Many people use the start of a new year as an opportunity to make new resolutions. Perhaps purified by the review of the past twelve months at the holidays, one or the other experiences a motivation to (re)start working on themselves. With this blog, I would like to give a focus for this very activity to all those who feel this desire for self-improvement within themselves.
In the last two blogs, I have addressed the legal framework that is of great importance for safety cultures in companies. Now I turn to the other end of the scale, where the central work on the safety culture (Just Culture) is entered. At the beginning of this scale is the human being with all his strengths and weaknesses. So we are at the point where everyone can ask himself or herself what he or she can contribute to making things happen safely in the company. Spontaneously, we certainly have answers ready. For example, make an effort, follow the rules, concentrate at work, don't get stressed, stay calm and much more. These are appeals that we make to ourselves and to others. The experiences we have had with these appeals are mixed, because sometimes, with the best of intentions and intact inner attitudes, it can be very difficult to live up to them. All of us have experienced in different ways our own fallibility; of having only a conditional ability to stick to resolutions. These experiences put the concept of resolution into perspective. A seriously intended plan is far from a guarantee of successful implementation. Knowing this, it makes little sense to once again keep clearly in mind for self-improvement, the appeals we make to ourselves. On the other hand, it might be a matter of creating an inner readiness to take a closer look at the fallibility of us humans in general in the coming year. That is, to take a little time to deal with the error and to use the opportunities that everyday life offers us. After all, the way we ourselves handle our own and others' mishaps, and what we as leaders do with the lessons learned from such events, is important. It is probably even more significant for safety than the current unfavorable regulatory environment for safety cultures in our companies. A good safety culture can only thrive if we constructively address the fallibility of us humans and the imperfection of the systems we create.
If you had made an effort, it would not have happened!
We humans are not perfect, we are fallible. That is not an assumption, it is certain knowledge. It is certainty. But how do we explain our reaction when we become aware of a mistake or directly witness or cause a mishap? A clumsily knocked over coffee cup, a scratch when parking, a missed penalty by the center forward of my favorite team, forgetting the mail that the customer urgently needed. In many such situations, it is impossible for us not to have the thought, "If he or she had tried a little harder, it wouldn't have happened." Try it at the next opportunity! Which already brings us to the core of the issue. This thought illustrates that we carry around an assumption that if we tried hard, we could be flawless. It combines poorly with the certainty that people are fallible. It ultimately says that if the condition of trying hard is given, we are infallible. It suggests that we can be without error if we want to be. But this contradicts all our scientific knowledge.
At this point, it should be noted that we are not talking about errors committed with intent or with gross negligence. Willful misconduct, deliberate acceptance of damage and gross disregard of obvious risks are not part of this discussion. It is usually not these types of errors that concern us in everyday life. It is the actions which have unintended consequences, the work errors or "Honest Mistakes".
The scientific image of man
We cultivate an image of ourselves that is characterized by rationality and predictability, which we are not able to satisfy in reality. We create complex systems and meticulously define the rules that should guarantee their functioning. This concept is based on two basic assumptions. We assume that the rules are correct and that everyone will follow them. Only to find time and again that neither really applies. In a claim caused by an employee's mistake, when we take the trouble to find out why it happened, we invariably discover two things. The system didn't work the way we meant it to, and the people in it are fallible.
One person who has scientifically dealt with this fallibility as a psychologist and was honored with the Nobel Prize for it is Daniel Kahnemann. In his book 'Thinking, Fast And Slow' he summarizes our fallibility in six hundred pages. He draws a picture of us humans, which is characterized by two systems, which mutually influence our thinking. Of 'System 1', which unconsciously works effortlessly, cannot be switched off and thinks intuitively and quickly. And of the 'system 2', which is willfully controlled, takes on the strenuous mental activities and thinks consciously and slowly. The focus of his book is the errors in our intuitive thinking. He illustrates how the influences of 'System 1' in the form of cognitive distortions significantly disrupt the supposed rationality of our being. He shows how we travel with a fair amount of hubris when we believe that our conscious, rational thinking sits in the driver's seat of our lives. Kahnemann explains the many effects that cause us to deviate from the rules of rationality when making decisions. He talks about the non-essential features that have a significant impact on our decision-making processes and our unfortunate tendency to look at problems in isolation. He explains how we have an overconfidence in what we think we know. And he addresses our inability to admit the full extent of our ignorance and the indeterminacy of the world.
Errare humanum est
There is a fallibility that has nothing to do with will. We can try as hard as we want, we remain fallible. The first, probably most difficult, task in dealing with error is this: Are you really convinced that people are fallible? If you cannot answer this question with a clear and unequivocal YES, you would have science against you and a lot of work ahead of you. The Latin saying that must not be missing in this context is "Errare humanum est". This is an abbreviation that hides from us an insight that the whole sentence reveals. In full it reads, "Errare humanum est, sed in errare perseverare diabolicum." Which means something like, "To err is human, but to persist in error is diabolical." Even the Romans were aware that questioning our fallibility is an inhuman thing to do.
Hand in hand with the thought, "If you had made some effort, it would not have happened," go accusation and blame. Because not trying hard is not okay (this, even though we know that our rational thinking 'system 2' is lazy). We are dealing with a deeply rooted paradigm of error that we can only get over with effort: where there is error there is blame. Often this unfortunate connection is emotionally underpinned. This makes it even more difficult for us to think clearly in such situations. But that is exactly what would be called for then. Here is a suggestion for all those who are working on their self-improvement as leaders:
How we can escape the annoying 'fault-blame-causality'.
The stimulus-response model can help us understand what 'happens' to us in such situations and it offers us a way out of the fault paradigm. The model states that an external stimulus is directly followed by a reaction. We still have this archaic form of action triggering built in. It corresponds to the instinct of the animal. If a bear is disturbed in the wild (stimulus), it attacks and bites (reaction). When I learn of a mistake (stimulus), the thought 'guilt' arises (reaction). Unlike animals, however, we humans have a consciousness. This provides us with a space between stimulus and reaction. In this space we find our imagination, which we use to create a desired image of ourselves. In this space we cherish our values according to which we want to lead our life. Our conscience and our free will are also stored in it. We have the ability to decide what our reaction to the external stimulus should be. This gives us the possibility to shape it in such a way that it corresponds to our principles and convictions as leaders and human beings? Thanks to this ability, we can resolve the unspeakable causality between error and blame. When we are confronted with a mishap, we can check our principles in dealing with it before reacting. If we find in our 'values database' the entry: "I acknowledge that human beings are fallible. As a leader, I am committed to continuous improvement and learning and therefore I am interested in WHY the mistake happened and not WHO made it," my response will not be one of blame. I then acted proactively because my response was not driven by the stimulus, but by my principles and values. This is how we manage to break free from the unfortunate fault paradigm. This process requires a fair amount of self-leadership. It manifests as a cognitive tour de force and feels counterintuitive. In other words, it is demanding. But we should be able to make this demand on leaders to refrain from blaming. After all, they are the ones who can establish and maintain a successful safety culture. In high reliability organizations, this personality competence should be an important part of the selection criteria for managers.
What can you expect?
If you succeed in understanding your fallibility and that of others in this sense and learn to deal with it in this way, a lot will change in your environment. Your employees will immediately recognize that you see mistakes as learning opportunities. They will see that you are not making it easy for yourself by blaming the individual for the undesired event. Rather, you will take responsibility for the system and address the question of what you as a leader can do to prevent it from happening again. Your people will learn that you consider the circumstances in which the mistake occurred because you explicitly ask about it. They will experience you as someone who nurtures the organizational learning process and who is available to employees as a resource in their individual learning. All of this builds trust and is living togetherness. It is nothing less than the ground of a good safety culture.
That is one thing. And the other? You have won a personal victory because you have become more independent as a person and a leader. You are no longer stimulus-response-driven, and your actions are based on your own decisions and are not the result of circumstances, needs and constraints.