Straightening The Deck Chairs On The Titanic

It is always preferential to have foresight where possible, as opposed to hindsight. Working today to prevent the accidents of tomorrow seems to be a sensible approach to Human Factors. With this in mind the irony of our blog writing has not escaped us, constantly we find ourselves looking backwards for examples of accidents to use within the articles. Often these examples are very tragic and sometimes difficult to relive, this is also something that does not escape us. This is important because to develop clear foresight requires an occasional touch of hindsight. The past is where our questions wait, and more importantly the answers to these questions lay, we need to shine a light on these shadows to illuminate the lessons.

                                             The crew of Titanic including Cap Smith

The Titanic presents, in our opinion, the single greatest lesson in Human Factors. When examined, nearly every strand of modern Human Factors is present within this single story. The Titanic lesson is so strong it has now become a metaphor for Human Factors.

Recently it was suggested that investment in ‘prevention focused’ training should be measured against the likely occurrence of a ‘big’ event becoming reality. Is it better to surrender to the hand of fate and hope that chance smiles on you (and potentially save money), or invest and prepare for an unlikely reality? This statement mirrors the corporate mentality of the White Star Liner when designing and building the Titanic. Discussing all of the contributing factors into this disastrous trans Atlantic crossing, from design and build to its maiden voyage, could not be achieved in one blog. With that in mind we would like to focus on one particular contributing element; the mindset and attitude of those involved.

Most organisations that have experienced a sizable accident will of held the mindset of ‘it might never happen’. Added to this investment in preventing something that might not actually become a reality is sometimes a difficult expense to swallow. This can create a paradox of planning and training for an unlikely event, hence the title ‘tidying the deck chairs on the Titanic’. The further paradox with this mindset is you can’t measure the accidents you never had!  

Is it better to ‘appear’ you are serious about accident prevention while really focusing on the more immediate and pressing issues associated with operating a large business? Surely as long as there is a measured approach that complies with industry recommendations this is fine, isn’t it?

Perhaps not?

The designers of the Titanic thought they had created an unsinkable ship, this provides the perfect conditions to test such profound humanistic statements. There is a famous saying that nature does not respect the qualifications or the competence of men. This statement can be applied to avalanches in mountaineering, fog and high winds to airline pilots and, as with Titanic, icebergs and ships Captains. Nature does not recognise their competence nor does it spare them when the time of reckoning comes. The Titanic had lifeboat capacity for only half of its passengers, because they presumed it was unsinkable. Recent evidence has surfaced that before departing Southampton a civil servant called Maurice Clarke expressed serious reservations about Titanic’s lifeboat capacity. His superior’s threatened Mr Clarke’s job and the original recommendation of increasing Titanic’s lifeboat fleet by 50% was overruled. Had this come to light during either the British or American enquiry there may have been a stronger case for corporate manslaughter against the White Star Liner?

                                                Computer regeneration of Titanic 

This ‘invincible’ mindset was intoxicating; the passengers believed it, the ships builders believed it and the crew did also. Even immediately after the iceberg struck still many felt safe. Perhaps the most poignant example of this wilful blindness was that of Wireless Officer Phillips. He was responsible for sending and receiving messages on the one radio channel that Titanic had, he chose to prioritise wireless transmissions of the super rich 1^st class passengers over the iceberg warnings. Mr Phillips went down with the ship, sending SOS messages to the end.

                                                 Both parts of Titanic on the sea bed

Although this seems an extreme example from over 100 years ago, do we still exercise this ‘wilful blindness?’ The answer in short is yes, albeit rarely thankfully. We need look no further than the Costa Concordia for a stark reminder of the hubristic inclination of man.  Part of this fallibility is our romance with courting chance, whether in a casino, bungee jumping off a bridge or performing a flamboyant manoeuvre with a large ship.  Human Factors learns the lessons of the past so to implement today for a safer future. Working with risk will always require measuring the consequence against the likelihood; this process helps us plan with foresight. A safety culture embedded within operational excellence allows for a clear and transparent vision for the future. We need only use hindsight once to know that one Titanic is enough.

"Eternal Father, strong to save, whose arm hath bound the restless wave,

Who bids't the mighty ocean deep its own appointed limits keep;

Oh, hear us when we cry to Thee, for those in peril on the sea!"

Fear of Being Safe

Operational Excellence is rapidly developing into the safety culture mindset of modern workforces operating in risk industries. More often than not a ‘zero accident’ policy will be at the centre of the method statements, risk assessments and permit-to-work policy. The truth is ‘operational excellence’ and ‘zero accidents’ are expensive. Changing culture and ensuring the highest standard of professional development for the workforce are not cheap options and both need time. The key to this equation is very straightforward however – compare the cost of ‘operational excellence’ against the cost of a ‘big accident’!

If BP were given the opportunity to go back to pre-Macondo Blow Out, April 20^th 2010, and ‘right’ some of their wrongs, I’m pretty certain they would jump at the chance.

Unfortunately though it often takes a big event to accelerate the culture change needed for initiatives like Operational Excellence to flourish. BP was proud of their safety culture pre-Macondo, even winning awards for excellence in the months leading up to the blow out. These awards, superficially encouraging, somehow contradict the internal messages driven by senior staff and certainly were not consistent with the email correspondence in the weeks leading up to April 20th.

On March 8^th, Deep Water Horizon experienced a ‘severe gas kick back’, which in every way resembled the April 20^th blow out that killed 11 people. During the subsequent Presidential investigation numerous emails were uncovered that do not marry with the ‘safety first’ message projected outwards by BP. Below is one extract taken just 3 days before the deadly Macondo blow out from the BP Well Team Leader to the BP Operations Manager:

David,

“Over the past four days there have been so many last minute changes to the flying operation that the WSL’s have finally come to their wits end. The quote is “flying by the seat of our pants.”… Everybody wants to do the right thing, but this huge level of paranoia from engineering leadership is driving chaos. This operation is not Thunderhorse. Brian [Morel] has called me numerous times trying to make sense of all the insanity… This morning Brian called me and asked my advice about exploring opportunities both inside and outside the company. What is my authority? With the separation of engineering and operations, I do not know what I can and can’t do. The operation is not going to succeed if we continue in this manner.

So, if the outward projection is ‘safety first’, what could drive the content of this email?

I have, in a previous blog, explored Transactional Analysis (TA) and the role it plays in Human Factors and safety critical communication. The belief within TA is that almost 70% of the transactions (communication) between humans have an ulterior level. The words spoken on the surface represent the social part of the transaction, however, the true meaning of the communication lie at the psychological level. We give these mixed signals all of the time, whether it is telling somebody which way it is to the shower, the words mean one thing while the meaning is something completely different.

Looking at the diagram below the words spoken represented by the solid lines and are Adult to Adult:

Stimulus (Adult) - “The showers are just down the corridor.”

Response (Adult) – “Thank you”

The psychological level however is not spoken but both people know the meaning intuitively.

Stimulus (Controlling parent) – “You need a shower.”

Response (Adaptive Child) – “OK, sorry.”

So how does this correlate with the Macondo blow out? BP had a safety system known as the ‘operating management system’ (OMS) that executives described as the “cornerstone of their safety practices”. This was not applied in the Gulf of Mexico. This would also appear counter-intuitive given the heightened risk when drilling in deep water, as Macondo certainly was.

NASA had a mantra of “better, faster, and cheaper” in the lead up to the Columbia disaster. BP’s mantra, as famously communicated by Tony Hayward, BP’s former CEO, was “every dollar counts”. Both of these carry messages that are disseminated throughout their respective organisations and both of these have ulterior transactions. When this message reaches the drilling teams at the ‘coal face’ it will have taken many subliminal twists, turning the ‘safety first’ policy into a ‘safety first’ with the injunction of ‘while not affecting the every dollar counts’ mindset. The social level is an Adult -‘safety first’, the psychological level is a Controlling Parent - ‘profit first’. This mixed message culture leads to confusion, despair and disillusionment, which are all present within the email in the days leading to the Macondo blow out. BP will feel the cost of this culture and mindset for many years but it would be foolish to believe they are alone in pursuing profits before safety. Other industries can and hopefully will learn from the lessons of Macondo. Safety culture is like all other corporate visions, it should be conceptualised at board level, communicated at management level and executed at the coalface. There cannot be a disparity between the policy at the top and the toolbox talk at the bottom. Added to this external analysis should be encouraged to share best practice.

There is a cost, but it is a cost worth bearing. You need look no further than the statement of the HSE for a sobering appraisal:

“If you think safety is expensive, try having an accident!” 

Operational excellence and a true safety culture require many ingredients. The vision needs strong leadership, delivered with energy, empathy and passion; empty words with ulterior transactions will not inspire and lack congruence. Above all transparency is key, this can mean accountability, or re-framed positively it gives ownership and allows honesty to flourish. When people are doing the wrong things its usually when nobody is looking, transparency encourages honesty – this can only be positive when managing risk. 

Phil Quirk    

REMEMBERING OUR LESSONS….

The Challenger Shuttle Disaster 1986

When I was growing up my friend lived an old fashioned cottage, the entrance to his cottage was particularly low and in my opinion ergonomically poorly designed. Every time, without exception, when leaving his cottage I would bang my head on the oak beam above the door. My pal would always laugh and ask me “will you ever remember the door frame?” – “obviously not” would be my predicable sarcastic retort.

Sometimes we have painful lessons, which enable us to draw the necessary knowledge to move forward and develop, personally or professionally.  Occasionally though we are met with such a painful lesson that the learning is etched into the minds of those present. NASA felt this pain with the Challenger disaster in 1986 and the Oil & Gas industry with Piper Alpha in 1988, painful lessons that could not be forgotten easily – but they were forgotten though? When the Columbia Shuttle broke up 16 minutes before landing in February 2003 the ensuing report was highly critical that NASA did not learn from the Rogers Commission, set up in the aftermath of the Challenger disaster. NASA’s disregard for the safety of its Astronauts brought particular criticism, especially once the Commission discovered that NASA had known about the fatal flaw in the rubber O ring seal for the Solid Rocket Boosters (SRB) since 1977. Many mistakes were made and many promises were undertaken to ensure space exploration was as safe as viably possible.  In the aftermath of Challenger, the Rogers Commission made specific recommendations to NASA surrounding the governance and management of the space program. In 1996 only 10 years after Challenger NASA returned to old practices to save money much to the dismay of the head of Space Shuttle Program at NASA, Brian O’Connor, who argued at the time:

Columbia Crew 2003

“Its is a safety issue, we’ve ran it this way (with the program management at HQ, as recommended by the Rogers Commission) for 10 years without a mishap and I don’t see any reason why we should go back to the way we operated in the pre-Challenger days.”

O’Connor’s concerns fell onto deaf ears and NASA chose to ignore his outspoken opinion, he felt this left him no other choice than to resign from NASA. Although both accidents are unique from a physical perspective, they are eerily close in managerial errors; this did not go unnoticed by the Columbia Accident Commission which was highly critical of the middle management hubris of NASA. In both examples a fatal flaw to both Shuttles, which was known by NASA, became watered down and a culture of acceptance of risk overtook the desired culture of safety first – without compromise.

Challenger Crew 1986

Deep Water Horizon 2010

It seems that this short term memory is not uniquely preserved for NASA, the Oil & Gas industry have a similar example with Piper Alpha in 1988, and the Deep Water Horizon (Macondo blow out) in 2010. Once again although the physical elements of the disaster have their uniqueness, the human factors bear similar resemblances – specifically with regards to the acceptance of risk in the presence of profit, although NASA's problems lay in the opposite end of the spectrum - maintaining the output with less financial resources.  It is this desensitisation of this risk acceptance, which runs through all 4 examples, in all cases the associated issues that contributed to the final event, became acceptable.

Can an organisation fully commit to a safety first culture while management decisions clearly reflect a profit first mind-set?

What signal, be at the conscious level, or unconscious level, is sent by organisations to the work force?  

My honest belief is no to the first question and the wrong one to the second, and so is Lord Cullen’s who led the enquiry into the Piper Alpha disaster.

           

Piper Alpha 1988

The similarities between these 4 catastrophes are striking from a Human Factors perspective. Effective decision making in the aftermath of both Challenger and Piper Alpha were criticised by the respective enquiries, however, it only took 17 years for NASA and 22 years for the Oil & Gas Industry to forget some of the vital lessons learned.

Once again the lessons taken from Columbia and Macondo are raw to those working within these risk related industries. In the immediate aftermath of such events motivation is at it’s most intense to ‘turn the corner and improve safety’. The pain of loss can be viewed as a metaphor for ‘the stick’ in motivation; this represents an organisational ‘away from’ motivational preference. It represents a motivational system which is at it’s most intense after the event - however there is another way to approach safety?

The ‘carrot’ which represents a ‘towards’ motivational preference encompasses an organisation continually moving towards a complete safety culture. Each day, week after week, the organisation works towards a common vision communicated throughout the workforce and embodied by the management.  This avoids the spike in activity, which inevitably follows a significant accident, more over acts as bow wave of activity continually evolving with relentless energy and without pause.

My stick typed lesson when banging my head on my friends door frame eventually became embedded, there was only so many times I seemed prepared to endure the pain associated with my clumsiness. My hope in the future is NASA and other risk related industries do not require persistent 20-year ‘bumps’ on the head.

  

THE TIME FOR DECISION IS NOW, OR IS IT?

Timothy Galloway, in his book ‘The Inner Game of Tennis’, explores the possibility that concentrating too much on a skill has profound negative effects – especially during the coaching phase of skill acquisition.  In short you can concentrate too much creating the conditions of indecision, or paralysis by analysis.

I have often wondered at which point in time is a human decision made? When, and how does a thought transmit into a behaviour, and equally important is a decision without a visible behaviour really a decision.  I once heard a story about the Commanding Officer of the SAS, he would personally interview new young Officers arriving at Hereford, and without exception he would always make the same statement.

“Right decision, well done. Wrong decision, unlucky; learn for next time. No decision, unacceptable!”

I have repeated this story many times when trying to coach someone into becoming decisive and taking action. Indecision is the friend of procrastination, delaying the call for momentum that acts as a precursor for a positive, or even negative, choice.

The question still remains, when does the decision take place, and is deciding to do nothing still a valid decision?

To help answer this interesting suggestion perhaps I could look at the decision making process of a TT motorbike racer, performing thousands of life or death decisions each lap of the infamous Isle of Man TT course. Athletes often describe a Zen like state called ‘flow’, in which everything falls into place without thought. The scientific minded people would ask how do we quantify this ‘flow’ and how do we know when exactly an athlete has it, what is present during flow that is not present without it?  The simplest explanation could be the surrender of the decision making process from the conscious mind to the unconscious mind. If the common hypothesis is true that the conscious brain can process around 7 bits of information (plus or minus 2), at any one time, surely there would be reliance on recruiting other resources needed to deal with incredibly fast processing of the world around at 180 mph. Decisions would need to be made instantaneously, without the benefit of hindsight, and without time for an effective review of the various options available – the right decision, every time, with no second chances.

Ayrton Senna once famously backed of a flying qualification lap; around a blind corner an accident had taken place without his knowledge. Had Senna attacked this flat out corner he would certainly of collided with the wreckage of the car in front, something told him to take is foot of the accelerator in a split second decision?  Somehow Senna had interpreted information outside of his conscious awareness leading him to make this incredible decision – he had effectively listened to his gut feeling! Senna at the time was the biggest star in F1; he was accustomed to all eyes being on him during races and qualification. This corner was different somehow, when the footage was reviewed of Senna’s approach to the corner the thousands of eyes usually looking at Senna were not, they were looking to their right at the crash scene, this piece of information, outside of Senna’s conscious awareness, was enough for him to abort the lap on the strength of a split second feeling inside his gut.

So, if an athletes ‘flow’ is achieved in the surrender of decisions to the unconscious brain could accidents occur when the conscious brain tries to muscle back in on the act? This can be quantified most clearly with footballers taking penalties under extreme pressure. Most missed penalties are a result of indecision that can be observed early in the attempt. Getting ‘caught in two minds’ suddenly becomes an ironic commentators pun. Contrast this 2 minded approach often seen by footballers taking penalties with that of the rugby player Johnny Wilkinson, he makes every aspect of the kick a ritual, almost entering a mild trance in which he can silence all around and hand over the task, in its entirety, to his unconscious mind.

The difference, however, between the decisions of footballers and rugby players should not be compared to TT racers. Richard ‘Milky’ Quayle once said, from his hospital bed after a 150mph crash, that the 37 mile course was incredibly hard mentally and that often he would have to battle to ‘stop his mind wandering’. This wandering of the mind could be the switch backwards and forwards between conscious decision process and unconscious decision process, science would suggest that travelling at 170mph through Kirk Michael village with houses either side added to the almost infinite other pieces of information, represents more than the 7 afforded to our conscious brain?

Science and neuroscience are providing us with some of the most incredibly interesting research on the point in time when a decision is made. Research from the Max Planck Institute for Human Cognitive and Brain Sciences suggests that a decision is actually made up to 7 seconds before we are consciously aware, which in and of itself provides ideas and theories to be explored in future blogs.

One thing is for certain though, through heightened awareness comes a heightened reliance on the unconscious mind. Information processing, situational awareness and decision making all require cognitive skill, perhaps there is no greater example of this than the men who average 130mph around a road circuit sandwiched between houses, hedges and stone walls.

Timothy Galloway discovered that rather than over coaching specific details, if he asked his tennis players to think only of bounce – hit, in time with the game, they had incredible results. The surrender of the skill to the unconscious brain allowed them to achieve the ‘flow’ so sought after by athletes.

The Parent of Miscommunication

The Parent of Miscommunication

There is a rapidly growing belief, with good reason, that Transactional Analysis can play a vital role in developing employees within Human Factors training. This body of knowledge born initially in the fields of psychotherapy and counselling, and now embedded both educationally and organisationally, offers an intriguing insight into the behaviours of, and between humans. Added to this and perhaps more importantly some of the simple reasons human communication breaks down while conversely, some communication flows naturally. With only a basic understanding of TA theory many serious and minor workplace conflicts could be avoided, the secondary gain by virtue of osmosis is a reduction in human related accidents.

Within this blog I will explore two specific elements of TA. Firstly, the Parent, Adult and Child (PAC) model, where I will attempt to explain TA in its most colloquial form. Secondly the role that life positions can play in the workplace, and the subtle situations familiarly linked with each life position.

Dr Eric Berne principally developed TA in the 1950’s until his death in 1971. Dr Berne, while treating World War II veterans, noticed they exhibited distinct and separate ‘Ego States’ when observed closely. These individual Ego States form the basis of our personality, more importantly how choosing an appropriate ego state can improve the successfulness of communication.

While in our Parent ego state we are replaying thoughts, feelings and behaviours copied from our parents or parental figures during childhood development. The Adult ego state is known as logical and rational, responding to the here and now situation with processed thought - often likened to a computer. Finally the Child ego state which is a little boy or girl, carried within, comprising of thoughts, feelings, language and responses relating to specific certain ages during the persons childhood development. It is worth pointing out at this juncture that the Child ego state is not ‘immature’ or ‘childish’ which are both Parent descriptions of behaviour.

Within this model of communication Berne describes transactions that occur between people, some transactions are complimentary and can run indefinitely. Communication is broken when we experience a crossed transaction, this occurs when the response you’re expecting does not come from the appropriate ‘ego state’ expected. Often played out in the workplace crossed transactions form the basis for miscommunication and misunderstanding – over prolonged periods suspicion and mistrust can manifest into unproductive or potentially dangerous situations.

Consider for a moment that I continually attempt to communicate Adult to Adult with my supervisor; she however returns my here and now rational questions with an unnecessary Critical Parent response. Communication soon becomes untenable, which leads me to a conscious choice not to engage with her unless absolutely essential to complete my work.  Politely we can both opt for the easy option to ignore each other, however there is a deeper issue at hand where in she feels professionally threatened, without cause, by my career trajectory – causing her to unconsciously select her Critical Parent ego state when in communication with me. It is also worth pointing out that there are two levels of communication, the first being the ‘social’ level which are the actual words used, more importantly however is the ‘psychological’ level which is the true meaning – not represented by actual words but by subtle tones, looks and expressions. Berne estimated that as much as 70% of all communication takes place at the psychological level. The behaviour exhibited by my manager is also driven by her life position, which can be one of four options.

1.     I’m OK – You’re OK / the position of win-win and productivity.

2.     I’m not OK – You’re OK / the position of the depressive.

3.     I’m OK – You’re not OK / the position of the bully.

4.     I’m not OK – You’re not OK / the position of the despairing.

Firstly the most important question is, what is not being said?

From her oppressive behaviour we can assume for the purpose of this blog she lives her life from the I’m OK – You’re not OK position, or bully. Trusting others is difficult for her because she sets her stall out early to manage subordinates with aggression and oppression. Opting for the ‘stick’ does not endear her easily to colleagues, although she will probably explain the lack of warmth shown to her by jealousy of her self-perceived career progression. This contaminates her model of the world and she will continually seek evidence to prove her distorted view point by playing work based psychological games that add weight to her theory that subordinates can not be trusted - meaning she must manage strictly to ensure both job standard and timely completion. Potentially she has a strong ‘be perfect (or be a failure) driver’ behaviour inherited from an early age from her mother and/or father, who both did not suffer fools gladly and enjoyed a good game of ‘now I’ve got you, you son of a bitch’ regularly.

Outside of her conscious awareness she may even actively set colleagues up to fail, something taught to her by her over bearing parents, which will allow her to take over and snatch projects from the impending disaster (while quiet appropriately flying of the handle at her victim). From this position she can claim two victories, the first being acknowledgment from superiors on her magnificent situational rescue (again), more importantly, and subtly, it manoeuvres her subordinate into a one down psychological position savoured by bullies from every level of society. The selection of her opponent to join her in this game is also vital; as to follow the game through to conclusion will require unequivocal failure from her opponent at some point. Once in the one down position rarely will the bully allow the person an opportunity to recover - periodically reminding them of their failings, unless off course, subconsciously they surrender completely and superficially join forces in entrapping other, stronger willed colleagues. In this arrangement we can move to the I’m OK, You’re OK, They’re Not OK position often used by bullies for shallow alliances. Most interestingly we both know at an unconscious level that this shallow alliance is both superficial and not without further clauses, which never requires verbalising or reviewing but can be brought to bear at any moment.

This scenario is played out throughout every office in every profession known to man, throughout time; the real question is what can be done? Evidently it is important honest and productive lines of communication are restored, especially when working within safety critical industries when poor communication can, and have, led to massive disasters with huge loss of life. With TA coaching, communication can be examined, not by content but by process. Much of what is happening is happening outside of the conscious awareness of everyone; perhaps all that is within immediate awareness is the familiar bad feelings that are the result of game playing and broken communication. The goal is to bring my supervisor to the I’m OK – You’re OK quadrant, which will allow her to start trusting her subordinates, at the same time I can develop my knowledge and understanding of the PAC model allowing me invite her Adult into our transactions at every opportunity. Continuing both of our education and development allows us to become ‘game free’ in the workplace, replacing unnecessary traps with improved productivity.

Transactional Analysis offers the knowledge to coach colleagues to improve their interpersonal relationships within the work place, which, in turn leads to more productivity, reduced miscommunication, and subsequently a huge reduction in accidents in the work place.  Communication is important in all industries, however in safety critical industries the cost of miscommunication can lead to potentially fatal accidents.