There's always Investigations Into What Went Wrong.
There should be Investigations Into What Went Right.
De-stigmatise 'Investigations' into simply a neutral process of gathering information.
Step 3: Assess the Information.
There's always Investigations Into What Went Wrong.
There should be Investigations Into What Went Right.
De-stigmatise 'Investigations' into simply a neutral process of gathering information.
Step 3: Assess the Information.
The New Yorker published an article describing how prosecutors of a high profile defendant in New York made a wrong decision about a key piece of evidence. Instead of firing the lawyers responsible as expected, the District Attorney decided to inquire into the organisational errors that had led to the mistake.
She knew the lawyers were skilled professionals. She knew that they had not intended to make the error. 'What factors, she wondered, had caused competent people to make bad choices?'
The DA introduced a procedure well known to the health care and air transport industries where objective searches for causes of error take precedence over blame and personal liability.
What emerged was a 'complicated web of events and conditions'. It was 'a classic organisational error: a series of small slip-ups that cascaded into an important mistake'.
The DA concluded that 'even in a busy office like hers, she needed to create a step in which everyone could pause during certain complex or high-profile cases and have someone else take a fresh look at the evidence.'
Mistakes are treated as inevitable in decision making as successes and thus there needs to be the capacity for dealing with, and learning from them in a blame-free environment.
Another study of errors in prosecutions culminated in several jurisdictions agreeing to each doing a systems analysis of a high-profile criminal justice failure.
'In every case, the horrendous legal accident turned out to have multiple causes embedded in the legal system. There was no single bad actor. '
One case convened a group of more than thirty people representing every agency that had made contact with a repeat offender. It was discovered that 'in almost every incident, the people who made decisions about the boy had not seen his larger pattern of violent behavior because they did not have access to his complete records, or did not see them.'
In another involving a police officer who had committed multiple acts of professional misconduct, the review was able to 'identify seemingly minor perturbations—poor performance evaluations, excessive medical leaves, discourtesy complaints—as warning signs for early intervention.'
One participant in the studies said that 'the idea is to create a culture of learning from error—to look at what went wrong, what factored in the cases, and how to change the system so that doesn’t keep happening.'
As an expert adviser from air transport safety stated:
'I stressed the fact that, although it’s perfectly reasonable to be angry at a staff member who makes a mistake, you’re deluding yourself if you think simply firing someone gets to the underlying cause of the error in the first place.'
A decision crashes to earth shortly after execution.
Shredded, mangled and smouldering plans and assumptions, and splintered egos lie strewn across the impact area, that is soon roped off with yellow and black tape marked with 'MISTAKE: DO NOT CROSS.'
Expectations - customers, clients, staff, connecting decision-makers - wait in vain to greet the decision at its scheduled outcome, then demand answers as to What Went Wrong and Who To Blame.
Connecting decisions are delayed across the decision making network, each spreading its own ripples of disruption.
Similar models of decisions are postponed or cancelled for fear that they share a fatal defect.
News of the failure affirms the procrastinators, cynics and equivocators' Fear of Trying. They celebrate by smugly busying themselves drafting agenda items for another meeting to discuss meeting formats.
A naive inquirer ducks under the 'MISTAKE' tape and picks her way past the debris of opinions, conjecture, conspiracies, myths, recriminations, and folklore scattered for as far as rumour and fear can exaggerate.
She's searching for the Decision Making Black Box.
Good decision making is a deliberate process of inquiry that advances you towards where you want to be.
The Process of Inquiry - the Five Steps to a Good Decision - is the 'Black Box' Data Flight Recorder equivalent in decision making.
In the aftermath of a decision, the decision maker can review each of the Five Steps that led to the decision, identify any element that may have contributed to the decision not having the expected outcome, and learn from it.
Did Step 1 allow enough time for the decision maker to purge herself of emotions that may have contaminated her decision?
Did Step 3 gather, verify and inquire into enough relevant information?
Did Step 5 identify all the people who might be affected by the decision and allow them to be heard on what the decision should be?
If the decision maker has the Five Steps she can review and learn from about why the decision didn't achieve the outcome she hoped for, then that knowledge can be applied to the next decision to make it more effective.
If, on the other hand, the decision is made like 45% of decisions are - by gut instinct or positional power, then there is no process of inquiry - no 'black box' - to learn from.
It should be routine for decision makers to review the decision making process to find out what can be learned from them and done differently next time, even when the decision did achieve the intended outcome.
It's Good Decision Making - a process that can reviewed and improved, and therefore advance us towards where we want to be.
'Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’
‘Truly I tell you, whatever you did not do for one of the least of these, you did not do for me.’
Then they will go away to eternal punishment, but the righteous to eternal life.
- The Gospel of Matthew
'If anyone has material possessions and sees his brother in need but has no pity on him, how can the love of God be in him? Dear children, let us not love with words or tongue but with actions and in truth.'
The Catholic Archdiocese of San Francisco decided to install sprinklers timed to soak and therefore deter homeless people from sleeping in the entranceways to its Cathedral.
The Archdiocese apologised in an unsigned media release.
It explained that the sprinklers were the solution to the 'problem' of 'needles, faces and other dangerous items' that were left in the 'hidden doorways' to the Cathedral.
The idea came from the use of sprinklers in 'the Financial District' as a 'safety, security and cleanliness' measure.
The dangerous items left in the hidden doorways were a risk to 'students and elderly people' who regularly passed the locations 'on their way to school and mass every day.'
We've all attended the equivalent kind of The Meeting where it was decided to install the sprinklers. We know it goes something like this:
Chairperson: 'Let the Minutes show that the Archdiocese Interfaith Council recorded yet another successful year of helping many thousands of people through food, housing, shelter programs for people at risk including homeless mothers and families, and in countless other ways. Well done and God bless to all concerned. Now moving on to Item 19 on the Agenda: 'Dangerous Items Left in Cathedral Hidden Doorways'. We've read Bob's excellent Facilities Management Report on the problem. Bob?'
Bob: 'Thank you Archbishop. My staff spend hours each week cleaning up shi... sorry Archbishop - human excrement - needles, and refuse from the hidden doorways around the Cathedral. It's time consuming. It distracts them from tending to the gardens. There's risk a needle stick injury.'
Harry: 'We have duty of care.'
Bob: 'Yes! Duty of care.'
Frank: 'To them and the children and the elderly coming to mass.'
Joe: 'We had this problem when I was with the bank. We installed sprinklers that were on timers to spray the areas where people gathered. It worked. And quite cheap too. I know someone who did the job. I can get a quote. They're Catholic so they'll do us a good price.'
Someone needed to apply the Widget Thinking brakes.
What's our Widget, Archbishop? Eternal Life? And how do we make that again? Parable of the Good Samaritan any help? Didn't Jesus say something about if we love our neighbour we will find Eternal Life? Isn't that also the origin of our secular 'duty of care'?
The interrupter (I think they're called a Leader) needs the courage to persevere beyond the inward and outward eye-rolls around the table, and Frank's response that will begin with an irritated 'That's all very well, but...' and end with all eyes glaring at her.
It's the right versus right decisions that are the tough ones. Choosing between the well being of the homeless and the safety of children and the elderly. Choosing between People Are Our Most Important Asset and cashflow says we need to make some of them redundant. Choosing between openness and transparency (I think that used to be called 'honesty') and the risk both brings to The Brand.
St Benedict, whose writings influenced European governance, said to begin all work with a prayer. Remind ourselves of what we're here to do. What's our Widget? Thanks for that idea Joe - and while we appreciate your wisdom with our budget, a bank's Widget is different to the Church's Widget.
All organisations are guilty of what the decision makers in the Archdiocese of San Francisco did.
All organisations engage in Decision Laundering.
They exploit the distraction of a 'secondary' problem with a soft and attractive outer moral layer - the risk to children and the elderly mass goers - to harness the analytical skills of good workers away from the 'primary' hard core failure of difficult decision making - the plight of the homeless and drug addicted. The diligent workers fix the secondary 'problem' and feel good about themselves and the organisation. The knotty primary problem remains.
Another more common version of Decision Laundering is to engage workers' intellect and eagerness to problem solve for their boss - in fixing the fallout from the boss's bad primary decision. 'Hey Larry - we need your expertise to wordsmith a media release that puts this sprinkler business into context by honouring all the hard work that our volunteers do in our homeless shelters. We don't want to jeopardise the donations we need to keep them operating.'
The bad primary decision is laundered into a good one by the workers employing Good Decision Making in the secondary decision. The workers will loyally (and rightly) defend their secondary decision making and thus the organisation - allowing their bosses and their flawed primary decision to desert under the cover of the smokescreen of the secondary decision's integrity. Imagine Larry on the phone to the San Francisco Chronicle: 'We'd like to invite you to do an exclusive story to raise awareness of the plight of women in our refuge and the grave consequences for them if we don't make our fundraising target this year.' Good work, Larry. What sprinklers?
Good workers' decision making can be like the water efficiently and effectively cascading down the sides of St Mary's Cathedral like clockwork - cleansing it of the risk to health and safety - and with it, the evidence of the unfulfilled Widget - the path to Eternal Life.
The prime job of a leader is to remind the organisation to become more like the thing it says it wants to be. To say to the Archbishop - we need to put the poor ahead of mass attendance. To say to the CEO - our brand will survive our apology. To say to the boss - I disagree and here's why. Then to stick around to help deal with the aftermath of that dissent. This is very, very hard. Which is why real Leaders are rare.
It took two years after their installation and an investigative journalist's exposure for the Archdiocese to acknowledge its decision. It will be redeemed if what it learned advances the faithful towards Eternal Life. Meanwhile, the homeless people just used umbrellas and raincoats.
God must despair. His followers fouling the entrance to His Kingdom. Filthy with our hypocrisy and egos.
He may yet deploy sprinklers.
'The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.'
- Clause 3.1 to Annex 13 to the International Convention on Civil Aviation
Vengeance. Retribution. Revenge.
Deterrence. Punishment. Justice.
We have a powerful longing for these outcomes from decisions that follow errors.
Maybe its a carryover from our childhood. Parents. School. Discipline.
If there's an error and no-one gets publicly named and shamed, it's like an enthusiastic waiter has cleared our coffee cup from our table before we've drunk the last mouthful.
Perhaps we're trained in our thinking and expectations by stories from books, movies, and the news about the adversarial winner-loser criminal justice system that relish arrest, prosecution, trial,confession, admission, guilt, judgment, verdict, conviction, sentencing, penalty.
There are no blockbuster movies where the hero rises to her feet in the middle of an Administrative Appeals Tribunal hearing and shouts 'You can't handle procedural fairness and natural justice and correct or preferable decision making in the inquisitorial process!' It's Crime and Punishment that is the classic bestselling literary novel. Not Ultra Vires and Certiorari.
Listen for assumptions about blame and punishment lurking ominously just beneath the surface of the benign, dull, haze-grey drone of our organisational language. 'Accountability' doesn't mean 'We'll celebrate and reward you and eagerly learn from you when it all goes well.' We know it really means 'Don't you screw it up - or you'll pay for it.'
Laws that were designed as shields to protect people are brandished like swords and waved menacingly towards us. Or instead of serving as cobblestones meant to pave society's streets of mutual progress, laws are seized by an aggrieved person grasping for reasons for some calamity and prised loose from their intended legal context to be used as missiles to hurl and draw blood from anyone deemed at fault.
The inquisitorial system is so alien to our thinking compared to the adversarial one, and our Whodunnit expectation so strong that it must be managed. Watch and listen to Datuk Kok Soo Chon, the Investigator in Charge of the Malaysian Airlines MH370 disappearance, solemnly repeat word for word Clause 3.1 to Annex 13 of the ICAO Convention as part of his Interim Report on the investigation as he looks down the barrel of the camera at you and me. 'You'll not find blame here,' he's saying. 'We're not going to give you a head on a platter,' he's warning us in more austere bureaucratic language. 'There's nothing more to see here except lessons for a better future.'
To paraphrase Clause 3, the sole purpose of a good decision should be to make a better decision next time.
There's also a lot of learning between 'It fell' and 'I dropped it'.
We don't become who we are on the back of the shamed and fallen.
On 20 September 2013 two Qantas Airbus aircraft with a combined passenger load of more than 600, nearly collided 12km in the air almost above Adelaide.
The Australian Transport Safety Bureau (ATSB) began an investigation that day. It said it would be finished by September 2014 - almost a year later. In November 2014 and already two months overdue, it updated the investigation status to be that the report would be made available to the public by January 2015.
On 5 March 2015, almost two and a half years after the incident, six months longer than the date it was first promised, and two months past the amended reporting date, ATSB Transport Safety Report Aviation Occurrence Investigation AO-2013-161 was published.
Meanwhile, hundreds of aircraft carrying thousands of passengers continued to fly the same routes each day in the control of the same systems and people and decision making doing the same things that failed on 20 September 2013 and nearly killed 600 people.
The more important the decision, the longer it should take.
Decision makers can be tempted to do the opposite: Important decisions must be made quickly. Urgently. Decisively. Get it done. Get it over with.
Not so for the ATSB. The risk that the undiagnosed errors in person and machine could be repeated with catastrophic results did not compel it to compromise its decision making process.
How long should a decision take? It should take as long as a good decision takes. How long do the Five Steps take?
The ATSB process was not initiated by a complainant. Decision makers resolving complaints are under pressure to decide quickly. Complaints policies impose response times. Complainants demand answers. Neither serves good decision making.
This is one of many examples where a clear Widget cuts through the complexity. Does speed, appeasing a demanding complainant, or meeting an artificial time constraint in a policy or self-imposed serve the Widget?
The ATSB had a clear Widget:
'The ATSB’s function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in: independent investigation of transport accidents and other safety occurrences; safety data recording, analysis and research; fostering safety awareness, knowledge and action.'
As each self-imposed deadline for the report approached, the ATSB would have asked itself: 'Will publication on the promised date serve our Widget? Which is more important: the integrity of our deadlines or of our findings and recommendations about aviation safety?' Appropriately the answer was the latter. Let's update the information on our website and continue inquiring with excellence.
Time constraints - 'Complaints will be resolved in x days' - should only be added to decision making processes if they serve the decision maker's Widget. 'Your decisions take too long' is not sufficient reason alone to impose deadlines. Better to manage expectations. Under promise and over deliver. Next time ATSB - promise us a report in two years and delight us by publishing it in one and a half.
A deadline may be appropriate to improve the turnaround time for a broken toaster under warranty. Yet it may compromise the careful analysis needed to understand the failure of a complex system.
Such as why two 240 tonne aircraft with advanced navigation aids and under air traffic control converged at a closing speed of one and half times the speed of sound 38,000 feet above the earth.
Or why that person did that thing.
'Don't worry if you break it Darcey. I can put it back together because I designed this house actually.'
- Five year old Scarlett to her one year old sister Darcey.
Often decisions break things.
If our decision breaks something -
- or someone in our team's decision did
- and we or they made it using a deliberate process of inquiry -
(Instead of 'Hey! Look at me! Let me show you how high I am up HR's wire diagram!' or 'Eenie, meenie, miney, mo...' or 'I need to do something or we're all gonna DIE!')
- then we can inspect the wreckage and work out what happened.
Learning is behaviour modified by experience.
We will make a better decision next time.
We will advance closer towards where we want to be.
'I was so incredibly lucky to grow up in the context of workshops...[I acquired] a natural understanding that everything...is made, and is the consequence of multiple decisions.'
- Sir Jonathan Ive, Senior Vice-President of Design, Apple Corporation.
Jony Ive understands and makes decisions. Apple has sold one and a half billion Widgets he designed.
A hundred thousand Apple employees and millions of shareholders and retailers rely on his decision-making.
He applies Widget Thinking. Steve Jobs described him as 'the most focussed human being I've come across.'
“I’m always focussed on the actual work, and I think that’s a much more succinct way to describe what you care about than any speech I could ever make.” He understands that design is ultimately about delivering something. It's all about the Widget.
Jony Ive is on a relentless pursuit of perfection. Billions of dollars depend on it and hundreds of millions of us benefit from it in our use of Apple products. How can he accommodate mistakes?
'Everything we make I could describe as being partially wrong, because it’s not perfect...We get to do it again. That’s one of the things Steve and I used to talk about: ‘Isn’t this fantastic? Everything we aren’t happy about...we can try and fix.’ ”
'That's how I make decisions. I draw how I approach a lot of issues from aviation when it comes to the management of ideas. One of my favourite sayings is that if you muck up the approach you muck up the landing.'
- The Hon. Sussan Ley, Minister for Health & Sport
‘Check wheels,’ the Air Traffic Controller would radio to the student military pilot as he commenced his approach to land.
'Wheels down,’ the student would reply by rote and habit as he continued his descent with undercarriage fully retracted and the ‘Wheels Up’ alarm in the cockpit blaring.
Process is important.
We get good at it.
We turn up to our desk.
Read and type emails.
The routine of our working day becomes the Thing We Do. The process gradually replaces our Widget as the Thing We Make.
We attend staff meetings and professional development days and listen and nod to sincerely but falsely acknowledge we’ve heard and responded to the 'Check Wheels' and cockpit alarms as our boss and peers and consultants and guest speakers and strategic papers and Ted Talks and even our own little voice warn us that we’ve forgotten to engage our Widget.
Our knowledge worker rituals and the clatter of weasel words that herald them deafen us to the feedback on our process and progress and obscure the Widget it is meant to serve.
If you tapped the student pilot on the shoulder at 500 feet from violently colliding with the runway and asked whether he was doing his job he would say 'Of course. I'm flying. Now let me get on with it.'
Tap any office worker on their shoulder and ask what their Widget is and in my experience, few can answer or even see it as relevant. 'I'm too busy being busy.'
The curt voice of the vigilant Air Traffic Controller radioing 'Go Around!' would interrupt the student's doomed approach and save him from belly landing in a shower of sparks and grinding metal.
Like monks being called away from their manual labour seven times a day to pray, bosses must regularly call 'Check Widget' and force us back into conscious, engaged, mindful recitals of our decision making process and the Widget it's ultimately serving.
We were outgunned, outnumbered and surrounded.
We were attacking Australia.
We were winning.
'I need to lodge small groups of special forces soldiers at various points on the Australian coast,' the Kamarian Commander of 311 Raider Battalion briefed me. 'I want to hide them beneath the decks of fishing vessels that will drop them off without the vessels being intercepted by the Australians. Can I fly the Mussorian flag on them under International Law?'
'Yes Sir. It's called a 'Ruse of War. It's legitimate. Your only obligation is to lower the flag and raise our Kamarian flag if we are discovered and need to defend ourselves. Your biggest risk of interception is by fisheries inspection officers so don't display any fishing gear.' It was much more fun being legal adviser to the bad guys on military exercises.
Following the sabotage and destruction of military and civilian infrastructure across the north of Australia by unknown foreign military elements, the Australian government responded. It suspended the right of innocent passage. No vessel, including ours operating under false flags, could transit Australian terrotorial waters. The Commander asked me for my advice.
'Declare victory, Sir,' I said.
$13 Billion of trade that came through Australia's northern waters annually was halted.
Australia's response to the threat of three civilian fishing vessels and a handful of commandos had self-inflicted billions of dollars of damage to its economy. Much more than the weapons of the armed forces of the mythical tiny island state of Kamaria could ever have done.
The first job of a Leader is to Create the Space.
Boundaries should be liberating catalysts for creativity.
Be generous and discerning in the size of space you create for people - in agreements, rules, policies, practice.
Once you limit the horizon, you have to patrol it. You have to enforce it. You have to mend it. You have to justify it.
You will add to the $250 Billion Australia already spends each year on compliance.
You will constrain and restrict innovation and cause other unforeseen damage.
You can be sure that each person down the hierarchy will define the operating space even smaller for their people.
If someone exploits your generous boundaries - breaks a rule, abuses your trust - be careful not to respond by drawing the lines in tighter. You'll catch more than the stray in your net.
If they breach the boundary again - don't shoot.
Instead, invite them to leave your space and create their own.
Invite them to be a Leader.
'The greatest enemy of any one of our truths may be the rest of our truths.'
- William James
With me/Against me.
These black/white filters of information sabotage good decision making.
They shut out new information.
Our fear is that it may compel us to do that terribly humiliating thing:
Change our minds.
It allows us to exercise the true test of our freedom:
At a cost:
Anxiety. (I might be wrong.)
Which is why we get paid.
Be the naive inquirer.
Treat all information that you receive as new.
'How interesting! Tell me more...'
You can fight the same battle each time: each dispute, each complaint, each conflict, each difficult conversation over and over.
Same skirmish, different combatants.
Or you can move upstream and address the root cause:
Come to the edge.
We might fall.
Come to the edge.
It's too high!
COME TO THE EDGE!
And they came
And he pushed
And they flew.
A perk of being a lawyer is that you learn a little about a lot in the course of taking instructions from clients and asking questions about their work and lives that will help tailor the legal advice.
An airman explained to me about microfails. The way I remember it, every new aircraft type is put in a test laboratory and subjected to flexing and bending and other forces that replicate the stresses it will experience in flight. The airframe's responses are electronically measured and calibrated into units called 'micro fails'. When the airframe finally breaks, the engineers and designers know how many micro fails it took to do so and therefore its tolerance to the unpredictable forces of flight.
An airframe's life is calculated as being as long as it takes to suffer a certain number of micro fails. An aircraft that does a lot of high stress manoeuvres that result in G forces on it will suffer more micro fails in a flight than if it flew straight and level. It will therefore have a shorter life.
Instruments in the aircraft detect and record each micro fail. The engineers monitor the total and when it reaches certain amounts, they will replace parts of the airframe, and 'rewind' the micro fail measurement instrument to zero.
MIcro fails are invisible. As the name suggests, they are tiny fractures of the integrity of the airframe that gradually degrade its strength until the point when one too many stressors adds the micro fail that breaks the aeroplane.
The airman who came to see me was alleging that the engineers were rewinding the micro fail measuring instruments to avoid having to ground the aircraft and put them into maintenance.
People have micro fails in response to forces around them in the workplace.
Missed promotion. Bang. A hundred micro fails.
Frustrating meeting. Shudder. Ten micro fails.
Brusque email written in haste. Ouch. Two micro fails.
A name forgotten. One micro fail. Catastrophic explosive decompression resulting in loss of a sense of proportion and humour and crash landing into stress leave.
Everyone has a unique total micro fail capacity before they break. A boss can rarely predict the stressor that will push the worker beyond their limit. It's not always the obvious less than perfect act of management. It might be an innocent misunderstanding. Crack.
Organisations wrongly assume that a new employee starts on zero (ignoring the legacy of their last job and their life in general) and assume to standardise the total micro fails for each employee by their contract, policies, pay and values.
People also wrongly assume that quitting a job and finding a new one will reset their micro fail metre to zero. There's almost always leftover fatigue that transfers to the new boss.
Organisations have various ways of doing the people maintenance that they again assume allows them to rewind the individual and collective worker micro fail meters to zero from time to time
Sometimes bosses just replace the people frames for new ones.
Worse, they introduce the equivalent of fraudulently rewinding the meter by running a professional development or team building day, introducing some new values of code of conduct, or emailing out inspiring and motivating words.
After the butchers paper has been binned, the mandatory training has been completed, the all staff email has been deleted - a boss chips a worker in front of their peers and deep inside the metal of each witness staff member, fissures grow and the individual micro fail tally resumes its countdown to breakdown.
Legions of experts, lawyers, consultants, therapists and researchers make their living both inside and external to organisations from training, advising, measuring, mentoring, coaching, facilitating, supporting, assisting, delaying, mending and covering up the human equivalent of the micro fail.
It's mainly placebos. Good and bad bosses alike are never sure what act of theirs will be the one too many.
A bad boss can routinely be bad and his workers will keep on building Widgets.
A good boss may omit one name from a speech acknowledging thirty others and the entire office is sprayed with debris and body parts from the disintegrating staff member for months afterwards.
So we keep on legislating, regulating, training, coaching and parenting in a vain attempt to smooth out the turbulence of the workplace and keep everybody happy.
It's not working. It can't. We can keep rewinding the meter or flying straight and level and avoiding tight turns and gravity, but we're deluding ourselves and each other.
“Life is difficult. This is a great truth, one of the greatest truths. It is a great truth because once we truly see this truth, we transcend it. Once we truly know that life is difficult-once we truly understand and accept it-then life is no longer difficult. Because once it is accepted, the fact that life is difficult no longer matters.”
The workplace is part of Life. It's difficult. The more we seek to protect people from the stressors of doing their jobs with good and bad bosses, peers, subordinates, clients, customers, machines, and gravity, the greater disservice we do to them by denying them the opportunity to confront Peck's Great Truth, learn from it, and to transcend it. All in a relatively safe environment - the workplace - compared to the unpredictability of the rest of Life where there is no boss to blame for what befalls us, and often no Widget to measure our bearings from.
I checked with my Aeronautical Engineer friend Francisco about my memory of micro fails. He'd never heard of them. He works on modern Boeing 787s.
'I think that you're referring to aircraft structures of the past that were built with a safe life,' he said. 'Newer aircraft are fail safe.'
We need to rethink our 'work frame' design and maintenance. We need to evolve from our artificial 'safe life' philosophy of minimising the consequences of engaging with the healthy human stressors that arise from doing any job that's worthwhile - ie Life. We need to stop demanding that the boss shields us from the natural turbulence and forces of doing innovative, creative, speed-of-sound work.
We need to come to the edge so that we can fly.
Dr Fiona Wood, AM is one of the world's leading plastic surgeons who specialises in burns patients. Earlier this year she was interviewed about what she had learned from her surgical research and practice about Good Decision Making and Leadership.
She started where all Leadership and Good Decision Making begins - the Widget - or 'purpose' as Dr Wood described it:
'I think decision making is something that you have to really take on - I was almost going to say a level of aggression - but a level of purpose might be a better term. Because you have to make a decision. There is someone in front of you that needs your help - you have to make a decision.
Dr Wood acknowledged that decision making is cumulative - that each decision informs the next:
'That decision may not be right – you have to take that. You have to understand that the decision you've made, the action you've taken, has led to then making the next decision. Sometimes it will be right, sometimes wrong. You've just got do deal with it with a level of purpose. And so you bring to the table all your experience - the knowledge that brought you to that point. And it's a question really of visualising the outcome.'
Her Widget focus is paramount in her thinking, and relies on the systems that have been developed to support it:
'I see this individual....If you meet me as a professional you're having a bad day. So they are damaged, and now I want to use everything in my power, in our systems that we work in, in our systems and the knowledge that is out there to make their path to the outcome the very best it can be.'
Even though in each operation she is focussed on the person before her on that day, she maintains her disciplined focus on a more strategic Widget. Each patient illuminates the path to her Widget, yet in such a way that nether the immediate needs of her patient, or the longer term Widget journey is compromised:
'And the outcome that I've visualised for many, many years is scarless healing. We've changed the goalpost. We've inched doggedly there...are we there all the time? Absolutely not. But we're making progress. So it's visualising that outcome and making every play such that you can move it closer to that outcome day by day. And it's learning. It's always taking the blinkers off and learning so that whatever the decisions you've made today, you make sure that you make better ones tomorrow. And that has been actually an entrenched coping strategy to make sure that you critically analyse the work of today to make sure that tomorrow is better.'
Dr Wood's focus does not mean that she is blind to other new information that can serve her Widget:
'I see people out there that do nanotechnology, or genetics or all sorts of different things - psychology, neuroscience and they've got parts of my jigsaw. I need to get parts of that jigsaw and bring it in to play here. And therefore you have to make decisions on lots of different levels. But when you pare that all away you look at the person in front of you, you've got to get the removal of the dead tissue without them bleeding out such that you can repair them the best you can with today's technology such that you set them up for the best outcome.'
Her Widget focus allows her to quickly engage a surgical team with the needs of each patient:
'I teach my guys: As you walk in you make sure you connect with everybody in the room and if there's people you've never seen before you write everything on the board that you're going to do. You should not be making the decisions while you're doing it. You should have visualised it - you go in knowing what you're going to do and knowing your escape routes. So all of that has to be in your mind. And you have to see the landscape. What is it that you've got to work with in terms of your human resources - and engage them. Make sure they understand what you're trying to do and feel the passion - feel that for that period of time the only focus is for that individual. And that's a really important part of the whole. Engaging everyone.'
Dr Wood explained how the path towards the Widget is a meandering one, and that we should not measure our progress on the result of one decision alone:
'The outcomes have got to get better every day. And it's not linear. I don't live in an environment where every day that passes your chance of survival increases. It's not linear - it's a roller coaster. The waves of infection come relentlessly over, unless we've completely sealed - the person weakens and weakens and weakens. A third of the patients who don't survive will survive somewhere around three months. And they're hard days.'
Dr Wood affirmed Step 1: Step Back as being important in good decision making:
'We have this concept that 'Oh, it's macho to keep going'. But it isn't macho to keep going if your performance falls away. And so for a long, long time I've been very aware of people around me and trying to work out who needs to be rotated out...and so it's having that awareness and as I've got older, I don't stay in and so part of it is rotating yourself out, so that it becomes acceptable....
Dr Wood's ideas on leadership are consistent with Creating the Space and Defining the Purpose and inviting people into that space and using the focus on the Purpose as vehicles to reach their potential:
'I think leadership…Vision...is really interesting. Because I believe that everybody can dream. I think leadership is giving people permission to dream. Because I think if you take the time to listen to people you'd be amazed at what they dream. And then you encompass that dream into a vision.'
Yet always the laser Widget focus:
'I saw a child in 1985 and it changed my life. I thought 'That child is so badly injured from a cup of coffee?' We've got to be able to do better. I've carried that photograph around with me for a long time.'
Dr Wood addressed the potential for conflict between Widget focus and learning where we are in relation to our Widget, and the need to get the day-to-day work done. She described the importance of being disciplined in routine and preparation in order to be creative:
'What we want to be is innovative problem solvers but we want to generate outcomes on a regular basis. In every field of endeavour that is a conflict - on the surface of it. But when you start to dig a little bit deeper… I indicated that it is not appropriate to be making decisions about where you cut when it's right there in front of you. You've made those decisions previously. You've visualised. you've gone to the table - whatever table it is - with your outcome in mind and understanding the opportunities you've got to get there. So there’s an element of planning almost on the run all the time. It's getting into the habit.'
She affirmed the idea that good decision making is being confident enough about what you know, to be attentively curious about what you don't:
'What is it that I bring to the table? What's my experience? What's my knowledge? The lawyers do it all the time with precedent, looking back at old cases. Get into the habit that it's always ticking over. Questioning the landscape. And I think underpinning that is a fundamental belief that today is not as good as it gets. Not in that you criticise today. It's not bad. It's the best it can be - today.'
Dr Wood's approach to learning is to seek out feedback. She goes beyond a healthy belief in relying on the power of complaints to provide it. In fact, why wait for a complaint to inform you, and assume that if there is none that you are doing okay? She advocates declaring your understanding of your Widget to the world and inviting it to comment:
'As you've finished, as you've closed up and you walk away, you don't strut. You actually think 'Okay - given that same situation happens tomorrow, how could I have analysed it better, and then you go through the whole exercise again…the debrief. That's not specifically surgery, It's not specifically sport. It's part of exercising your mind. And the next step is doing that in public. Because that's when it starts getting exciting because there's absolutely no doubt we're in an environment where you need multiple minds to solve problems. And so you have to have that level of inquiry and sort of ticking over and then you connect. And you start to develop a language of innovation and visualisation. So you can push forward.'
Dr Wood shared her belief in the value of 'trauma' as a stimulus to growth, extending the literal trauma to her patients' longer term recovery and resilience, to a metaphor about character:
'I can track periods of my life where I went through post traumatic growth. And it wasn't painless. The hardest thing for me post Bali was that people wanted to know my name. Yet I recognised that as part of that I became stronger. And I became able to engage in this positive energy, in this positive good news stories. And I had my blinkers taken off such that i engaged with the community in a broader sense....How we can use energy that is so profoundly negative and turn that around - I think that's fascinating. It's tiring sometimes. And it's hard. But part of that post traumatic growth is having the infrastructure around you, having the people and connectivity around you that give you the ability to lead.'
She had some powerful advice to give on how to deal with criticism and how innovation challenges conventional thought about 'the way things are done':
'There's an element of inertia in practice. Whether that be clinical practice or business practice...This level of inertia is really quite an interesting animal. Because it's useful, but it's also a hindrance. We need to have a level of capacity to maintain things moving forward at a pace that can be managed. And equally, we have to have people testing out the front. And so I have engaged with surgical inertia up front and centre and I've had to make the decision not to engage in that negative energy but to continue to be driven by the positive outcome, collect the data, present the data. And as the things roll forward, the data will speak for itself. And so that inertia starts to be overcome. And I think that the challenge when you're in a situation with that level of inertia is to understand you've got a choice. You turn around and you fight it…and it's bigger than you. Or you stay out the front and you wait for them to catch up. And they get there.'
Yet always returning to the supremacy of the Widget - and the need for a leader to be clear about defining it to the team, regardless of how clear it is to her or how passionate she is about it:
'I had a really interesting lesson in leadership inadvertently in the early 90s. 1991 I hit the ground running. I was very focussed on time to healing. Every day in a burns unit is a day too long. I aggressively engaged in a skin culture programme....the social worker at the time who was a bit older than the rest of us came and said 'Stop!' I thought 'What do you mean, Stop? ‘Sit down. I need to talk to you. I've been asked to come and speak with you. Well you're too intimidating.’ (Give me a break! )‘We understand that what you're doing has got to be right. It's got to have some real benefit. But we don't know what it is. We can feel your passion. We have no idea how we can explain it to the parents, to the patients, to their relatives, to the new nurses when they come on. We're all at sea…’
Dr Wood learned the definition that a leader is someone who makes good decisions that others choose to follow:
'Leadership 101. No team - no leader. Done. The elastic was at breaking point and almost snapping behind me. And had I not had that energy that they all got caught up in, it would have snapped well and truly. So that's the point when I said 'Right. Everybody who's at this table is here for a reason. You've got to be able to be leaders in your own right....Passion on its own doesn't cut it. The communication bit has to be strong.'
A Leader retreats:
There is absolutely no point in me being so entrenched that as I get through my final kick, everything fades away. Succession is so important. It's not because I want to be remembered. It's because the people need treating! And they need to be treated better and better and better. So for me, it's delegation. But delegation with meaning. Empowerment in a real sense. I need to let them deliver. Such that I can get out of my head, get it on paper and challenge them into the future. But in a way that is not intrusive. Not imposing my surgical inertia on them. But allowing them to grow.
Dr Wood leads a team in Good Decision Making in life and death situations. It's not just theory to her. She is still able to use the language of 'dreams', 'visualisation', 'mistakes', 'passion', 'innovation' and 'personal growth' while literally operating at the leading edge of science.
If Dr Wood can save lives while still creating the space for these ideals that allow others to become who they are, then most workplaces have no excuse.
'No man is an island entire of itself; every man
is a piece of the continent, a part of the main;
if a clod be washed away by the sea, Europe
is the less, as well as if a promontory were, as
well as any manner of thy friends or of thine
own were; any man's death diminishes me,
because I am involved in mankind.
And therefore never send to know for whom
the bell tolls; it tolls for thee.'
- John Donne
What information moves us?
One Australian cricketer is killed by a ball bowled during a game of cricket.
28 people are killed by missiles fired from drones for each terrorist suspect killed.
Information refracts and bends through our biases.
Recognise this and pay attention to it.
'They that have the power to hurt, and will do none...
...they rightly do inherit heaven's graces.'
- William Shakespeare, Sonnet 94
The Investigation into the loss of separation between Airbus A330 VH-EBO and Airbus A330 VH-EBS near Adelaide SA on 20 September 2013 continues.
It was estimated to finish 'no later than September 2014'.
On 17 November 2014, two months after it was expected to conclude, there was a progress update:
'Completion of the draft investigation report has been delayed due to other investigation priorities, and the draft report is now anticipated for release to directly involved parties (DIPs) for comment in December 2014. Any comments over the 28-day DIP period will be considered for inclusion in the final report, which is anticipated to be released to the public in January 2015.'
'Released to DIPs for comment' and 'any comments...will be considered for inclusion in the final report.'
Step 5 in the Five Steps to a Good Decision: Give a Hearing.
Allow any person who may be adversely affected by the decision the opportunity to consider your reasons for potentially reaching that decision, and to offer an argument why you should come to a different one.
Inviting a person affected by a decision is a powerful tool in good decision making:
Despite this impressive list in its favour, many decision makers avoid offering a hearing for fear that they will find out something that may undo all the time and energy invested so far; that it may create an expectation that they will be persuaded to change their minds; and that such an invitation undermines their authority.
A good decision maker acknowledges these fears, (perhaps even taking another Step 1: Step Back to indulge and then purge them) - then reminds herself of the logic of the benefits listed above, drafts the invitation to be heard such that it manages expectations, and reads Shakespeare or the writings of any good leader to understand that real power is demonstrated in the restraint in its exercise.
John is a manager who tosses a coin to decide half his decisions, only implements about two out of ten effectively anyway, and bases the majority on practices that are proven to fail.
John should be terminated.
Yet John is the average manager.
45% of managers use instinct to make decisions.
Only 15% of organisations can make and implement important decisions effectively.
Two of every three business decisions are based on failure prone practices.
95% of a typical workforce does not understand the organisation’s strategy.
90% of organisations fail to execute on strategies.
86% of executive teams spend less than one hour per month discussing strategy.
76% of Australian workers are disengaged from their jobs.
Australian bosses lose an average of three months per year productivity from each worker due to disengagement.
Australia ranks second last on productivity growth – ahead of Botswana.
Is the above average worker profile any wonder when John is her boss?
There is evidence that many organisations' priorities are not defined by productivity, customer or community service, share value or sales growth. They are defined by self-interest.
Prescriptive decision making strategies [ie The Five Steps] in workplaces were more successful no matter what the urgency, importance, resource level, initial support, decision-maker level, industry sector or type of decision.
Want to be a 'high performing team'?
Teach and apply good decision making.
'Being right is occasionally useful in bars but it's very useless in life. It just doesn't open avenues for learning.
[Hospitals] engage in serious errors. The nature of Lourdes is that they don't get better at miracles because they're not learning from their mistakes.
400 years ago everyone believed that broomsticks could fly. Then these views of the world bifurcate and we have broomsticks that still don't fly terribly well and Jumbos that fly rather well. Jumbo Jets are just broomsticks with feedback.'
A Leader's decisions create errors that teach and invite us (educate - educare - 'to draw out') to overtake her, and make different errors for others to learn from and overtake us.
Contempt for the mistakes of others and fear of making our own are why true Leaders are rare.
'Leaders and followers collude in the imagining of leadership as heroic feats that will fix problems and usher in a new era. These practices are seductive because they release individuals from the work of leading themselves, from taking responsibility for thinking through difficult problems and for critical decision-making.'
- Amanda Sinclair, Leadership for the Disillusioned
The dominant narrative in Leadership is the Leader as hero, protector, parent.
A recent article in Bloomberg Businessweek is evidence of the power this story has in our culture.
It also shows the myth of 'If only I had more power, things would be different'.
The President of the United States is the most powerful man in the world.
The article quoted 'administration veterans' as saying that President Obama responds to crises in 'a very rational way, trying to gather facts, rely on the best expert advice, and mobilise the necessary resources'. He is said to treat a crisis 'as an intellectual inquiry' where he 'develops his response through an intensely rational process'.
'As former CIA Director Leon Panetta said recently in a TV interview, “He approaches things like a law professor in presenting the logic of his position.”'
In doing so, he is said to 'adhere to intellectual rigour, regardless of the public's emotional needs'.
President Obama 'disdains the performative aspects of his job' and resists 'the theatrical nature to the presidency.'
These characteristics of the President were cited as weaknesses.
The article quoted a poll that found that 65 percent of Americans say they fear a widespread outbreak of Ebola in the U.S, despite the facts showing otherwise. 'People fear what they can’t control, and when the government can’t control it either, the fear ratchets up to panic.'
The President was said to be 'hampered' by 'an unwillingness or inability to demonstrate the forcefulness Americans expect of their president in an emergency.'
'A thought bubble over his head seems to say: “I can’t believe everybody’s flipping out about this stuff!” But as Panetta also said, “My experience in Washington is that logic alone doesn’t work.”'
The article acknowledges that President Obama's record 'even on issues where he’s drawn heavy criticism', is often much better than the initial impression would lead one to believe.
'He may tackle crises in a way that ignores the public mood, yet things generally turn out pretty well in the end. He and his economic team, though deeply unpopular, halted the financial panic and brought about a recovery that’s added jobs for 55 consecutive months. His signature health-care law addressed a slower-moving crisis; while similarly unpopular, it has delivered health insurance to more than 10 million people. Even Deepwater Horizon was nothing like the environmental cataclysm it threatened to become. “It really became a parable of how government can mobilize to solve a big problem,” Axelrod says. And he adds, “Bush didn’t get bin Laden—Obama did.”
Author Peter Block noted the dominant 'patriarchal leadership narrative' when he said that:
'Obama is reluctant to attack Syria. When he decides to consult with Congress on it he's considered like he's waffling...and then when Russia comes along and says 'Wait a second you don't have to attack I think we can reach an agreement' and they play a good third party role, [it is portrayed as] a sign of Presidential weakness that he allowed another country not so friendly to us to be decisive in bringing peace and avoiding war in the world. That interpretation of events is what we're dealing with. There needs to be an alternative narrative - an alternative story telling.'
One of the hardest demands on a new leader is to resist the pressure to take people to where they already are.
A leader invites people to go where they otherwise wouldn't.
She needs confidence in her Widget before she can invite us to join her in its creation.
She assumes the best in us that we crave to be discovered and acknowledged.
She draws us out of the comfort of our fears and prejudices and oppressive, suffocating narratives, cadences and routines - and into the anxiety that is the surest sign that we are free.
The Blue Angels is the United States Navy's flight demonstration squadron.
Its Widget is 'to showcase the pride and professionalism of the United States Navy and Marine Corps by inspiring a culture of excellence and service to country through flight demonstrations and community outreach.'
After every flight the team goes through a critical debriefing process which they consider is as important as the actual flight itself. They talk about what worked, what didn't, and 'no punches are pulled'.
'We are as wide open as can possibly be to criticisms. We want to become our own worst critics.'
The debriefing process takes twice as long as the flight took. 'Rank doesn't come into play.'
'We have a term that we use: 'Glad to be here''. It's a way of reminding themselves of the privilege of flying with the Blue Angels while their fellow pilots are doing night carrier landings in the Mediterranean Sea.
'We have two 'critiquers' on the ground that look at the manoeuvres and tell us their impressions basically.'
'We make these mistakes and we 'fess up to them and we do it every time we fly. It's an extremely important aspect of what we do. What we do after we've said it is 'I've made this mistake. I'll fix it. You always say you're going to fix it It leaves the rest of us with the feeling that you've recognised your mistake and you're going to take corrective action not to let it happen again. So it doesn't drop our confidence level in another person in the formation.'
'You gotta be able to learn each and every time you go flying because there's never been the perfect flight demonstration yet.'