A scientist spills a toxic chemical. His entire building is forced to shut down for a week to clean up. This ruins years of research.
An electrical engineer flips the wrong switch. A $100,000 transformer is destroyed within seconds.
A vice president of an electric power utility orders $1,500,000 of new customized bucket trucks. Due to a simple miscommunication, the trucks arrive missing an essential design feature that her line workers specifically requested. The trucks cannot be redesigned or returned.
All these events have actually happened.
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Unwanted errors & surprises
In high-hazard industries, unwanted errors and surprises can threaten safety, derail careers, and capsize company reputations overnight. According to one study, they lead us to waste over $37 billion each year.
Many leaders in high-hazard industries think that errors and surprises themselves are the problem. They treat every error as a defect -- every surprise as a failure. They try to eliminate errors and surprises by writing detailed rules and procedures, by enforcing strict compliance, and by increasing predictability and control.
This “Control-Based” approach was designed for factory work over 100 years ago. But today, in most 21st century workplaces, we depend more than ever on highly skilled, technical experts who constantly adapt to solve complex problems that keep changing as we work on them.
If your company is still trying to apply a horse-and-buggy approach in a hybrid car world, please understand it’s not their fault. Skepticism is healthy. Change is scary. And comfort is addictive.
But life evolves. And an increasing number of people are discovering a better approach to errors and surprises in complex, adaptive, high-hazard industries.
It’s a Learning-Based approach.
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How Sandy transformed a work culture of fear and silence
Imagine a company where 2,000+ scientists and technicians work on some of the most advanced projects in the nation. New energy sources. Vaccines. Supercomputing.
There’s enormous potential to help humanity, and serious risks too. Toxic chemicals. Radioactive liquids. Fragile, expensive superconductors.
For decades, leaders at that Laboratory relied on a Control-Based Approach to errors and incidents. Unfortunately, decades of rules, procedures and compliance accumulated to create a culture of fear.
Most employees were scared to admit that any project went anything other than 100% perfectly. And when something went wrong, the investigation that followed felt more like an “Inquisition.” The result? Most front-line technical experts tried to comply with increasingly frustrating rules and learned to not say anything unless they had no other choice. Leaders scratched their heads and wondered why employees were so disengaged. Countless insights, ideas, and innovations were lost forever.
I started teaching workshops for that Laboratory several times per month. One of the core concepts of the Learning-Based approach I teach is Psychological Safety. Instead of trying to “punish their way to excellence” by treating errors as failures, the world’s most successful High-Reliability Organizations (HROs) treat errors as opportunities to learn and improve their systems. So, if you want to reduce unwanted errors, then eliminate blame and finger-pointing to create more trust & Psychological Safety.
One of the students in an early workshop of mine was Sandy. She was the full-time, senior Investigator for that Laboratory. Sandy was an expert. For 20 years, she focused on understanding how to prevent complex incidents and errors in high-hazard industries. After my workshop, she told me that she had, “been looking for an approach like this her whole career.”
Still, Sandy knew that trying to change 30+ years of tradition in a highly-regulated workplace was an Olympic-level challenge. I worked with Sandy one-on-one several times over the next 2 years to show her practical methods like the Substitution Test, and After Action Reviews. Sandy ran dozens of low-cost, low-risk micro-experiments or “pilots” to find out what worked and what didn’t. I gave guidance and feedback when needed. Sandy attended more sessions of my workshop, each time, soaking in more nuances of core concepts like Psychological Safety, and the System View vs the Person View of errors. And in my workshops, Sandy told some powerful, real-world Success Stories that showed how the strategies I taught generated real-world results. Eventually, some of the regulators themselves attended my workshop. They gave reserved, but quite positive feedback. Word started to get around.
Skepticism turned to curiosity.
Curiosity turned to interest.
And fear changed to cautious optimism.
But the biggest challenge lay ahead.
Before Sandy started this journey, investigations were not only punitive, they were slow. They regularly burned up 3-6 months of time and effort before any results were published. By that time, most people’s memories of the original event, and their motivation to learn from it, had simply evaporated.
For two years, Sandy kept streamlining and simplifying her Event Debriefing process. She built trust by keeping the process 100% transparent to executives, regulators, other event debriefers, and every employee who she debriefed.
By the spring of 2020, Sandy had refined her process so well that she and her team reduced the average analysis time from 3-6 months to only thirty-two (32) days! And quality remained high. The new Event Debriefing process included thorough fact-checking, causal analysis, a review of human and organizational factors, and clear, actionable conclusions.
Over three years, Sandy’s persistence paid off. Her new non-punitive Event Debriefs generated far more useful ideas than the old blame-based investigations ever did. And the technical experts who Sandy debriefed were no longer scared to speak up. Now, about 5-7 times per year, front line teams voluntarily share with Sandy’s team priceless success stories and eye-opening cautionary tales. These “Check-ins” are rich with valuable insights, best practices, and lessons learned that seep throughout the culture, and spark powerful discussions that benefit the entire organization. No one is required to share these stories. Sandy simply created enough Psychological Safety throughout the culture that people now want to share far more than they ever did before.
In three years, Sandy transformed a heavily regulated work culture from one of fear and silence into one of trust, communication, and Psychological Safety.
I’m honored to have helped her.
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How Chris reduced his team’s technical errors by over 60%
If you ask a kid, “Where does electricity come from?” they’ll likely say, “Well, from that little white outlet in the wall, of course.” Chris knows that the real answer is a bit more complex. When I met Chris, he supervised 200 electric power utility substation relay technicians. These women & men spend every day installing, configuring, and maintaining the complex, hair-trigger relay systems that help keep electricity flowing to our little white outlets 24/7. Relay technicians often work alone, with constant distractions, in uncomfortably hot or cold environments. And they work on systems where even one error can shut down an entire power plant. Errors like that can waste more than $1 million per day.
Yes... this has actually happened.
Chris’ team of relay technicians are dedicated. They often work evenings or weekends to ensure our lights stay on even during harsh winter storms and muggy Virginia summers. But they are human. So sometimes they make errors. Chris created a great learning-based culture, and his people openly share their successes, close calls, and lessons learned. But the company’s 3+ million customers and the executives who ran the company always wanted more reliability.
So, I started teaching workshops for Chris’ team. Since I’m not a relay technician, nor an electrical engineer, I couldn't tell them exactly how to improve human reliability in their unique job. But as Peter Drucker used to say, “My ignorance may be my best asset.” In my workshops, I asked questions that sparked new, non-obvious conversations that veteran technicians rarely had anymore. I knew the research on errors, Human Performance and High-Reliability Organizations. I loved translating complex, hard-to-understand concepts into practical tools, and clear, concise “Kitchen English.” And I loved the seeing people's eyes widen when they came up with clever ideas on how to apply practical skills from my workshop to be more reliable and safe at work… and at home.
I led several advanced one-on-one discussions to help Chris apply some of the key concepts from our workshops into practice. Chris knew that a top-down, compliance-driven approach would have minimal results with his team. Instead, he figured that if he asked them what they would do, and how, and why, then together, they would come up with solutions that not even Chris nor I could think up on our own.
And they did.
Several months after Chris and his team
took my workshops, Chris showed me that they had run a few low-risk micro-experiments to pinpoint the specific Human Reliability techniques that worked best for them. They even created their own “Work Zone Marking Kit.” It included low-cost, cleverly designed cable marking clamps, brightly-colored placards, and other simple tools to minimize errors. It was designed by relay technicians, for relay technicians.
It was genius.
The improvements that Chris’s team conceived, created, and put into practice after taking my workshop helped them reduce their overall error rate by over 60% within three years. And they beamed with pride at conferences across the nation when they showed off the Work Zone Marking Kit they invented. Many of the human reliability solutions they created after taking my workshop are now standard practice in hundreds of electric power substations across the nation.
I’m proud to have helped them.
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How Katie Engaged her Technical Experts
Most corporate training stinks.
I worked in the Safety & Training department of a big power utility for a decade. A lot of corporate training is dry, abstract, and confusing. It seems to be designed to check the box on some compliance-based regulation on paper, not to inspire & educate living, breathing front-line technical experts who do the work every day. Many people call it “Death-by-Slideshow.”
Bad training does more than bore people. It wastes hundreds of millions of dollars every year. It lowers employee engagement. It creates confusion that winds up causing expensive errors and deadly incidents. And bad training creates a culture where employees say “whatever you do, don't pay attention to any of the training around here.”
That's not a learning culture.
It’s an anti-learning culture.
Meet Katie. She leads the Human Performance initiatives in her company. She develops systems and practices to ensure that thousands of front-line technical experts in her company do their jobs safely and reliably. Katie took my workshop on Human Reliability and liked it. But she needed to turn around and immediately use these new skills in her job and teach these skills to others. She did NOT want it to be “Death-by-Slideshow.” But she didn’t have a better alternative. That was the problem.
I worked with Katie and about 15 of her colleagues. I not only gave them some powerful Human Reliability strategies. I also showed them practical methods to:
Quickly build trust and Psychological Safety in a new team
Uncover hidden misunderstandings that people don’t even know they had
Use Board Plans to lead an engaging, yet structured discussions
I had Katie and her team immediately apply these methods in small group demo presentations and discussions. At first, they were reluctant to take the risk. But their comfort, confidence, and skill grew rapidly.
The results?
Learners are participating, asking questions and most of all, are actually retaining more information than before. Discovering how to elicit information from the audience was a big learning curve for me, but Jake gave me small practical tips that have made a BIG difference… Using this course design method not only helped me create a more dynamic presentation, but more importantly improved my ability to connect with my audience in a way that has increased information retention and engagement.
~ Katie Smith
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If you’re a leader in a high-hazard industry that relies on skilled, technical human expertise, then the Learning-Based approach may help you improve human reliability, safety and engagement just like it did for Sandy, Chris, and Katie.
To learn more, schedule a free call with me here.
~ Jake Mazulewicz, Ph.D.