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.    

When Money And Mountains Meet

On May 10^th, 1996 Mount Everest played out one of its most dramatic 24 hours in its formidable history. The mountain claimed the lives of 8 people – 5 on the south side and 3 on the north, included within this were 3 expedition leaders and 1 guide. Never before, even with Everest’s formidable reputation, had the mountain provided such drama or poignancy. The culmination of a harrowing 24 hours finishing with Expedition Leader from the Adventure Consultants, Rob Hall, widely acknowledged as the worlds leading Everest guide, dying alone on top of the world, the final twist of fate being a chance satellite telephone call to his heavily pregnant wife in New Zealand.

In my last blog I explored the hubristic decisions made by NASA prior to the loss of the shuttle Challenger. Today I look closely at the Human Factors that were present as 4 separate expeditions attempted to summit the world’s highest mountain on the same day. Specifically I will examine the loss of situational awareness from the teams who lost their expedition leaders on the South Side of the mountain – Scott Fischer from Mountain Madness and Rob Hall from Adventure Consultants.

Essentially, as with most disasters, a culmination of many errors compounded to create the necessary ingredients required for such a catastrophe. Colloquially referred to as the Swiss Cheese effect (Reason 1990). As the title suggests, the many holes of the cheese are a metaphor for individual mistakes which when compounded and then repeated will sooner or later result in a number of holes aligning, allowing a beam of light through the cheese - the disaster event. Often combinations of errors will either go unnoticed or perhaps provide near misses, which may, or may not be reported. The presence of a near miss, especially when repeated, can indicate potential future disasters; unfortunately these near misses are seldom reviewed and even less frequently acted upon. A culture of, ‘wow! We were really lucky to get away with that; best keep it quiet to avoid embarrassment’ presides over a culture of, ‘wow! We need to discuss and explore what happened there to prevent a re-occurrence in the future’.

Unfortunately on this day a culmination of multiple errors in judgement combined with a terrifying storm at over 28,000ft. As ever, there are many contributing factors, which resulted in this terrible loss of life that fateful day. Each survivor tells their own version of events, complete with accompanying blame proportioned towards different individuals. The mistake that ultimately triggered all that came after was a simple, yet golden rule that was ignored.

·   The turn around time, which is set in stone, was 1300 on the day; this is considered a fundamental rule for Everest summits, even if the group is 100m from the summit you turn back at this pre-agreed time. 

·      This timing has many permutations; the reliance on oxygen in the death zone, above 25,000ft means there is only a narrow window to push up from Camp 4, summit, and then return safely to Camp 4.

·     Physical exhaustion and the prospect of potentially descending in the dark while completely exhausted from the summit attempt.

·      Rob Hall was famous for obeying these agreed cut off times religiously; he had, on occasions scolded other leaders for being flagrant towards these timings, he had even turned climbers back within touching distance of the summit. On this day he did not, in fact he was still struggling to summit his last client, Doug Hanson, well past 1600 – 3 hours late.

What unravelled in the hours proceeding that fateful decision would never had the opportunity to develop, had this cut off time been adhered too.

Within Human Factors we teach, discuss and develop Situational Awareness (SA), this can be accurately described as:

“An awareness and understanding of what you are doing and what is happening around you combined with the Knowledge to interpret this data to predict future events.”

 The lack of oxygen while working at the incredible altitude of Everest places more strain on the mental capacity of the climbers, when climbers approach task saturation (overfilling their ‘mental cup’ with information) simple decision making becomes laborious and unreliable – this multiplied by the lack of oxygen available. Consider a time when you perceived yourself working at your maximum capacity, you probably found yourself struggling with basic prioritisation, the effect of this is – you can’t seem to start anything and quickly become annoyed, anxious and irritable? If you have, this is what occurs with task saturation. In an office environment, a mildly annoying emotion resulting from trying to focus on multiple tasks simultaneously – at the summit of Everest a matter of life or death.

These simple decisions, which often lead to further exasperated problems, are not uncommon in Human Factors. Often the loss of SA is, in and of itself, an entirely unconscious process, the climber starts to suffer with tunnel vision and fails to notice glaringly obvious flaws in their strategy. Some of the last photographs of Rob Hall’s expedition approaching the Hilary Step clearly show the impending storm approaching from behind the doomed climbers. With only a basic knowledge of weather and geography a relatively novice mountaineer would of quickly concluded that the summit attempt was not possible.  Why then, did two of the most experienced high altitude mountaineers lose such basic situational awareness?

Perhaps both Scott Fischer and Rob Hall had different reasons for their individual loss of SA. From the South Summit to the Hilary Step Fischer had become laborious and had fallen behind is own clients, unheard of for such an extraordinarily robust and strong guide.  It is now believed that Scott Fischer was in the grips of either High Altitude Cerebral Edema (HACE) or High Altitude Pulmonary Edema (HAPE) – or perhaps both? Tragically for him the naivety and lack of experience of his clients meant that correct diagnosis was never identified, even though he was clearly displaying all of the symptoms. Doug Hansen, on the other hand, was being cajoled and spirited to the summit by his expedition leader - Rob Hall, while not far away Scott Fischer was incoherently talking about jumping to his death Hansen and Hall had hopelessly missed the agreed cut off time. The previous year in 1995 Rob Hall had turned back Doug Hansen within touching distance of the summit, at between $30,000 - $60,000 a summit attempt perhaps Rob Hall felt a ‘moral obligation’ to summit the likable Doug Hansen.

On reflection it is always easy to analyse others actions, in truth the most experienced professionals will suffer from lapse in situational awareness. With training these statistics can be affected, with every mistake a human is capable of making we also possess the qualities to develop, learn and modify our behaviour. Human Factors is this continuous developmental process of understanding humanistic decisions and actions, especially when working in challenging conditions.

Similar to the Challenger disaster, the learning from Everest was short lived. Within a decade the mountain would become the focal point of arguments about the suitability and morality of allowing at times inexperienced mountaineers to be guided to the summit of the earth - for the right price.  Arrogance and greed fuelled by commercial blindness at 29,000ft will always provide the theatre for such disastrous days.

The Dark Summit brilliantly written by Nick Heil highlights this uneasy truth. In May 2006 over 40 climbers either ascended or descended past David Sharp, a young British mountaineer. While he lay dying from high altitude sickness his like-minded climbers, all of which in the grip of summit fever or suffering complete fatigue, callously ignored his plight. The moral question each of these climbers asked of themselves was:

 “Am I prepared to sacrifice my $50,000 summit bid to save this young climber?” 

Unanimously they chose no.