Richard Cook. REdeploy 2019. Management.

The late Dr. Richard Cook shared many insights in the panel discussion at the REdeploy conference in 2019. On this page we collect a few favorites about getting leadership involvement or support in learning from incidents. youtube

(raw transcript from youtube) it would be very hard for me to talk about the whole tech industry um it's a very heterogeneous environment that's got lots and lots of exemplars and across a huge range there is no as far as i can tell central tendency in the industry there's lots of variability it's partly because fairly young and hasn't had the opportunity to develop lots of these traditions much of the learning that happens in other domains is driven by professional affiliations of the people who participate in those things so nurses physicians pilots engineers uh in in other domains have responsibilities and and expectations about learning that are part of their connection to their profession rather than their connection to a company and i i think there is a um there is a tendency in in the tech industry to and to make the company uh organization the the company itself much much more influential in the overall scheme of things than is the case in in other domains and and i think it's putting a huge burden on um uh corporations to be the carriers of the responsibility for learning and for advancement i think that they're ill-suited for that and they're obviously ill organized for that they're not motivated by those things the professions have in general sustained learning and advancement in those career paths but they've done that more or less not not completely independently of the companies that they work for but certainly not completely tied to those companies you know i'm i'm a physician first and i work at ohio state second and and my physician my learning is not contingent at some level upon just what the company or the corporate entity of ohio state does so i think we should be a little cautious about who we are charging with the responsibility for advancement and learning especially related to the development of opportunities in careers and long-term pathways the kind of responsibility that people have for mentoring i don't think flows from a corporate source or it should not entirely um there's a couple we we make some con we get confused about learning in a variety of different ways one is the one of the ways that i think we mistake this is we think that the learn that there is some sort of learning contained in events that there is a that there's this encoded message which if i only simply had the right way of you know if i could rework the hash on however it got in there i would be able to say what that message was and once i had that in hand i could just broadcast that and everybody would somehow appreciate the the relevance of it and that's clearly incorrect people learn different things from events they learn in different ways asynchronously they they often learn things that are completely unrelated and there are very few events that have sort of a learning in them i think the the one of the things that we see that's a pathology is organizations trying to state what the learning is from an event that's a pathology that that's present when an organization feels that it needs to control the meaning of an incident you can be sure that public relations people and and senior managers are busy shaping that meaning and and it's just it's a very bad idea so so the question for me becomes one becomes a slightly different one from just how do we make the learning make them invest in learning but how do we how do we generate environments that are conducive to learning and generally support that and sustain that across a variety of different opportunities and give people that that kind of a rich environment in which that can happen and and to some extent that requires giving up some control of this which i think is the the sort of central idea of we're going to ask what the central idea of the facilitation guide is uh the etsy facilitation guide or the central idea of what i would call the aus all spa idea okay that's because it's not the etsy guide it's it's the all small idea and the the fundamental idea that the fundamental all spa idea is this we don't control what's learned we're not in charge of what is learned we facilitate people to allow them to have learning experiences but we don't control the learning it's not our job to extract the messages it's not our job to figure out what the meaning of this is and transmit that to everyone our job is to fill facilitate that kind of learning environment and i think when you switch to that perspective many things become available to you that were that that wouldn't be available if you as the as the single soul source of learning had to extract the lessons and disseminate them and all the rest that stuff which is a ridiculous idea on the surface of it so i i think there's a reason for optimism here and and i i get that optimism from the presentations that people have which is that they are able to gain valid important and and business and and business meaningful insights from the events that they are experiencing and one of the things that they're able to do and i think ryan show this very nicely is they're able to demonstrate by pursuing these kinds of inquiries more deeply how the interconnectedness of the system creates the environment that breeds these kinds of problems and why it's important for us to have that insight why it's important for us to learn about that and so i'm pretty optimistic about about what's happening and and to some extent i would i would almost like to suggest the opposite to what's been proposed which is i don't know please okay so turn the camera off [Laughter] okay look here's my view of management um so so we often say we'd like managers to be more involved and get them engaged and have them be more supportive and all the rest of that stuff i have tried to do that and we would get these people coming into the operating room every once in a while and after they've been there for about five minutes my my the thing i would say to them is don't you have a meeting you have to go to um because they're not very helpful and they don't they don't they don't understand the stuff and they don't do very much and they they inevitably screw it up so what what what an alternative view is you know you are the you are the underground you're the resistance you are the people who are going to make this happen not because management gives you the resources that you are clamoring for but in spite of the fact that management exists and and so i i think that would be and and if that's the case then reformulating the problem is one of reformulating a kind of guerrilla movement right we're making cells we're you know engaging in training people you know we're making punji sticks and we're doing all sorts of stuff like that because our goal is is really to to enrich this world in ways that are are productive and and to some extent partly and i think several people have touched on this idea that very often the messages or news that comes out of this is not management friendly right and and if you try and build a program in your company that's going to produce a string of bad you know pretty much continuous stream of bad news you're going to find that you're not a very popular person um so don't do it do the opposite go underground you know be be do use subterfuge hide spy you know sneak in break in do it do it but do it under do it under the radar

You probably can get very senior buy-in. The question is whether or not you want it. There are events which are so powerful and become so disruptive, in terms of the organization's ability to function, that high-level executives will pay attention to this in ways that are sometimes productive or can be unproductive. I would suggest having a plan in place for dealing with that when that happens. Because, one of the biggest difficulties that we see is the reactive kinds of responses to major events that then can make it actually harder to get to meaningful understandings of resilience and where the resilience exists in the system. Setting that up and being prepared for that very often is a matter of doing the kind of work that Ryan and others have demonstrated. And doing it over and over enough, so that, as event size increases, the willingness to have that group of people look into those events that provide the insights is greater. That can be very helpful to build that ability before the big event occurs. Is actually very valuable. And to demonstrate that ability, that capacity to do this kind of deep look and this moderated exchange of views about that that that's productive is is really very valuable. In fact, I know a whole company that's involved in trying to do that. Yes you can you can make these investments, but recognize that if you simply wait for the event to occur without being prepared for it, very often high management's responses are not productive.

41m38s (TODO timestamps) there are specific things about the industry that you're in that now make this a much much greater problem which is that the rate of turnover of knowledge is very high a lot of knowledge gets steel very quickly especially because you re architect your systems so often so that keeping up is a real problem that in turn reflects back on this learning issue which is that it you've just made an argument very much in favor of putting more and more energy and resources into building this learning opportunities world in which people can stay abreast of things and get new information and learn new things based upon the experiences that they're having in the systems that they're having I think you've made a very eloquent a point about the importance of that and to the extent that people feel that they are uncertain they may actually be well calibrated because they know that there's a lot of stuff that they don't know and our collective future it seems to me to be very much vested in trying to create worlds in which those people have opportunities to learn at very high rates across the entire spectrum of the systems and knowledge that that are involved in these endeavors that you're undertaking

What I remember from earlier editions of the panel discussion at REdeploy... "look, you have to treat this like a resistance movement. You need to be organizing cells, sharpening punji sticks. Don't expect help from management, do the work in spite of them.

Pirmin Schuermann. You Are The Resistance. LFI Conference 2023. Paraphrases the advice Richard Cook gave as part of the panel discussion at REdeploy 2019. youtube 16m50s

When asked for advice for how an executive can observe value from learning from incidents, "Richard encouraged us not to think about selling or clamoring for resources, but as a kind of resistance movement."

An alternative view is, you are the underground. You are the resistance. You are the people who are going to make this happen. Reformulating the problem is one of forming a kind of guerilla movement. We're making cells. We're engaging in training people. We're making punji sticks. We're doing all sorts of stuff like that. Because our goal is really to enrich this in ways that are productive. Go underground. Use subterfuge. Hide. Spy. Sneak in. Do it. But do it under the radar.

There is no plan you can follow. Everybody's context is different. You'll have to figure out a lot on your own. Progress isn't linear.

Do things that don't scale. Wanting to scale too early can cause you to stop experimenting. It takes some resistance to push back and not nail things down too early.

From correspondence:

The acquisition of demonstrable mastery of core ideas of the modern view of systems typically requires several years of concentrated, deliberate effort. I’ve had the chance to observe a number of graduate students run the gauntlet of ideas and virtually all of them required 2 full years of effort to ‘get it’ — by which I mean, be able to work through a problem in their home domain in sufficient detail to have captured and described the important aspects of that problem and, especially, the aspects of human performance that matter there.

Learning in this space seems regularly to be a succession of disillusionments. People are attracted to an idea, e.g. Reason’s ill-fated slips vs. mistakes because they are, in a sense, ready to grok things from that perspective. But the flaws and inadequacies of this idea become apparent over time, readying the person for the next idea. The sequence seems inevitably to recapitulate the history of the subjects — so much so that we can get a rough assessment of the maturity of an individual’s views by the stage of their current fascination. What graduate school does — when it works well — is to accelerate this process so that the student gets through the sequence at speed — again, in most cases a process that takes 2 yrs. People do ‘stall out’ in the sequence, with predictable results. Fatigue and impatience can derail the process and other distractions are always beckoning. When this happens progress slows or even stops. There does seem to be a great advantage to having mastered and practiced extensively in some domain. Because the problems that constitute the core dimensions of cognitive systems engineering and resilience engineering arise not from the theory of a domain but from the interactions that real work produces, only such intimate involvement in work brings contact with the problem space that CSE/RE address. People who have had a career in something (pilots, docs, nurses, ops people) have a distinct advantage in learning this stuff and this is readily apparent to all who have worked closely with graduate students.

From Two Years Before the Mast.

8. Learning recapitulates the sequence of research that comprises the New Look. Certain components of the New Look are essential groundwork for others. Although there are variations, the primary sequence of learning that we observe is one where individual and organizational learning retraces the history of the research that makes up the New Look. This sequence is roughly from (1) understanding complex system failure, to (2) characteristics of human expertise in context, to (3) the social character of “error” and problems with attribution of “cause,” to (4) the limited and paradoxical effects of countermeasures designed to forestall “error,” to (5) the broader consequences of reactions to failure that shape individual and organizational function, to (6) the notion of safety creation as an active product of efforts at every level of the organization, to (7) to the search for means to support creation of safety. It is also clear that people get sidetracked along the learning path at various places for a variety of reasons. For example, because consequences of failure overwhelm learning, because of lack of resources or guidance in interpreting failures, or because the need to make immediate improvements overwhelms the need to understand. 2:09

The realization that safety is the active creation of people marks the end of the first phase of learning about safety.

so seven steps to getting started on the learning journey of this paradigm shift. Given Richard published this paper in 1998, I wonder how he would enumerate the steps that follow from there.