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The Five Principles of Weick & Sutcliffe

Tracy Pyke • Nov 09, 2020

What is preoccupation with failure?

For the Individual:

Karl Weick told me that when he and Kathleen identified preoccupation with failure they were looking at system mindfulness and system failure. He did not consider failure of the individual in this concept. Those of us who came from high-risk activities automatically thought preoccupation with failure applied to us as individuals.

On another occasion, an academic group discussed with Kathleen Sutcliffe the use of the word “preoccupation” in Preoccupation with Failure. While Dr. Sutcliffe insisted that the word "preoccupation" was significant and critical others criticized it because some managers felt it meant we should constantly be thinking about it. Organizations seem to have an image problem with this.

As a participant I think she had very good reasons to use preoccupation as, on an individual level during high-risk processes, I am preoccupied with my failure that could harm other people or me. Unfortunately, we do not always know our procedures are high risk and, besides, this becomes habit much to the consternation of others without these experiences.

The culture I developed in came from men who experienced live-or-die situations and I have experienced my own on more than a few occasions. I look back to the events seconds, minutes, or hours earlier to see how I could have avoided the situation I found myself in. I don’t want to do it again. I guess you could say I am preoccupied with failure.

A better way to describe it is looking for early heralds of failure. In the intensive care unit I taught caregivers to look for covert, compensated states of physiologic dysfunction. These early heralds were precursors to shock or respiratory failure. It is at this point our interventions are easiest, cheapest, and have the greatest effectiveness with the least risk. It is a routine activity for us to always look for the early signs of deterioration. This is preoccupation with failure.

As paramedics working in an area with high drug use and gang activity we were vigilant for early heralds, subtle nuance, or vague signs of problems developing. We would watch for the subtle eye movement or nuanced behavior that would tell us the call was turning the wrong way. We were vigilant in the same manner towards our patients, before paramedic school all we had was observation and a few treatment tools. This carried over to my work in healthcare where I taught my students to look for signs of subtle change despite the difficulty of clearly understanding what was happening. 

Vigilance for early signs of failure also gives you boundaries within which you can feel safe. This produces the paradox of feeling secure because you look for the danger. To those without this insight we seem to be pessimistic, always looking for the dark side.

My question is, "Can we make preoccupation with failure a habit without creating pessimism?"

What is preoccupation with failure?

For the Organization:

Karl Weick told me that, in his estimation, preoccupation did not have an action component in it while in the world of operators it drives anticipation, action, and learning from action. He also stressed that preoccupation with failure presumes that the organization has good communication. Nothing really matters much if there is not good communication in the organization. Communication is another blog.

One complaint about preoccupation with failure is whether it takes away from other duties and whether it creates an image problem to the organization. Preoccupation with failure means searching for early failure points, which means looking for bad news. In, as one administrator told me, to discuss openly improvement is to imply we were doing poorly. At the worst, the individual preoccupied with failure is considered disloyal while at the best individual is criticized for "crying wolf," overreacting, or acting the Cassandra.

But if you look for bad news and you can correct it earlier then it is more amenable to intervention, the intervention has less risk, and you correct the problem before it becomes systemic. In the HRO, leaders in the organization consider "bad news" a "good sign" and seek bad news to improve the organization.

The organization will seek out hidden failure, that is, the failure people consider inevitable or part of the job. When there is open discussion of problems, those who have solved the problem can share their solutions with those who believed it was unsolvable. This requires not only open
communication but also requires frank discussion of all outcomes. In this manner, the organization creates a common language and grammar.

I asked a US Army Sergeant, a veteran of the war in Iraq, how the Captain of his Company found out about important information, such as weaknesses in the Company or outside threats, when the men did not talk about it. He said the captain would come by and play cards with the men and eventually they begin talking to him. Management by Walking Around sounds nice but if the leader is on a pass-through it accomplishes little. It is simply "showing the flag." While this is also a leadership issue it is and organizational issue because it can act as a conduit for information flow between line workers, administrators, and executives.

For another discussion, are we preoccupied with failure in communication?

My question is, "How can an organization make looking for bad news a good thing?"

By Tracy Pyke 09 Nov, 2020
This is a discussion with Thomas A. Mercer, RAdm, USN, (retired) RAdm Mercer, as Captain of the aircraft carrier USS Carl Vinson (CVN 70), requested an evaluation by academics from the University of California, Berkeley, to improve his crew's performance. He also desired to have an MBA program available for his crew. The academics did offer some suggestions but the end result was the codification of RAdm. Mercer’s command philosophy and modern leadership techniques as the High Reliability Organization. CVN 70 was the third of Nimitz class aircraft carrier, commissioned in March of 1982. The crew did an around the world cruise and reported to Alameda, California, a year later. This was unusual because they were not getting the normal support from their support command on the west coast before they departed. RAdm. Mercer reported one-third of the way into the cruise as the ship was transiting to the Indian Ocean (where the support from the west coast for spare parts and replacement aircraft engines dramatically improved). The accident rates as far back as the 1950s and 1960s were 17 accidents per 100,000 flight hours. Accidents, embarked and shore-based, are down now to less than 1 accident per 100,000 flight hours. The entire carrier force is now nuclear powered, which brings more capability and professionalism, appreciation for training and culture of doing things "right" that was not so before. The USS Nimitz was commissioned in 1975 while the fighting in Viet Nam was largely over in 1973. Throughout the Viet Nam war, most of the super carriers were conventionally powered starting with the USS Forrestal. The USS Enterprise was commissioned in 1961. All the carriers were "driven hard" because of the Viet Nam war. The USS Enterprise had a major fire off Hawaii, killed about 100 people, bombs cooked off (burned or exploded) after being hit by a rocket fired on the flight deck. The USS Enterprise had 8 reactors. All Nimitz class carriers have just two large reactors. Safety and readiness is a full system approach. The primary component of safety are the people, it is a people system with a very low authority gradient. Anyone can, and should, question what is being done. [Aside: VADM (ret) Gene Wilkinson, was the first CO of the USS Nautilus, the world's first nuclear powered warship. He passed away this year (2013). He originated the famous phrase (at least in the Navy) "underway on nuclear power" in January 1959.] All nuclear trained officers, particularly the CO, are personally selected by the Director of Naval Nuclear Power. The first was ADM Rickover, the longest tenure of any four star flag officer in the US military. Nuclear operators are very technically competent. The CO sets the tone for the entire organization. Always on duty. Low authority gradient, anyone can stop an operation and question what is being done and is encouraged to do so. In the USS Enterprise grounding off of Bishop Rock, California, no one questioned the CO because he had trained each person on the bridge. A carrier’s Executive Officer is also nuclear trained and aviator. All COs of nuclear aircraft carriers must be aviators; they have not driven ships their entire career. The CO must rely on all his post-command department heads (Air Boss, Navigator, Operations Officer, Reactor Officer), senior Medical Officer and Supply Officer. The Navy's Chief Petty Officers (CPO), the senior enlisted officers, have become stronger and stronger during Tom's career. There is a lot of technical training and expertise, they make things happen on a daily basis with cross coordination with their counterparts throughout the ship. It has been said that the Navy is run by the CPOs. One of their most important roles is training the junior officers. In aviation squadrons, all the junior officers have many collateral duties in addition to flying so the officers depend on the Chiefs to get the work done. Some of the most junior people are the plane Captains, the enlisted person in charge of individual aircraft maintenance. There have been many improvements in the carrier (the ship), too. We have moved to angled flight decks to allow simultaneous launch and recovery. Planes touch down 92% on final and 100% on landing, four arresting wires and other barriers and pilots would sometime amiss and hit, have glide slope indicators and Landing Signals Officer to guide the pilots in, steam catapults instead of hydraulic catapults, just enough night lighting to keep you from having to sit in ready room in night goggles for 30 min to be night acclimated for night flying, still try to keep lights from casting to submarines and others, we have automated carrier landing systems so you can make hands off landing, he had in his career, but not perfected. Comment on responsibility toward the other person, to help and protect others on the ship. This is part of the sense of duty we discussed. Overall level of training and the culture are key components. People know they are top line people doing important work for the Navy. The formal training has become more and more detailed and viable. The Navy has an all volunteer force now as opposed to the draft during the Viet Nam War when we did not always have the highest caliber people. Many people want to enlist or reenlist and we don't allow it because they don't meet our standards. People feel like their trainee is their responsibility and would be very embarrassed if anything that happened to them. Always looking out for their buddy on the flight deck and throughout the rank structure people always have the philosophy and attitude that they are training their relief as they move up in responsibility. At an EMS conference 20 years ago, and EMS veteran with 40 years of experience remarked that he missed the camaraderie between EMS personnel and hospital staff. There was pride not only in the organization but also in the system. The other person's welfare is part of the training. In the Navy is this part of recruit training or is it emphasized later? Yes, it is part of recruit training but it is also part of unit policies and cultivated unit pride to build camaraderie and professionalism. You see a problem and you own it until someone gives you help. You teach people that everyone's job is valuable, trying to make sure that no one messes up another person's work, feeling that we are all in this together, there are few special privileges. Every person has worth no matter how menial his or her job. In healthcare people tend to look down on rookies and novices yet in the 1970s on the ambulance and in the fire department it was a source of pride by how much the rookie learned. How much the rookie learned reflected the quality and performance of the crew. In healthcare, the novice or rookie seems to be in the way. How do you encourage people to look after the new guys? Some personalities of course do not fit in, but there are ways to shuffle them off to the side or weed them out quickly. The demands for people and advancement make it necessary to ensure the new people learn as much as possible. People are always new in something. We know they will have to step in in an emergency and have a role to play in keeping the aircraft carrier or submarine running. The quicker you can get the person trained and reliable, trained like you are, the better it makes your quality of life. Every person can save the boat. Numerous groups want to bring High Reliability into their organization. It is easy to say but it is hard to do. You said that you always encounter opposition. You advised to move forward despite the opposition not in spite of the opposition. How do you work despite or with the opposition? You do get the feeling that it is you against the world. People try to take it as a matter of pride and good discipline. A book came out five to six years ago, It's Your Ship, by Michael Abrashoff. He happened to be the junior skipper in the destroyer group. He prided himself on not cooperating with other COs, to try to one up them. This banter must be friendly and not get out of hand. In some systems this type of friendly competition can further each other’s performance and make people better. You raise the bar for others. If you come in and change what they are doing there is resentment. Rather, tell them what is good, then, ask what else we can do? If it is not working, then in private discuss how we can do better. You are going to get resistance when you tell people they are not doing things the right way or need to improve so you have to be careful about appealing to their sense of pride and professionalism. We are designing out the hazards of a system, which may lead up as to designing out the capacities of the individual. For example, the use of auto landing systems in aircraft is such a system. Will this result in an effort to drive out risk and human reliability. As part of an High Reliability Organization, you have to have systems that are designed to allow humans to adapt to changing conditions that could be lost if we rely on more automation. A doctor he met at a conference at USC had the impression that the automated systems and air traffic controllers should be held accountable for accidents and that accountability had shifted away from pilots. While the academics from Berkeley focused on flight decks the piece de resistance of what you did involved kitchen duty. Some loved it, some hated it, and for some that was the best they were going to do yet you instilled in them pride in their job. As you said, “If you can take care of the ship below decks the flight deck takes care of itself.” In hospitals, no one pays attention to the lower ranks. How do you instill pride in in the lower ranks and acceptance by the higher ranks? Everyone does kitchen duty or compartment cleaning. When they report to the ship no matter what their technical training is (with only few exceptions), the first cruise in the summer at the naval academy is in the role of an enlisted man. Everyone in the organization has had to do their fair share of the "menial" work. Even the military academy must learn the job from the ground up. In medical school and residency this is called “scut work” and everyone is assigned these duties. However, it has the reputation of being meaningless, that it has no useful purpose. As a novice in many organizations you get free pass to ask any questions you wanted. This is a golden opportunity to learn. Health care does not seem to value this period. Is it to learn how the system works or because you are the lowest on the totem pole? You described a lot of technology that was implemented at the same time as you were involved with cultural dynamics and personal leadership. What kind of change accounted for what kind of improvements? Did things ever get less safe when you were introducing technology? Transition to some of the technologies was often not as smooth as you might think. His predecessor on CVN70 had a lot of time to work with marine architecture people at MIT and Carnegie Mellon in 1981 and 1982. They had a Wang beta email system throughout the ship. It had a very colorful and interesting map display system on the bridge and other areas of the ship well before GPS. It had a high-speed printer for generating all the paperwork the ship needed and some expert systems to improve air operations (fuel management, etc.). They had tried to automate many of the pre-underway checklists. All ship instructions automated and electronic. The problem was that no one was used to using them, computers were not strong enough to handle the load, checklists not easily updated when things needed to be changed. It did well in REFTRA, but it did not do well in the Operational Readiness Exam that followed. Many of these systems were detriments to the tried-and-true ways of doing things. Now the aircraft handler that manages plane status, arming, and fuel, and maintenance has automated systems to support him, but the automated systems cannot do all the thinking and coordination needed. Right now the LA water system is putting in system called Safe Start: mind on task, eyes on task, behavioral safety . The real problem is just keeping people motivated to do things they don't want to do. How do you motivate people to do those things they don't want to do? Make those basic unpleasant things universal so people know they cannot escape them. On the carrier, it is a test of how well you internally communicate, how much do you let people off at these training events know that they are still part of the team? Need them to know that someone is looking out for them and to return to their real job When people are sent off for training in tasks not relevant to their job, we must convey that they own the material. We must let them know they are not going off just to do something. People have to feel a sense of owning something or vision of how these things they don't want to do are important It seems like the sustainability of the motivation falls back to leadership to make it clear to front line staff that what they are doing is of value to leadership. They will see the value as well this way. What are we modeling when we say one thing and do another? The staff pays a lot of attention to the signals the leadership send.
By Tracy Pyke 09 Nov, 2020
Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO
By Tracy Pyke 09 Nov, 2020
Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO
By Tracy Pyke 09 Nov, 2020
Notes from a panel of people experienced in HRO
By Tracy Pyke 09 Nov, 2020
Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO
By Tracy Pyke 09 Nov, 2020
Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO
By Tracy Pyke 09 Nov, 2020
Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO
By Tracy Pyke 09 Nov, 2020
What is High Reliability?
By Tracy Pyke 09 Nov, 2020
Comments by Randy Cadieux, Major, USMC, MS
By Tracy Pyke 09 Nov, 2020
[Note, this is Duty and not referring to Duties.] Duty is the moral commitment that results in action. High Reliability is a choice. You choose to want to do well. Duty is willingly accepted, it is not an external motivation. Duty is intangible but it keeps drawing you back into your job. Dharma is duty or character, an essential truth in Hinduism. People may work at a job for money (utilitarian employee) but Dharma, duty or pathway, is why people perform well on the job. With duty you evolve personally while you are evolving the organization. Duty is the global overview of the mission; where the organization needs to go. The most direct quote regarding military duty is from Lord Nelson, “England expects that everyman will do his duty.” In an HRO they do their duty and then one step more. This brings relief to the team or organization when you do your duty. The Lord Nelson quote is also alignment – as with England. There is alignment between individual values and the country’s values. Duty is an ethical relationship to others; you are your brothers’/sisters’ keeper. Duty is responsibility for the welfare of others. In Crew Resource Management (CRM ) if you see something abnormal you must bring it to the attention of the crew. There is an individual sense of agency in the organization. This is part of who you are and you are a part of the organization. Duty is related to purpose – why you are doing it; not the what of your actions. Duty is why the organization exists; the values are real and they are used. Duty must be in relation to the mission and vision statements. “I am agreeing to do this as I like what the organization does. This is different from individual responsibilities; this is beyond the tasks of the organization. Duty has emphasis that certain things are required but HRO has a voluntary piece to it. You are required to do duty and this seems opposite of what HRO is. In reliability they range widely to see and do things you might not have thought of. [We are beginning to differentiate duty as task responsibility from duty as sense of duty or character trait aligned with mission of organization.] Duty is related to cause; what is the cause of an organization? You believe in the cause of the organization therefore you help it move forward. Alignment the culture of the organization between the person and the organization; then the sense of duty is profound. Alignment between organizational culture and the individual is through the belief/value system. Duty may not be appropriate for civilian organizations. Individual responsibility to the organization as a whole is seen in the uniformed services. They understand that their action and inaction can harm or help the organization. Duty comes from that. Duty of the individual – show up on the job; be responsible for yourself; you have responsibility for things in an HRO; all these are instilled and then branch out to make you prepared for the next big job when you can contribute (not getting by). Individual duties and higher level group duties exist. “In the presence of avoid, move forward,” Jim Denney. In High Reliability people move forward. Every individual believes it is their job even if others are also problem solving. Make duty infectious – don’t tell them to do it but they want to do it on their own, it is infectious to others who will then do it. An infectious attitude toward the cause and purpose, then each person will flourish and want to participate. They will self-sacrifice and go beyond their ego. Infectious or contagious – these are good in an HRO. You set the reputation of the ship when you go into a foreign port for five days after being as sea for 75-80 days. When a 6,000 member crew can leave without a significant liberty incident then you see the infectious nature of duty.
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