic societies. Schwartz’s point highlights how in the process of designing work processes to maximize efficiency we may have made assumptions about human nature that are not only false, but may be inherently dehumanizing. We design work that is designed without consideration of meaning with assumption that people will only work for the money and then are surprised when we have uncommitted workforces.
Hinted at in the TED talk and dealt with in more detail in the book, Schwartz makes the point that our theories of people are not value neutral. When we theorize about geological or cosmic forces these forces are not affected. Whether our theories are right or wrong, physics is physics and our abstractions make no change in nature. However, when dealing with living systems, people in particular, when we develop a theory it has the potential to dramatically affect the behavior of that system. In a process that seems similar to the concept of enactment that Weick speaks of, when we tell people how they are it changes how they are. It reminds me of something Erik Hollnagel mentioned to me at a recent conference – in social science when you are trying to understand them, they are also trying to understand you.
Reflecting on Schwartz’s message, I can’t help but think that we in safety have so much to learn here. We design work processes designed to protect workers based on a worldview that we rarely reflect on and in the process we create self-fulfilling prophecies that serve no purpose except to confirm that worldview. For example, when we see people as untrustworthy and as a problem to control, we design systems based on this worldview – rules, procedures, zero tolerance rules, incentive programs, behavior-based safety. Although intended to help workers be “safe”, none of this is designed to help workers do their jobs and often they simply make the work more difficult. As a result we see violations, sneaky behaviors (such as underreporting) and distrust. This confirms our initial suspicions, our theory has been confirmed and therefore the solution is simple – tighter controls. We must protect you, from you, in spite of you. The vicious cycle continues.
However, as damning as the above seems from the outside, we must remember that there is an inherent local rationality to it lest we fall into the trap of blaming safety professionals and managers for blaming workers. Rather, we must understand that the problem is not the people, but the system created based upon our false assumptions. For me, the most important take away from Schwartz’s message is that safety professionals and managers must remember that we are dealing with real people. Fathers. Mothers. Sons. Daughters. All with hopes, dreams, fears. All looking to live a life that means something to them. None wanting to get hurt or to hurt others. All with the ability to anticipate the desires of the organization and adapt accordingly.
As we intervene in our organizations, we must do so with humility. Everything we do will engender a response and those responses will create more responses, reverberating throughout the organization, often in unforeseeable ways. But our worldview, our own theories may blind us to this complexity. Instead, we may see only what we want to see.
The easy answer to this problem is a change in perspective. Unfortunately, this is not as easy as it sounds, because the perspectives we and others have often influence us pre-rationally in ways that we don’t really understand. This means we may not even have the opportunity or ability to completely change our perspective on our own.
Perhaps a better approach is to put ourselves in a position where our perspective can change naturally rather than trying to force the change ourselves. Identify the perspective you’d like to see and get into that environment. I don’t mean this figuratively. I mean literally get into those environments where you can see the perspective you’d like to see.
For example, I was recently speaking with a safety manager at a public works organization and I asked her about some of the keys to the success the organization has had despite significant resource challenges. She pointed to the movement of her department’s office to be in the same location as where her employees dispatched from and having her department’s work hours moved to be same as the workers’ hours. Something she said resonated with me. “We see each other in the parking lot each morning,” she said, “we ask about each others’ kids.” Something as trivial as being forced to work in the same location and time as the ones they were supposed to serve was identified as a key factor in being successful despite an otherwise problematic working environment. And not because the safety people could keep a stern watch on the workers to make sure they followed the rules, but because it helped them develop relationships.
Humans are inherently relational – when put into situations where we must interact with others we naturally develop relationships. Certainly if you know someone on a personal level you are more likely to see their perspective and understand how your actions affect them than if you are dealing with strangers.
Not all of us work in organizations where this is possible though. Sometimes our organizations are too big or too spread out to personally interact with workers. Other options are still available to us. You could regularly have “Days in the Life Of” events where you work side-by-side with workers, or you could conduct “blackout periods” where you shut off distractions and learn about normal work.
Other alternatives methods to put yourself into a situation or environment where you can evolve your perspective may be out there (perhaps you can suggest some!). But if we cannot put ourselves into those environments where our perspectives can shift we must tread carefully and be wary of the assumptions that underpin any interventions we recommend in our organizations. In those situations we maneuver with significant blindspots. Unfortunately, as Schwartz points out, the workers are often the ones who suffer in those situations.
Beautifully written Ron.
Reminds me of a discussion a family therapy colleague related to me, between talk and action approaches. The talk therapists had families talk out their problems, in therapy session, ad infinitum. The action group did things like “you must eat dinner together 3 times a week — I don’t care if anyone talks, just sit down and eat together 3 times a week”. Action in general worked better.
There’s a link here to the Cartesian fallacy of mind-body separation that’s too much to get into.
I don’t see the link, Bob.
Where’s the link?
Good work Ron!
“Every adverse consequence results, in part, from dysfunctional relationships among human beings?”
“Every adverse consequence results, in part, from dysfunctional relationships among organizations and organizational units?”
Not sure if dysfunctional applies Bill. Dysfunctional implies outside the norm or in an abnormal manner etc.
Although a failure has occurred because someone or an organisation zigged instead of zagged doesnt make it abnormal, or out of the ordinary. Most disaters are committed through acceptable or considered normal functions, best practices or within agreeed parameters etc. being applied.
They only become dysfunctional if they act outside what is at the time considered normal, accepted or within certain parameters or a socialpolitical context.
Safety among many things is considered dysfunctional as many safety perspectives, practices or recommendations lie outside what is considered acceptable or the normal way to do business etc. by most and also involve certain parameters and considered variables such as cost, acceptable practices, human dynamics or perspectives etc.
However i understand your point, it,s just that what is considered normal from a particular perspective is whether something is really dysfunctional or not.
Abnormal and dysfunctional overlap. Abnormal and dysfunctional are not mutually exclusive.
The Challenger Accident gave us the term “normalization of deviance.”
The term “dysfunctional culture” captures the confluence of normality and dysfunctionality.
Envision a two-by-two matrix of normal-abnormal versus functional-dysfunctional.
That matrix can be populated respectively with organizations, programs, processes, procedures, practices, cultures, conditions, behaviors, actions, and inactions.
The causation of most harm from organizational accidents includes the usual, normal, and accepted business practices of the organization.
Please provide links to counter-examples and/or examples.
The cultures of FedEx and UPS would fall into the normal/ functional box.
The environmental compliance program at VW would fall into the normal/ dysfunctional box when considered over time.
A useful role of a safety professional is to prevent the dysfunctional from becoming the normal, as happened at FEMA (Katrina), BP (Macondo, Texas City), Union Carbide (Bhopal), GermanWings Pilot Fitness for Duty, etc.
Many safety professionals lead lives of quiet desperation, having the capability to see that the normal is dysfunctional while lacking the capability to make a difference.
Roger Boisjolly is their patron saint.
The cockpit of Air France 447 in the final two minutes is their recurring nightmare.
There are no unreceptive audiences, but only ineffective messages.
A word to the wise is deficient.
Roger Boisjoly is considered dysfunctional as he was not in the majority or followed the considered norm. Further on devulging his evidence in the presidental commission, although his view was vindicated, he was ostracised and was shunned by his collegues etc. https://en.m.wikipedia.org/wiki/Roger_Boisjoly
The problem with the word dysfunctional is that it doesnt matter if your view is correct, if its considered abnormal by a consensus or majority within that system or environment for whatever reason it makes you or your view dysfunctional.
dys·func·tion (dĭs-fŭngk′shən)
n.
1. Abnormal or impaired functioning of a bodily system or organ.
2. Failure to achieve or sustain a behavioral norm or expected condition, as in a social relationship.
http://www.thefreedictionary.com/dysfunctional
Every engineer should be drilled on The First Law of Business:
Production minus sales equals scrap.
(It doesn’t matter how important your message is if you don’t convince the right people.)
Nicely put Ron! I also recently read the book and I also thought that the message is profound.
And about changing perspectives: fairly basic is that you have to try to speak to people about their work in their own daily environment. In that way you see/feel/hear/smell the same as the operator and he can then reflect upon his work in his natural habitat.
Recently, I was talking to someone about the way he uses his IT system and in this case we did that from a piece of paper with the possible new design of system and in an office. He just couldn’t remember the normal steps he takes because it is so routine for him. In the office environment it is very difficult to get good intell about work as done (unless the office IS the normal daily workplace of course ;)).
Eloquently written Ron. In reading it, I can’t help but feel how unfortunate it is, and how far into the weeds we have gotten, when we as professionals have to teach, cajole, shape, influence and to a large extent fight for something that “should be” so painfully self-evident. I sometimes think there’s a resistance to attach a dollar value with safety simply because we don’t really want to learn how far we have devalued each other. Thanks again for this important message Ron. Well done!
Problems worthy of attack
Prove their worth by fighting back.
Piet Hein
http://www.phys.ufl.edu/~thorn/grooks.html
I enjoyed your writing and the Barry Schwartz video, now looking forward to the book. I recently taught a class for firefighters that included systems thinking and how Donella Meadows recommends that we stop blaming people for their behaviors and look at the systems that we have in place that creates those behaviors. We created those systems so we can alter, modify, adjust and even replace them. People just need to see a viable alternative!
An easy and valuable read on a viable alternative is The Appreciative Organization, published in 2008 by the Taos Institute (ISBN-10: 0-9712312-7-3). It describes many ways we could work toward the implementation of our New View and give us the results we want!
Keep writing and living the life of a New View advocate. You’re doing a good work!
I wouldn’t say that our way of thinking, whether it be about work or anything else in the world, is broken, but our way of thinking is just merely human. Its nearly impossible to take on a new perspective if immersed in an environment when one already has a view based on preconceived ideas, knowledge, values and anything else that makes up their subconscious being. Bill highlights normalization of issues, but this is essentially collective habituation. So if one was to immerse themselves in an environment of collective habituation of poor work organisation or leadership, they too will probably normalize or leave, and problem still exists. However, thinking can be changed if thinking is understood. Daniel Kahneman theorizes two different systems of thinking, but just for the purpose of commenting here (and you probably only know this), most people will just use system 1 thinking because its easier, and this fast, automatic, frequent, emotional, stereotypical, subconscious level of thinking can still occur when put into a different environment (i.e they will already have a perspective before they even get in there and will be reluctant to change). Only when an environment is established which enables and facilitates system 2 thinking (slow, effortful, infrequent, logical, calculating, conscious) that a change of perspective may occur.
Interesting perspective Shane. As I read your post I was reminded of the limitations we all face within the confines of our own bounded rationality coupled with the influences of our own biases, heuristics and limitations. There’s a challenge to learning to know when we don’t know. A bit of a conundrum as I see it but, on the plus side, if we stay the course and heighten awareness within the audiences available to us, we just might be able to initiate something of a paradigm shift. Thanks for sharing your perspective Shane.
Ron,
In advancing our cause we should guard our integrity.
“The greatest lack of integrity is to have a more relaxed standard of logic and evidence for that which one likes to believe than for that which one likes to disbelieve.”
Bill Corcoran
Bill,
Not sure if this was your intent or not but I get the sense you’re challenging my integrity which, in this forum, is both offensive and inappropriate. Having been around these discussions for a while now, you seem to be far more inclined to provide individual cryptic comment than to take position on the topic being discussed.
Knowledge is to be effective Bill and, for me, this was not effective.
Ron Butcher
Sorry.
I’m pointing out a frequent issue of activists and advocates.
I see it often and it embarrasses me when my side does it.
I did not intend a personal challenge.
I have no grounds to doubt your integrity.
Please forgive my error.
Thanks ever so much.
Bill
“The true mystery of the world is the visible, not the invisible”.
Oscar Wilde
Irish dramatist, novelist, & poet (1854 – 1900)
I’ve been an avid follower of Barry Schwartz’s work for several years. His work on Practical Wisdom with Kenneth Sharpe was eye opening. In the book they acknowledge the need for both rules and incentives. But rules and incentives are not enough. They leave out something essential. It is what classical philosopher Aristotle called practical wisdom (his word was phronesis). Without this missing ingredient, neither rules (no matter how detailed and well monitored) nor incentives (no matter how clever) will be enough to solve the problems we face.
I sadly discovered over 20 years ago his latest criticism on designing work processes to maximize efficiency at the expense of people. It was called Business Process Reengineering. A ton of assumptions about human nature seemed right at that time because business was in a socio-technical systems thinking paradigm. It was Process supported by technology (IT) and, oh yeh, run by People we have to train. So Change Management was “bolted-on”. A couple of consequences? Downsizing and outsourcing.
BPR has morphed into BPM – Business Process Management with still a higher focus on IT and more powerful hardware and software. Examples: Big Data analytics that can predict injuries, online safety standards, SMS.
Maximizing efficiency is now Lean and we have Lean Safety being offered. I’m all for removing waste but against removing slack and buffers. Loose coupling, not tight, is critical in complex systems and high reliability organizations.
Yes, I’m concerned that they way think about work is broken. But I’m more concerned about the way we think about fixing work.
Gary,
I support what you said:
“Yes, I’m concerned that they way think about work is broken. But I’m more concerned about the way we think about fixing work.”
How should we think about fixing work?
What are some of the “first principles” we should use in the way we think about fixing work?
In the instance of Complex, High-Consequence Circumstance institutions, if the effort in Work Design is multi-disciplinary and represents the (genuine) collaboration of a modest surplus of relevant experience (i.e. no single point expertise vulnerabilities) then a practical forecast is that the expectations of work performance (i.e. “standards” of all types) will be navigable with respect to the collection of applicable goals.
At the sharp end, we can:
1) monitor how well our forecast proved supportive of actual performance and
2) observe the instances of avoidable rework (as distinguished from that which was truly unforeseeable.
We must look at portfolios of similar work and trends (including distribution spreads) over time if we are to give useful feedback to the process of Work Design.
Note that for service related work (as much as 75% of the US economy), avoidable rework is strongly correlated with customer satisfaction (both internal and external).
“Rework” got my attention.
“Rework” used to be one of the disposition choices for nonconformance reports (NCRs).
The others were “Scrap”, “Repair”, and “Use as is.”
The old NCR processes did not include determining the causation of the nonconformance.
When you say “rework” what do you mean?
What definitions are used by organizations that recognized the truth of your implied proposition that rework conflicts with customer satisfaction and take measures to eliminate reword?
A little rework: correction of my last posting.
“Rework” got my attention.
“Rework” used to be one of the disposition choices for nonconformance reports (NCRs).
The others were “Scrap”, “Repair”, and “Use as is.”
The old NCR processes did not include determining the causation of the nonconformance.
When you say “rework” what do you mean?
What definitions are used by organizations that recognized the truth of your implied proposition that rework conflicts with customer satisfaction and take measures to eliminate rework?
(The spell corrector made me do it. :<))
Dr. Bill,
This significant aspect of my suggestion is the need to focus on the “avoidable” not the “rework” per se. Thus I mean “rework” in the sense of something that must be done over after an earlier attempt to “meet the applicable standard.”
However, the insight involves the realization (or acknowledgement if you prefer) that some rework is “unavoidable.” In the design of work, it is important to take a stance (with a conceptual-based hypothesis) as to how much uncertainty might be encountered during work performance.
One example would be the conduct of electrical device (e.g. larger voltage breakers) troubleshooting and repair. There are controls put in place for purposes of investigation authorization, but in some instances the actual course to repair cannot be predicted with any confidence until the device in opened to inspection.
One early lesson for me was the observation in the shipyard of HY-80 experienced welders reinstalling a thick hull patch in HTS steel – it was weld, x-ray, grind and weld again for much longer (about 10 days as I recall) than was anticipated when the job was planned.
Theoretically, the duration of this work might have been shortened by more advanced weld practice; practically, only the local supervision could decide if it would be a lesson learned to take a different approach to such a situation in the future; there would be pros and cons in such a discussion.
There is always a matter of judgment by the planner and responsible supervisor and/or workers themselves in designing work with an eye toward unanticipated outcomes. In many instances there can be no absolute criteria for “do it right (i.e. to completed repair) the first time.”
However, my contention would be that overtime, an attentive planning department can gather some Figure of Merit type measures that are agreed upon instances of avoidable rework. There can be no axiomatic definition, but that doesn’t mean the recognition criteria for post delay binning can’t be created.
An example would be mustering in full anti-c’s at a work site only to discover that pre-planned tools are not available. The delay associated with that type of error can be counted (even if it’s not on the critical path of the schedule) and from the analysis of such delays, insights about systemic causes of avoidable rework can be hypothesized and validated.
What is initially identified as an Unanticipated Unwelcome Outcome might be turned in to a Welcome one because despite the rework, the new risk insight will save time and resources in the future – for this reversal of fortunes to happen there must be an institutional commitment on-going, not simply to increase efficiency in every instance, but to Minimize Avoidable Rework.
If we are going to reduce avoidable rework and measure our progress we need to be able to tell people what rework is, how to tell rework from other activities, and how to tell avoidable rework from unavoidable rework.
Where would I go to find that out?
If I constructed an “as done” Gantt Chart of a job done without rework and an “as done” Gantt Chart of the same job done with rework, would the differences between the two Gantt Charts be “rework?”
I contend that any reasonably conscientious worker knows exactly when they’ve managed to conjure up avoidable rework – you know it in your gut.
If people have the courage to talk among themselves, through their own embarrassment, to the point where they can accept it happens to everyone from time to time, then it is quite possible to move to the point where we provide each other some backup in the lead up to actual performance
That mutual commitment to treat each task in an Complex, High-Consequence Circumstance as worthy of that level of vigilance is the gist of any HRO I’ve ever been associated with; make the commitment then noticeable improvement will follow and the amazing thing is people will know where it come from and even develop a taste for it.
There is no need to “tell people” – as for Gannt Chart, take any bad project day you’ve ever had on a weekend at home and you’ll have no difficulty illustrating the difference. Like all things simple, it is a challenge to overcome some of our reservations about Facing Facts when we’re the “boss” who dropped the ball.
If rework is a “harmful event”, does the following apply to rework?
• Elementary Failures
An inescapable fact is that the competent investigation of every harmful event reveals that the causation of the harm includes the failure to apply elementary principles of design , human factors , human behavior technology, engineering , science, operations, communications, administration , quality , regulatory compliance, and/or management. Often there is a contemptuous/ dismissive/ arrogant/ ignorant disregard for even needing to know what these elementary principles are, much less flowing them down to where they might need to be applied.
It is seemingly a brand of dangerous Idealism to conclude that each circumstance of rework is a “harmful” event – that sounds like so much engineering tribalism to me.
I certainly don’t subscribe to the linear deterministic theory of “failure to apply…” That humans sometimes deal with their own shortcomings ungraciously – and that some individuals often are highly reactive that way, is what Hannah Arendt termed the Human Condition.
Human variability comes with the territory of Work Definition, it is like terrain and atmosphere, not a thing apart as in evil. I struggle to understand what is at stake in the instance where it is maintained that “requirements” are the be all and end all of Work Control.
Well said Bill. Thanks for your contributions and clarifications.
As the need for reliability or safety increases, so does the need for a supporting structure and process. Identify where the failures/deltas occur and institute a QA/QC check at those waypoints in the process. The purpose of the QA/QC should be both to identify errors and coach technical refinements to reduce future occurrences. The behaviors and observable characteristics of the process will shape the attitudes and influence assumptions about errors. We are all constrained by the local rationality of competitive markets and many institutionalized competitive workplaces. Those don’t typically lend themselves to an openness about errors or process flaws. At the end of the day, it takes the individual courage and maturity to recognize our individual human limitations and the commitment of an organization to the development of a just culture that encourages reporting and limits punishment in all its forms. It’s an imperfect world with lots of agendas. We have to remain mindful that the organization relies on the input and improvement of everyone of its membership.
Ron,
Thanks ever so much.
Do you have links to any examples that would help drive home your points?
• Acceptance/ Check Issues
An inescapable fact is that when harm occurs that checking was intended to prevent, the checking was not conducted as required or the requirements for acceptance were not adequate. Often this involves missing or inadequate acceptance criteria .
Sorry…as a lifetime practitioner I don’t have “links” to the lessons learned over the years through experience, observation and thoughtful consideration. My “point” was, and is, that it’s an imperfect world filled with competing objectives and personal agendas that tend to conflict with pursuits of the greater good. I believe (and please bold the word believe) that behavior and attitude are inextricably intertwined and mutually reinforcing. I believe (bold again) that Dr. Deming left some excellent guidance on the fallacy of trying to inspect quality into any process and I also believe that thoughtful inspection and supportive feedback enhance the effectiveness of the processes while encouraging and reinforcing individual growth. Cock-eyed optimism aside, I don’t believe people come to work to do a bad job or with the intent to cause harm. Perhaps we’ve lost sight of the Human in the resource but it’s unlikely that any organization will be reliable or sustainable without that human element.
When you get what you didn’t expect,
Think about what you didn’t inspect.
I think that when you get what you didn’t expect, you may want to consider that you’ve experienced a learning opportunity. The challenge of complexity is that we likely don’t know all the variables, synergies and interactions so to assume that we “should know” to a degree that we could inspect for the unknown seems extremely unlikely and a dead-end of exploration. Just my opinion.
“The mass of men lead lives of quiet desperation and die with their songs still in them.”
Henry David Thoreau
Forgive my ignorance on this one but I’m not following the applicability of Thoreau to this discussion. Is your assertion that a 19th century poet/philosopher who seldom left the boundaries of Concord, MA in his 47 years speaks for the modern workforce?
Ron,
Here’s a real live rework case.
What would your learning be?
https://youtu.be/AsPA3u7JSFQ
How about some more real life rework cases?
What are the specific lessons to be learned?
No thanks Bill. I was hoping for an answer to my question about your reference to Thoreau but recognize that isn’t likely to happen. I think we’re far enough into the weeds away from the beautifully written original posting that cessation is in order.
“The mass of men lead lives of quiet desperation and die with their songs still in them.”
Henry David Thoreau
From actual post-event interviews:
Many workers are working long hours with long commutes.
Their diets don’t promote fitness-for-duty. They subsist on sugary drinks with caffeine.
They are not given adequate instructions, training, or supervision.
They are encouraged to be “team players”, i.e., don’t report safety and quality problems.
They truly lead lives of quiet desperation. The day’s top priority is to get to the end of the shift without getting in trouble with the boss.
How can we understand work unless we understand rework?
The need for rework was discovered too late.
http://www.texascityexplosion.com/site/headlines?post_id=76
Lessons to be learned:
Put it back together the way it was before you took it apart.
If you don’t keep track of the way you took it apart you can’t be sure you are putting it back together right.
If you don’t tell people that it matters how it gets put back together they will just make sure it goes back together.