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Stop looking for what went wrong… Part 2

Below is a copy of an article I wrote for an aviation safety newsletter. It’s reproduced here and edited slightly for general readership.

I believe these concepts should be of interest; not just to people in safety-critical industries, but also of interest to anyone who desires to improve workplace quality and performance; I would advise that ‘Safety and Quality’ are close siblings.

I wrote an earlier post that introduces this: Stop looking for what went wrong – and look for the things that go right. Part 1 (Introduction)


Have you ever seen references to Safety II and “positive” reports? Safety II is still, largely unexplored and not fully embraced within safety management systems. But what is Safety II and why is a positive report a relevant thing?

Safety I

First a quick reminder of how we traditionally manage ’safety’:

Traditionally safety has been considered a matter of risk reduction, in both a proactive and reactive manner. Processes and guidelines are given to employees; training is supplied to the employees; equipment (eg aircraft) are engineered (and monitored) to withstand wear/ fatigue/stress and designed to be as easy to use as possible; and then work is done. After an accident, incident or near miss, processes are dismantled and examined. ‘Causes’ are searched for – a broken component, a broken rule or a human error is searched for until the “a-ha” moment is found and the cause or causes can be reported – eg, the cause of the accident was a failure to follow procedures, or a broken widget etc. These causes are important in Safety I systems because they allow the creation of more risk reduction, through more rules, or strengthened components, monitoring of trends, or penalties for guilty and negligent personnel1, 2.

However, Safety I is incomplete thinking: aircraft and their associated systems are too complex for every possible outcome to be predicted – therefore rules, procedures and trend-monitoring cannot be created for events that are not yet known.

Safety II

The Safety II model is based on building resilient systems that recognise that people and their behaviour are the solution and not the problem. Safety is built and encouraged based on successful outcomes – successful outcomes are shared and disseminated for others to learn from. A Safety II system might not even be thought of as a system but instead as an organic and live process that responds, monitors, learns and anticipates and is therefore resilient to the changes and variations of complex work systems and environments3. People therefore need to be empowered to have self-determination and collaborate to create safety based on the circumstances at the time, and not based on a previous risk-assessment or set of rules that may have become out-of-date or inappropriate.

In Simple terms….

In simple terms, let’s think of traditional safety as “what went wrong?” and “don’t do that because it’s bad” and “follow these rules”

Lets think of Safety II as “what went right?” and “do this because it works well” and “take the necessary action required at the time”.

How do I achieve Safety II?

You already are… but you don’t know it. Every time you operate and have no unsafe events, it’s because YOU, the operator made hundreds of correct decisions, used your experience & knowledge and collaborated effectively to achieve a completely uneventful outcome! Well done – sounds a little boring doesn’t it? Well before we start congratulating ourselves, let’s see how we can improve our Safety II culture. It’s important to look for the things that people do to make things work and succeed – and not just look for the hazards to avoid.

Examples:

Normal, routine activity is interesting! Don’t take for granted all the little actions that you carry out when operating. Only a fraction of what we do is actually prescribed in a flying guide or contained in an SOP. The vast majority of our actions are the result of habits that we have created for ourselves. There could be many hundreds of positive little things that you do which have never occurred to a colleague. Have a think – can you share ideas and tips? Can others learn from what you do? If you’re in a training role then do you praise the little positive successes that you observe? Do you spot neat little ideas and think to pass them on to the wider community? Or are you just concentrating on finding errors in technique?

Here’s a quick example from Exeter Airport: when taxing out of dispersal the windsock is not easily visible to the pilot – but it is to the LHS Operator. When we leave the dispersal on a dark night with the airfield closed, the LHS operator looks at the wind sock and says, ‘Chris the wind’s from the south’ or whatever. Great – that’s added a little positivity to my situational awareness and helps me plan my departure. There’s no way that can ever be in a rule book. But it is one of many useful little things that build safety and create a routine successful outcome.

When flying with a similarly qualified person are you looking for the little differences? Are you saying to your buddy “hey, you do that? – that’s neat” and put it in your own back pocket… or are you concentrating on being “standard” and not messing up in front of your oppo, and in so-doing stifling the extra stuff you do? (The obsession with critique (in preference to praise) throughout military flying training/assessment has a lot to answer for I’m afraid…)

Safety Reporting

If you report an in-flight malfunction, then report what you did to create a safe outcome – did you use the AP (autopilot) upper modes (height, heading, guidance holds)? did you use ACANS (iPad mapping system) to assist with navigating to a diversion? did a member of crew make a suggestion? did Air Traffic Control give assistance? There are so many variables – but some key decisions about the positive actions you took is how someone else could learn to have a similar positive outcome. In other words, what did you do? Just reporting that “you carried out the drills iaw the flight reference cards and landed without further incident” omits a lot of Safety II opportunities.

Summary

Safety II is a big area but largely unexplored – it shouldn’t just be thought of as ‘best practice’ or ‘common sense’ or CRM (Crew Resource Management) or ‘correct techniques’. It encompasses those, but a Safety II culture also requires the sharing, learning, reviewing, updating, rethinking and positive enactment of all the little granular decisions and actions that you make every time you fly. People makes things safe; not rules and regulations.

References:

1. Drift Into Failure, Sidney Dekker

2. The Field Guide to understanding ‘Human Error’, Sidney Dekker

3. Safety-II and Resilience Engineering in a Nutshell, Dong Han Ham

4. Trailblazers into Safety-II: American Airlines’ Learning and Improvement Team

5. https://safetydifferently.com/instead-of-top-down-safety/

I’ve also drawn on my own experiences in Quality Management in commercial business: encouraging employees to achieve quality work can generate similar barriers through fear of mistakes and error – telling staff what to do via a set of rules never worked! Giving staff guidelines, telling them what to achieve (and giving them the decision making power) achieves better outcomes.

A PDF of this article is available for download below.

Setting the best example – always

Set high standards for yourself – and maintain them. Always. It takes effort – but it’s worth it. And it soon becomes quite easy because you can turn high standards into good habits. Setting high standards for yourself puts you in a good position for several reasons:

  • First – it means you’re always in the right ‘frame of mind’ – and if you’re in the right frame of mind, then you’ll perform well.
  • Secondly, most people are actually quite easily influenced – it’s human nature; we all want to fit in. So, if you’re a leader, manager or an influential figure in your workplace, then the people around you will adopt aspects of your style and manner. It’s nice to inspire and positively influence people and, ultimately, it contributes to creating a high performing team.
  • Thirdly, if you ever find yourself in the position of needing to change or criticise or introduce new practices, then people are more than likely to trust you and believe in what you have to say.

A word of caution – this is about setting high standards for yourself! It’s not about laying down the law and being pedantic with your colleagues. Be the person who sticks to the dress code; who turns up on time; who carries out the daily routines; and who knows their subject – do it cheerfully and willingly. And encourage others to help you. You’ll be infectious and the workplace will be better for it.

Why I think military leadership is dull and why commercial leadership is the place to be.

Friday 9th January 1998: it’s a dark, wet, rainy night in The South Hams, Devon. I’m in the first week of my year long Officer Training at BRNC Dartmouth. Along with my Division of new recruits, I’m standing in a dark field and about to commence a map-reading night navigation exercise wearing my newly issued DPM combats, beret and boots. To be honest, the exercise was pretty easy and not that different to the stuff youngsters might do in the Scouts or Cadets. It was only a ‘starter-for ten’. However, it was my first training exercise in military leadership as a paid, professional trainee Officer. The thing I remember most was my Divisional Officer, a Royal Marine Major, stating that “leadership is not about handing out sweets when it’s your turn to lead the map reading exercise!”… (I made a mental note to keep the sweets I had to myself!) I don’t remember what he did define leadership as.

“leadership is not about handing out sweets when it’s your turn to lead the map reading exercise!”

And that was the start of a constant stream of leadership training that ended in 2014 when I left the RN. Every training course throughout flying training had a ‘character and leadership’ assessment that ran alongside all the flying assessments. Every annual report ever, assessed my leadership ability and therefore my suitability for leadership roles and promotion. At suitable points throughout an officer’s career, he or she will likely attend a major leadership, command and staff course at The Royal Military Academy, Shrivenham which will be several weeks long or even a year for the senior officers.

And it’s not just the officers – all the non-commissioned officers and junior ratings also receive leadership training throughout their training and career.

So, with all this training, you’d expect all Officers in the Royal Navy to be excellent leaders. In fact, with the resources, technology and access to information that we have, you might expect the military to be a centre of excellence for leadership, development, innovation and progression.

So, with all this training, you’d expect all Officers in the Royal Navy to be excellent leaders

That would be a fair assessment to make I suppose. In which case, why were all of the senior officers that I worked for so convincingly unremarkable? Squadron Commanding Officers, Ships’ Captains, The Base Commanders and Heads of the Fleet Air Arm? I cannot think of a single noteworthy example of leadership from any of these Military Officers. For that matter, I can’t really think of any household names of military leaders since, um, about 1996 perhaps.

Now, people reading this with their own experiences might immediately accuse me of writing total nonsense and counter with many examples of military leadership in combat scenarios etc. These are very real and of course commendable and have my utmost respect – but where are the modern-day Admiral Nelsons, Captain Scotts, Wing Cdr Gibsons, Field Marshall Montgomerys, General De Labillieres and General Jacksons? Where are the new leaders that should be filling the history books? Where is the inspiration for school boys and girls with tales of strategy, adventure and discovery?

I’m not saying today’s Senior officers are bad leaders – just simply that there is no need to really lead anyone… they are custodians of their role. By this, I mean their role, duties and responsibilities are pre-defined and the officer is appointed into the role – they fulfill the role and then move on to their next post after a couple of years thus making way for the next incumbent. Furthermore, they are also not given the scope to be genuinely innovative and creative, and nor do they foster these attributes in the men and women for whom they are in charge of. And in many respects, they’re not incentivised to! They merely need to fulfill the role within their posting in order to tick the box for the CV – which is usually is enough for an often preordained promotion to the next rank…

Leadership is needed when things change

And here’s the thing: stable, unchanging conditions do not require leadership! And, in the context of war and death, this is a good thing. Stability is good.

Leadership is needed when things change, for example:

  • The location is changing – eg an expedition
  • The geo-political situation is changing (or change is the threat) eg resulting in dispute, conflict and war
  • Ambition is driving a change – eg, technology needs to change and advance in order to meet new needs and desires
  • The commercial market is changing
  • Death Rates are changing (increasing) due to disease/pandemic

Ultimately, a leader needs an understanding of ‘the change’

What is leadership and its attributes? Ultimately, a leader needs an understanding of ‘the change’ – then the leader needs to do the following:

  • Create a vision of the final/desired outcome
  • Create a solution(s)/plan (using all effective available resources).
  • Create/select methods to convey to your team (and delegate as required) the necessary logistics, actions and incentives to reach that vision.
  • Monitor progress

Note my use of the word “create” – creativity, lateral thinking and pragmatism are key to a leadership team. An effective organisation needs space and utilities for creative thinking – merely hoping to use pre-determined SOPs or previously used routines are unlikely to create bespoke, innovative solutions to progress (or retard) change. Leadership without creativity is really just ‘management’.

This is where leadership in the business and commercial world is so exciting. In the 20th century the Government (and Government funded organisations) pioneered new technology and innovation through military equipment, the cold war and the space race all supported by healthy public funds. But governments are no longer the custodians and vanguards of new technology.

Ultimately, we are all trying to solve problems with solutions. The problems are the root cause of the change. If there is no problem, then there is no need for a solution – and if there is no need for a solution, then there is no need for a change which means there is no need for leadership. Any entrepreneur is usually looking for a problem to resolve:

  • How can a task be done quicker?
  • How can a task be done cheaper?
  • How can a task be done more reliably?
  • How can a client have a better experience?
  • How do we reduce greenhouse gases?
  • How do we create enough food?
  • How can we reduce transport requirements?
  • How can we streamline our supply chain?
  • Where will humans live when planet earth becomes uninhabitable?

There are, very definitely, many more problems to solve in the commercial and civilian world than in the military world. And many large organisations are spending huge sums of money on technology, innovation and creative output. The opportunities are endless and, for many organisations, there seems to be an endless supply of money. Small businesses can be in the party as well: software, apps, automation, 3D printing, collaborative systems, virtual-reality and simulation are all bringing really cool solutions right into the workplace. We’re living in exciting times. Our modern day leaders and household names are global: Bill Gates, Elon Musk, Richard Branson, James Dyson, the late Steve Jobs, Jeff Bezos.

Summary

In business, you need to lead – you need to lead your staff when your business develops, grows and changes. You need to lead your clients when they are in the process of using your services – they are seeking your services, probably because something is changing in their life: a house move or a job change or a change in financial circumstances or children are growing up or their physical or mental health is changing, or a desire to change (eg, get fit, lose weight, learn and instrument) etc. This is when the business owner, or employee needs to lead.

  • In your business do you have a system for logging and developing new ideas?
  • If you’re a business owner, are you keeping up with technology in your industry?
  • Does your business embrace change and new developments to overcome problems?
  • As a business owner, do you revise and envisage where you want your business to be in 1, 2, 5, 10 years time?
  • Do you have a team, business partner or even just a trusted adviser with whom you can create ideas and lay down the path that your business needs to follow?

Remember, leadership is not about handing out ‘sweets’. You might give your staff benefits, a generous salary and bonuses and they might all really like you. Its doesn’t make you a great leader. But that’s not to say staff rewards, incentives and treats are not allowed. But’s another article.

Are you being stupid?

I recently received the following article from an acquaintance – it was topical as his organisation were undergoing a seemingly bizarre restructuring process which, to employees on the ‘shop floor’, seemed to be arriving at some odd conclusions in the context of their operational output:

https://psyche.co/ideas/why-some-of-the-smartest-people-can-be-so-very-stupid

The main point of the article is that smart people can be stupid when they lack the correct ‘conceptual tools’ as a result of culture, ethos or specific pressures within their organisational group.

However, is the article fair? It’s a bit like accident investigation: no one consciously decides to do a bad job; no one consciously wants to cock it all up; actually, people/teams make a decision(s) that makes sense to them at the time, and which factors in the pressures, aims and objectives in their immediate world – it’s not possible to select new conceptual tools when you think you already have the right conceptual tools.

it’s not possible to select new conceptual tools when you think you already have the right conceptual tools.

Which is why good leadership should also be humble and garner opinion, thoughts and advice from a wide variety of areas. And it’s why people on the outside-looking-in should be forthcoming and, in a constructive way, question and query ‘stupidity’ when it arises.  

  • If you’re a business owner, do you consult with your team with a genuine desire to get ideas and fresh inspiration for business development?
  • Does your business/organisation have a genuine and real forum for allowing constructive criticism?
  • If you’re a lower/middle-manager, do you have the confidence to constructively comment and advise your senior management on business processes?

And it’s why people on the outside-looking-in should be forthcoming and, in a constructive way, question and query ‘stupidity’ when it arises.  

You can be stupid – just allow other people to tell you when you are! And if they do, then take heed.

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