ABOUT THIS EPISODE
Part two of a deep conversation with Professor David Woods examines five decades of safety practice and argues for a stronger science base, foresight, and continual revitalization. Topics include the Command–Adapt Paradox, the fluency law, the law of stretch systems, and the novelty inequality, showing why plans must be paired with guided adaptability.
The episode urges putting safe and effective outcomes first, working together to innovate, and rebuilding practical tools and research so safety programs scale and adapt in an increasingly complex world.
Here is the cited article for your reading pleasure:
English
United States
SHOW NOTES 🔗
00:00:09Veterans and Perspective
00:00:58Part Two Begins
00:03:41Complexity Demands More
00:06:27Safety’s Broad Mission
00:11:19Beyond Sloganeering
00:13:43Command-Adapt Paradox
00:17:26Plans as Resources
00:20:16Revitalize Safety Programs
00:21:43Fluency and Adaptation
00:22:52The Stretch Systems Law
00:24:56Hindsight’s Big Gap
00:27:26Defending Safety Together
TRANSCRIPT 🔗
WEBVTT
00:00:00.417 --> 00:00:04.697
You and I as veterans, it hit me right off the bat because the guy's going,
00:00:04.697 --> 00:00:07.383
well, I've been around since blah, blah, blah, blah, blah happened.
00:00:09.212 --> 00:00:13.177
And LinkedIn, I just went, well, I've been around for 47 of those damn 50 years.
00:00:14.929 --> 00:00:21.425
And I think you're right. I have a different perspective on what's gone on in those 50 years.
00:00:21.971 --> 00:00:25.006
And you've been around for a lot of those 50 years.
00:00:25.355 --> 00:00:30.283
So we should reflect a little since people wanted to do this and we're doing it I thought in a very,
00:00:31.114 --> 00:00:35.967
they were undercutting would be the fair word undercutting where we stand rather
00:00:35.967 --> 00:00:41.057
than empowering us to go further and do better it was undercutting everything
00:00:41.057 --> 00:00:45.503
and that's really the last thing we need in a time of change and challenge.
00:00:58.643 --> 00:01:02.278
Pre-accident investigation podcast. It's me, Todd. How are you?
00:01:02.632 --> 00:01:07.653
This is part two of the David Woods conversation. If you've not heard part one,
00:01:08.170 --> 00:01:12.363
you know, I'm of mixed minds, but it's probably worth going back and listening
00:01:12.363 --> 00:01:15.443
to first because it kind of sets the story.
00:01:15.783 --> 00:01:19.292
It builds the case for what part two talks about.
00:01:19.467 --> 00:01:23.133
But if you're in a hurry and, you know, you got a lot of crap going on and you're
00:01:23.133 --> 00:01:26.438
super busy and important, and many of you are, I realize.
00:01:26.763 --> 00:01:28.720
You're fine jumping in here as well.
00:01:29.051 --> 00:01:34.573
He is a great podcast guest for a bunch of reasons. One, Professor Woods is
00:01:34.573 --> 00:01:38.153
just smart. Every time he talks, I have pages of notes I take down.
00:01:38.495 --> 00:01:43.569
Just the way he phrases things makes me think. I hope you feel the same. I bet you do.
00:01:44.074 --> 00:01:47.783
Secondly, he requires very little feeding and maintenance. I mean,
00:01:47.783 --> 00:01:50.866
he'll take off, baby, and he'll go.
00:01:51.290 --> 00:01:56.623
And I like that because he has lots to say and he's thought a lot about this,
00:01:56.623 --> 00:02:03.241
a bunch about this. So this is kind of a very interesting and very important conversation.
00:02:03.849 --> 00:02:08.493
And I have to tell you, I don't want to ruin the ending because it's good,
00:02:09.115 --> 00:02:13.904
but it really ends in a way that I think it probably must end and should end.
00:02:14.368 --> 00:02:16.295
And it's the right thing to do. You know me.
00:02:16.928 --> 00:02:21.593
My theory is the meaning of life is good work done well for the right reasons.
00:02:21.593 --> 00:02:23.819
I've said that to you guys a million times.
00:02:24.417 --> 00:02:30.013
This kind of builds that case beautifully. And I think you'll appreciate it immensely.
00:02:30.518 --> 00:02:34.064
And it's a great conversation. It's very important. For a part two,
00:02:34.500 --> 00:02:37.286
this is killer good. That's how good it is.
00:02:37.928 --> 00:02:40.912
I'm having a good time here. I hope you're having a good time there.
00:02:41.342 --> 00:02:45.364
There's much for us to share. And I kind of want to jump right into this because
00:02:45.364 --> 00:02:52.354
there's so much information for you just to chew on and think about and enjoy.
00:02:52.679 --> 00:02:56.149
Yes, if you're not enjoying this, we're doing it wrong. It should be pretty fun.
00:02:56.544 --> 00:02:59.498
I mean, that's the whole goal is to learn something and have a good time.
00:02:59.910 --> 00:03:04.166
You know, it's about professional development. And that, my friends,
00:03:04.560 --> 00:03:10.005
that is something that we've been on a journey together for a long, long time.
00:03:10.377 --> 00:03:15.706
So without much further conversation, and I promise you, I don't have a lot more conversation.
00:03:16.281 --> 00:03:20.849
Let's hear part two of the talk that the three of us are going to have,
00:03:21.134 --> 00:03:23.426
Professor Woods, myself, and you.
00:03:23.885 --> 00:03:28.434
And it's going to be on what do we do with this information and how do we move
00:03:28.434 --> 00:03:32.784
forward as a community of people who are directly involved in safe,
00:03:32.784 --> 00:03:35.185
reliable operations. That's our goal.
00:03:41.140 --> 00:03:44.296
Because the other thing that's happened is the world keeps getting more complex.
00:03:44.818 --> 00:03:51.761
So those old things that kind of work some don't work so well anymore or the impact isn't so great.
00:03:52.092 --> 00:03:56.109
And that's why I'm always talking about, especially in patient safety,
00:03:56.109 --> 00:04:00.005
is can you produce an order of magnitude effect?
00:04:00.690 --> 00:04:06.338
I'm looking for 10 times an effect, not a percent. Yes, you could do a study for a percent effect.
00:04:06.881 --> 00:04:10.091
Usually they want us to give them a few percent effect. Right.
00:04:10.567 --> 00:04:14.419
Right. And we're like, no, I'm looking for an order of magnitude of fact,
00:04:14.419 --> 00:04:21.074
given the nature of the systems that change and the potential harm as our systems grow in capability.
00:04:21.399 --> 00:04:25.579
The harm when they break goes up by orders of magnitude, too.
00:04:26.272 --> 00:04:30.533
That's what I've said to you before When things go wrong now,
00:04:31.214 --> 00:04:36.561
The potential for harm When things go wrong Is at least two orders of magnitude
00:04:36.857 --> 00:04:42.799
Bigger than the maximum impact Of our traditional safety initiatives We did our initiative,
00:04:43.459 --> 00:04:49.220
They let us do it And they gave us reasonable funding Within the normal organizational constraints.
00:04:50.039 --> 00:04:54.609
And it was pretty successful It would be a percent improvement Not an order
00:04:54.609 --> 00:04:55.729
of magnitude improvement.
00:04:55.729 --> 00:05:00.389
And we're looking at harm that is two orders of magnitude. And as I said to
00:05:00.389 --> 00:05:03.499
you last time, measles is a simple example.
00:05:03.667 --> 00:05:08.834
And by the way, when I talked to you last time, we're now in the seventh month,
00:05:09.467 --> 00:05:11.799
right? And we have set a record, right?
00:05:12.339 --> 00:05:15.199
We are way past the max number.
00:05:15.759 --> 00:05:19.190
We're way on our way to three orders of magnitude. We might hit,
00:05:19.579 --> 00:05:22.836
we're definitely going to hit two and a half orders of magnitude in measles cases.
00:05:24.779 --> 00:05:32.849
As a canary in the coal mine on how the exposure to harm is increasing at the
00:05:32.849 --> 00:05:35.402
same time that our systems grow in capability.
00:05:35.728 --> 00:05:37.231
How will we break that cycle?
00:05:38.697 --> 00:05:42.256
Well, the irony is we can rock the boat with a science base.
00:05:43.509 --> 00:05:48.222
But it is kind of the answer in a way, right? Or it's a vital part of the answer.
00:05:48.851 --> 00:05:54.662
Yes. I mean, we have to have a generalizable set of what goes on.
00:05:55.869 --> 00:06:01.359
Because the normal context and pressures and constraints in which we do practical
00:06:01.359 --> 00:06:03.311
safety programs, they're very narrow.
00:06:03.590 --> 00:06:05.860
We get lost in the details of every setting.
00:06:06.295 --> 00:06:08.286
And it's driven very reactively.
00:06:08.849 --> 00:06:12.919
Even the, you know, the, our proactive, we get proactive successes,
00:06:12.919 --> 00:06:14.858
but it's hard to sustain.
00:06:15.217 --> 00:06:19.889
It's hard to have them organically multiply. It's a uphill climb each time we
00:06:19.889 --> 00:06:22.897
pull one off and that doesn't scale.
00:06:23.263 --> 00:06:26.670
And we've seen that when, if you take the long look, you go, yeah.
00:06:27.117 --> 00:06:32.999
So I want to go back to this issue of everything in the human experience pretty
00:06:32.999 --> 00:06:35.244
much is encompassed in the label safety,
00:06:35.859 --> 00:06:39.159
success, failure, reward, harm, fear, blame, responsibility,
00:06:39.159 --> 00:06:44.301
ethics, courage, disaster, heroic saves, the drama of the very near miss, right?
00:06:44.746 --> 00:06:47.765
It covers the C-suite. It covers regulatory policy.
00:06:48.509 --> 00:06:52.949
It goes all the way down to people who have to operate critical systems under
00:06:52.949 --> 00:06:56.868
enormous pressures to do amazing things at the sharp end.
00:06:57.488 --> 00:07:02.669
We cover a new technology that can do more and extend human reach,
00:07:02.669 --> 00:07:06.273
human vision, human action to new scales and distances.
00:07:06.911 --> 00:07:08.786
They have an enormous range of things.
00:07:09.512 --> 00:07:16.609
But in the end, you know, a mantra for proactive safety that I articulated 26
00:07:16.609 --> 00:07:24.269
years ago, been in print 21 years, is this our fundamental obligation as safety people, right?
00:07:24.269 --> 00:07:28.199
If you're engaged in creating safety, our fundamental obligation is to create
00:07:28.199 --> 00:07:32.645
foresight about the changing shape of risk before harm occurs. Mm-hmm.
00:07:33.774 --> 00:07:38.083
This came out first in the patient safety movement around 2000,
00:07:38.083 --> 00:07:43.024
and then very significantly in the Columbia space shuttle accident.
00:07:44.655 --> 00:07:54.843
And so now those two things, this huge encompassing of human systems issues and this obligation,
00:07:55.450 --> 00:08:01.847
for foresight about the changing shape of risk, means we've got a lot.
00:08:02.347 --> 00:08:06.625
I mean, what scope? I mean, what fun we get to have over the years, right? You and me.
00:08:07.234 --> 00:08:09.873
All the places we get to go, all the things we get to interact,
00:08:09.873 --> 00:08:13.803
all the scary places we've been, right? That's what we talk about over beers.
00:08:14.903 --> 00:08:19.837
Who went to the scariest place and came out alive?
00:08:20.875 --> 00:08:28.763
The so the key is building science base but that science base is about it has
00:08:28.763 --> 00:08:31.762
these funny constraints on it how do you do,
00:08:32.598 --> 00:08:36.543
lab how do you do what science people when people say science they usually think
00:08:36.543 --> 00:08:41.753
of lab experiments and definitive results with laws and you go big laws to hold
00:08:41.753 --> 00:08:43.215
everything up yeah i'm with you,
00:08:43.846 --> 00:08:48.920
and well when safety encompasses so much of human experience you have to look at the real world,
00:08:49.574 --> 00:08:54.393
and how do you and are you understanding human aspirations are you understanding
00:08:54.393 --> 00:08:57.793
why we build technology why we operate in certain ways why we're willing to
00:08:57.793 --> 00:09:02.563
invest in some aspects more automation less people maybe sometimes we should
00:09:02.563 --> 00:09:04.458
grow human expertise and have
00:09:04.847 --> 00:09:08.123
and maybe that's a better investment in the long run sometimes,
00:09:09.103 --> 00:09:11.244
always be one way or the other right.
00:09:12.462 --> 00:09:18.896
The and and and so you end up with this thing of we can't really do what our
00:09:18.896 --> 00:09:21.046
social norm of what science is.
00:09:21.046 --> 00:09:25.076
We have to do something that looks at the real world. So all of those practical
00:09:25.076 --> 00:09:28.716
experiences you and I have been in, we've treated we were just joking about
00:09:28.716 --> 00:09:32.182
it as research opportunities. Right. We're not just helping them.
00:09:32.634 --> 00:09:36.924
Each time we do it, we're going, I'm looking for patterns and understanding,
00:09:37.499 --> 00:09:40.886
whether that's at the sharp end, whether that's about the technology or the
00:09:40.886 --> 00:09:46.178
human technology interaction. whether that's about the organizational beliefs, how do you move them?
00:09:46.636 --> 00:09:49.388
How do you change their models and biases?
00:09:50.227 --> 00:09:55.286
I mean, another one is that makes this hard and different than usual areas of
00:09:55.286 --> 00:10:00.016
science is how do you do science when the people trying to do the science are
00:10:00.016 --> 00:10:02.887
part of the processes the scientists are trying to study?
00:10:03.445 --> 00:10:06.394
If you're trying to understand safety, you're influencing safety.
00:10:06.748 --> 00:10:12.076
You can't study it without being related to the process that's trying to build
00:10:12.076 --> 00:10:13.834
safety or sustain safety.
00:10:14.142 --> 00:10:16.220
You're studying how it breaks, right?
00:10:16.551 --> 00:10:21.398
You're part of the thing you study. You're not an outside objective observer.
00:10:21.538 --> 00:10:24.556
You're in something that's changing all the time.
00:10:25.172 --> 00:10:31.419
So the third thing is creating safety is about all kinds of skills,
00:10:31.791 --> 00:10:37.196
but they're all about balancing competing interests, right? In a changing world,
00:10:37.196 --> 00:10:39.165
not a state, not a category.
00:10:39.531 --> 00:10:44.146
It's about rebalancing how activities need to shift relative to goals,
00:10:44.146 --> 00:10:51.519
how goals need to shift relative to risk, how resources need to shift relative to uncertainty and risk,
00:10:52.406 --> 00:10:54.865
and new technology and new opportunities.
00:10:55.753 --> 00:11:01.791
It's a dynamic balancing And it's very hard To get organizations In today's world,
00:11:02.633 --> 00:11:06.216
That's why I use a lot of military examples Because they have to be good at
00:11:06.216 --> 00:11:12.953
balancing Dynamically Otherwise they lose Even if they start in the best position And they stay there.
00:11:14.177 --> 00:11:18.356
The best position doesn't stay best because there's somebody else adapting to.
00:11:19.074 --> 00:11:26.474
And so that gets us to this current situation we've been talking about of people
00:11:26.474 --> 00:11:28.704
looking back at 50 years and saying,
00:11:29.291 --> 00:11:34.374
yeah, it's just a lot of noise, a lot of labels, not much progress. Sloganeering.
00:11:34.852 --> 00:11:38.589
Pre-scientific sloganeering, right?
00:11:39.222 --> 00:11:43.414
And I think we want to blow away any confusion That there is,
00:11:43.414 --> 00:11:46.774
in fact, fantastic progress And,
00:11:47.834 --> 00:11:52.567
that the world keeps changing And that progress is necessary And needs to be,
00:11:53.190 --> 00:11:55.036
sustained and sped up even,
00:11:56.086 --> 00:12:01.174
And that it's easy, given the pressures Limited resources, huge variety of situations
00:12:01.174 --> 00:12:06.413
And distractions we have to face in safety It's easy not to know a lot about what we know,
00:12:07.734 --> 00:12:08.627
It's hard to keep up.
00:12:08.952 --> 00:12:12.290
It's hard to be part of this. It's hard to synthesize.
00:12:14.149 --> 00:12:17.574
God, that's interesting. You know that's an incredibly interesting thing you
00:12:17.574 --> 00:12:19.257
just said. That's remarkable.
00:12:20.894 --> 00:12:24.894
I mean, so we're getting a little bit to some of the punchlines.
00:12:24.894 --> 00:12:30.834
One is got to put effective and safe, safe and effective up front in order to
00:12:30.834 --> 00:12:34.594
be viable in both the short run and the long run, to be adaptive both in the
00:12:34.594 --> 00:12:35.754
short run and the long run.
00:12:36.374 --> 00:12:42.494
That are put faster, cheaper first assumes a stable world. Right.
00:12:43.325 --> 00:12:47.784
Where it's just a quick race. But when the landscape changes and the rules change
00:12:47.784 --> 00:12:52.784
and the destination changes and the trophy at the end changes, you got to adapt. Yeah.
00:12:53.974 --> 00:12:59.342
So what I want to highlight with you and encourage everybody is to spend some
00:12:59.342 --> 00:13:05.462
more time investigating, arguing, challenging, revising, extending, limiting.
00:13:05.462 --> 00:13:09.002
I'm not even going to say the scope of what we know is more limited than we
00:13:09.002 --> 00:13:10.678
thought, building more.
00:13:11.061 --> 00:13:15.362
But I want to give a couple examples that we have generalizable findings that
00:13:15.362 --> 00:13:19.744
are both concrete to guide how to work in a particular situation.
00:13:20.069 --> 00:13:23.610
Right. One general generalization doesn't apply everywhere.
00:13:23.964 --> 00:13:30.251
But it applies in lots more places. In fact, the reason we know it's a generalization or a law even,
00:13:30.790 --> 00:13:35.732
or a theorem even more that we can prove, is because we see it in many different
00:13:35.732 --> 00:13:40.102
settings play out, even though there are differences because of the unique features
00:13:40.102 --> 00:13:42.627
of those settings or the layer at which we observe it.
00:13:43.461 --> 00:13:49.816
And so I want to give one, right? It's really simple. It's a short paper under 4,000 words.
00:13:50.170 --> 00:13:52.185
It's a synthesis of syntheses.
00:13:52.800 --> 00:13:58.642
It's called the Command-Adapt Paradox Paper And it was written in frustration,
00:13:59.002 --> 00:14:04.372
I admit it Because people kept coming back and saying Well, what about compliance?
00:14:04.372 --> 00:14:09.572
And how much pressure for compliance should we be putting on our subordinate
00:14:09.572 --> 00:14:15.992
managers and personnel To just comply with the policy, to comply with the plans,
00:14:15.992 --> 00:14:17.605
to comply with the rules?
00:14:18.372 --> 00:14:22.314
And I kind of went, oh my God Are we re-litigating this again?
00:14:22.633 --> 00:14:26.012
How many times have we re-litigated this? Why are we doing this?
00:14:26.012 --> 00:14:29.942
This is an example of us We're in the washing machine going around and around
00:14:29.942 --> 00:14:33.186
again I'm tired of getting an ounce in your head off the wall You know,
00:14:33.985 --> 00:14:38.482
And so I reviewed the papers and syntheses To remind people about the basics
00:14:38.482 --> 00:14:45.339
And tried to summarize the synthesis of the syntheses You know, in plain, plain terms,
00:14:46.280 --> 00:14:51.074
compliance says there's plan and conform we often turn the plan into automation
00:14:51.074 --> 00:14:53.251
to try to make sure there's conformance right,
00:14:53.899 --> 00:14:59.554
right and the pressure to plan to behave by plan and conform reduces adaptive
00:14:59.554 --> 00:15:06.717
capacity this is laid out and a variety of things and i went through them in a ways like.
00:15:07.744 --> 00:15:12.844
Here are i had it up but anyway you should go look at it and i'll put the paper
00:15:12.844 --> 00:15:14.614
i'll put the paper in the notes for this.
00:15:14.614 --> 00:15:20.291
You know, it's like one of the findings, one, two, three, four, finding one.
00:15:20.645 --> 00:15:23.048
Okay. Well, the, the modern, right.
00:15:25.120 --> 00:15:30.494
There will always be surprised to challenge your plans. The modern date on that
00:15:30.494 --> 00:15:32.882
is in the 1980s on that finding.
00:15:33.387 --> 00:15:39.190
How far does it go back? It goes back to 1836 in Clausewitz.
00:15:40.741 --> 00:15:49.615
Another one is people outside models of work are miscalibrated.
00:15:50.684 --> 00:15:56.584
Your model of how someone else confronts the world is not the same of the model
00:15:56.584 --> 00:16:00.249
of the person confronting uncertainty, complexity in the world.
00:16:01.909 --> 00:16:08.434
That model confusion really dates back to again, some developments and papers
00:16:08.434 --> 00:16:12.660
and findings in our 50-year history.
00:16:13.832 --> 00:16:18.168
But you know how far it goes back? It goes back to 1890.
00:16:19.892 --> 00:16:24.347
William James, and he called it the psychologist fallacy.
00:16:25.067 --> 00:16:30.393
When the person studying human behavior substitutes their model for the situation,
00:16:30.944 --> 00:16:34.456
for the person's model of the situation, they have to act it.
00:16:35.136 --> 00:16:38.767
And he says, your job is to discover the model the person brings,
00:16:38.767 --> 00:16:42.287
not because it's right, but because they'll behave according,
00:16:42.287 --> 00:16:44.853
that model will influence their behavior.
00:16:45.387 --> 00:16:48.272
And then you can start to see what they're missing, what they're getting right.
00:16:48.568 --> 00:16:51.320
And you'll see that both of your models are wrong.
00:16:52.069 --> 00:16:56.767
Both of your models are incomplete and the risk of miscalibration exists,
00:16:56.767 --> 00:17:00.467
whether the person acting in the world and the person trying to understand the
00:17:00.467 --> 00:17:01.891
person acting in the world.
00:17:03.048 --> 00:17:09.267
And that's in Behind Human Error. That's in the 1983 paper at the Bellagio,
00:17:09.887 --> 00:17:14.792
the first formal official meeting on going behind the label human error in 1983.
00:17:16.287 --> 00:17:21.237
Those were, that fundamental is there. And that comes out in how we deal with
00:17:21.237 --> 00:17:24.767
hindsight bias and the techniques and a whole bunch of different things.
00:17:24.767 --> 00:17:26.335
And we can go on and on in there.
00:17:26.989 --> 00:17:31.331
Very quickly, we see research coming out. And again, we could date it earlier,
00:17:31.575 --> 00:17:37.833
but 1986, Lucy Suchman, plans are resources for action. Plans aren't specifications of action.
00:17:38.359 --> 00:17:41.348
All right. And then we go through how that developed.
00:17:42.153 --> 00:17:47.694
And what that means and what you end up with, oh, and that plans are necessary
00:17:47.694 --> 00:17:51.084
to recognize anomalies and surprise, right?
00:17:51.084 --> 00:17:54.304
If I don't have a model of what's typical, what's supposed to work,
00:17:54.304 --> 00:17:58.625
how things usually work, how we usually handle disruption and variation,
00:17:58.811 --> 00:18:01.464
I can't recognize anomalies, right?
00:18:01.464 --> 00:18:04.914
And therefore, I can't revise models. I can't revise tactics.
00:18:04.914 --> 00:18:06.764
I can't learn new strategies.
00:18:07.037 --> 00:18:10.560
I don't understand and diagnose the anomalies and where they come from.
00:18:11.202 --> 00:18:16.234
So learning and change comes from recognizing anomalies And to do that,
00:18:16.234 --> 00:18:21.651
I need a baseline of typicality that comes from plans So plans help me revise,
00:18:22.364 --> 00:18:27.075
And that's an old finding Eisenhower said that one in the 1950s.
00:18:27.944 --> 00:18:33.394
As well as scientists in the 80s and 90s So that led us to the idea of It's
00:18:33.394 --> 00:18:39.121
not plan and conform, it's plan and revise But revision isn't freelance,
00:18:39.578 --> 00:18:43.414
So then we run through what's the interaction between, right,
00:18:43.414 --> 00:18:46.569
what do we want to achieve? How are we trying to achieve it?
00:18:47.167 --> 00:18:52.826
Variability, surprise, and opportunity will arise outside the boundaries of that scope.
00:18:53.268 --> 00:18:58.132
And how do we revise relative to that? How do we recognize, revise,
00:18:58.319 --> 00:19:03.286
reframe, revitalize, right, head in new directions?
00:19:03.594 --> 00:19:06.544
And we've seen that now that we've lived decades in this.
00:19:06.544 --> 00:19:11.184
We see that over and over again Where safety programs, safety innovations Were
00:19:11.184 --> 00:19:16.884
turned into programs The programs, these were all fights The programs eventually
00:19:16.884 --> 00:19:18.646
were widespread in the industry,
00:19:19.335 --> 00:19:22.630
Even transferred to other industries And then you go and look.
00:19:23.384 --> 00:19:27.820
A while later, and you recognize they're not fit for purpose anymore.
00:19:28.473 --> 00:19:33.781
They're not doing the job. They've lost vitality, right? They need to be revitalized.
00:19:34.182 --> 00:19:38.744
Some of those were the successes in teamwork at crew resource management.
00:19:38.744 --> 00:19:43.782
And then you go into places that have crew resource management or other teamwork programs and you go,
00:19:44.419 --> 00:19:47.604
yeah, but when you actually look at the organization closely,
00:19:47.604 --> 00:19:52.221
you're finding a lot of breakdowns in teamwork, a lot of working across purposes,
00:19:52.581 --> 00:19:57.144
a lack of synchronization over different organizational boundaries within,
00:19:57.144 --> 00:19:58.644
you know, within the organization.
00:19:58.644 --> 00:20:01.416
And you go, there's not great teamwork here, guys.
00:20:01.851 --> 00:20:05.954
You need to revitalize the program and expectations around this.
00:20:05.954 --> 00:20:11.657
And it become routinized and rote and fine and a distraction.
00:20:12.034 --> 00:20:16.376
I get to go off and take my team training, but nothing effective came from it.
00:20:17.022 --> 00:20:21.824
So we have to re-energize the pursuit of safety We have to revitalize That should
00:20:21.824 --> 00:20:27.204
be seen as a basic in safety Not only do you need to You're in a place of.
00:20:28.984 --> 00:20:33.427
Re-energizing, revitalizing safety We want to do this before bad accidents happen
00:20:33.747 --> 00:20:38.324
But down the road, it's not one and done It's a phase And then you're going
00:20:38.324 --> 00:20:43.164
to have to re-energize and revitalize And some of that will be on different aspects,
00:20:44.144 --> 00:20:49.074
That weren't critical before And, you know, were okay to handle With the other
00:20:49.074 --> 00:20:52.934
programs you had But now needed to be more the focus and central thing Because
00:20:52.934 --> 00:20:53.994
the world keeps changing,
00:20:54.693 --> 00:20:59.167
So anyway, so if somebody comes and says to you, it's all noise and it's pre-scientific,
00:20:59.735 --> 00:21:03.024
read the Command-Adapt Paradox paper, right?
00:21:03.024 --> 00:21:06.904
It synthesizes lots of research. It encompasses a broad set of things,
00:21:06.904 --> 00:21:10.904
and it ends up with an actionable strategy, and it's being carried out.
00:21:10.904 --> 00:21:15.524
Guided adaptability is being used by pragmatic people working with everyday
00:21:15.524 --> 00:21:20.344
organizations like Dave Provan and Bethleh and their book coming out on this,
00:21:20.785 --> 00:21:25.713
and they're turning it into practical action so that you can meet those demands.
00:21:25.992 --> 00:21:28.889
Do it now, do it fast, and don't cost me money. That's right.
00:21:29.624 --> 00:21:31.095
And make it better, make it better.
00:21:31.904 --> 00:21:36.134
What a great conversation. Thank you, my friend. Well, the other ones,
00:21:36.134 --> 00:21:41.244
I mean, there's other ones I want to mention quickly to remind people of this
00:21:41.244 --> 00:21:42.829
before we bring it to a close.
00:21:43.724 --> 00:21:48.164
Just to highlight to people, I already mentioned the fluency law and now that
00:21:48.164 --> 00:21:50.440
goes back to the psychologist fallacy.
00:21:51.349 --> 00:21:56.028
But the fluency law and all that stuff is critical to our analysis of how things
00:21:56.028 --> 00:21:58.048
go right and how things can go wrong.
00:21:58.645 --> 00:22:02.388
You have to go in and understand how people are adapting. And to do that,
00:22:02.388 --> 00:22:06.134
that's where in resilience engineering, we said study how things go right. Why?
00:22:06.511 --> 00:22:10.198
Because people are doing fluent adaptations to make things go right.
00:22:10.198 --> 00:22:12.129
So go study how things go right.
00:22:12.558 --> 00:22:17.088
So make sure you understand the fluency law. It's critical out there in the
00:22:17.088 --> 00:22:19.780
last 25 years of how we pursue safety.
00:22:20.308 --> 00:22:24.858
And forget the big labels and arguments over this And putting numbers on it,
00:22:24.858 --> 00:22:28.980
whatever There's a fundamental law, right?
00:22:29.236 --> 00:22:34.958
Now, it's an empirical law But we can derive this from some first principles
00:22:34.958 --> 00:22:39.545
That gives it extra strength It's not just empirical that we see it a lot It
00:22:39.777 --> 00:22:41.676
kind of has to work this way Right.
00:22:42.958 --> 00:22:46.808
And so then when you understand it You can make use of it in a variety of settings
00:22:46.808 --> 00:22:50.628
To help understand and direct your action and also understand how sometimes
00:22:50.628 --> 00:22:52.045
people get on the wrong track.
00:22:52.702 --> 00:22:56.468
The other one is, this one came, there were some things anticipating it,
00:22:56.468 --> 00:23:00.911
but it was first, the label was first used in 98, it's the law of stretch systems.
00:23:01.513 --> 00:23:05.621
Every system is stretched to operate at its capacity as soon as there is some improvement.
00:23:06.638 --> 00:23:10.318
When a new form of technology comes along, the capabilities will be exploited
00:23:10.718 --> 00:23:13.291
to achieve a new intensity and tempo of activity.
00:23:13.925 --> 00:23:20.029
The statement of the law is actually a paraphrase of an after-action report from a U.S.
00:23:20.319 --> 00:23:27.708
Military operation that was Kordsman, Anthony Kordsman, summarized the use of
00:23:27.708 --> 00:23:30.682
new modern military technology in the Gulfs.
00:23:31.618 --> 00:23:35.454
To do more, do it faster in more complex ways. It didn't make the work on the,
00:23:36.054 --> 00:23:37.580
sharp end operator easier.
00:23:38.160 --> 00:23:41.364
It enabled them to do more, do it faster in more complex ways.
00:23:41.364 --> 00:23:45.811
What did that mean? You could do more. It was good. A capability also meant it was riskier.
00:23:46.578 --> 00:23:49.132
Things could go wrong. When they went wrong, harm was bigger.
00:23:49.312 --> 00:23:52.533
Right. And some of that were friendly fire incidents.
00:23:53.642 --> 00:23:58.994
So notice this highlights how everybody's adapting and how when people say we're
00:23:58.994 --> 00:24:05.324
going to improve the system in this way, I'm sorry, but that's not what's going to happen.
00:24:06.008 --> 00:24:09.824
Do I know what's going to happen? No. What I know is what we think is going
00:24:09.824 --> 00:24:11.774
to happen is not what's going to happen.
00:24:12.554 --> 00:24:17.144
Because people are adaptive. And what they'll see as an advantage is different
00:24:17.144 --> 00:24:19.013
than what we thought it would be.
00:24:19.517 --> 00:24:24.234
We'll think more narrowly and linearly. They'll see it relative to their goals.
00:24:24.234 --> 00:24:26.124
Remember that psychologist fallacy.
00:24:26.443 --> 00:24:31.464
They'll see it in a new light. And they'll go, look what this will do for me.
00:24:32.156 --> 00:24:37.104
And that means maybe it won't do something so good for a different role at a
00:24:37.104 --> 00:24:40.103
different layer of the operation or organization.
00:24:40.798 --> 00:24:44.694
And we see this in the adaptations around AI coding.
00:24:46.414 --> 00:24:51.144
We just see it all the time in all of this. one that is really,
00:24:51.144 --> 00:24:56.054
really important and has been there since 19.
00:24:56.054 --> 00:25:01.230
I first said it in 83 at the Bellagio meeting, and then it's in the 94 Behind Human Error, is how,
00:25:01.843 --> 00:25:05.934
hindsight, knowledge of outcome changes your perspective and changes your ability
00:25:05.934 --> 00:25:11.224
to understand what happens when people confront situations with uncertainty and risk.
00:25:11.912 --> 00:25:15.499
And so I gave it a new name a few years ago, the novelty inequality.
00:25:16.109 --> 00:25:20.994
I think this is a mathematically provable situation. I have not found a partner
00:25:20.994 --> 00:25:23.644
to help me pull off a mathematical Bayesian proof.
00:25:24.997 --> 00:25:30.001
Well, you know, I've always argued with Bayes. Now I want to use Bayes to help me.
00:25:30.334 --> 00:25:33.820
I haven't quite found a way to do this. Bayes is kind of intransigent.
00:25:33.820 --> 00:25:37.460
You know, I'm not sure I'm on your side, Dave. You've criticized me so much.
00:25:38.990 --> 00:25:44.610
But the novelty inequality, when you're in a situation facing uncertainty and
00:25:44.610 --> 00:25:51.662
risk, the potential novelty in front of you is much, much greater than the known novelty,
00:25:52.179 --> 00:25:54.379
that's determined after the fact.
00:25:55.182 --> 00:25:59.472
Right. Afterwards, we can hone in on this is exactly what was different.
00:26:00.064 --> 00:26:04.520
This is exactly where the rules didn't apply. This is exactly the surprising
00:26:04.520 --> 00:26:08.951
nature. This is exactly what needed to be adapted relative to normal practice.
00:26:09.578 --> 00:26:14.400
But beforehand, you're not sure There's multiple forms This was shown in the
00:26:14.400 --> 00:26:18.120
hindsight cartoon That Richard Cook came up with And we used in the patient
00:26:18.120 --> 00:26:23.840
safety movement In the 90s Based on the Behind Human Error book Trying to explain what this,
00:26:24.666 --> 00:26:30.691
meant And literally the cartoon used It's in the 2010 book You can see,
00:26:31.418 --> 00:26:36.810
The range of uncertainty factors And trade-offs that the Sharp end person confronts
00:26:36.810 --> 00:26:43.620
In the face of uncertainty and risk versus the after-the-fact analysis can hone in on only a few.
00:26:44.007 --> 00:26:47.860
And as I always joked about Three Mile Island, they had 10 minutes to make a
00:26:47.860 --> 00:26:53.684
decision for a situation they had not been trained for and didn't know even could exist. Right.
00:26:54.950 --> 00:27:03.120
When the after-action analysis took six months and $6 million of the best engineers
00:27:03.120 --> 00:27:08.060
in the field and $60 million in 1980 terms is a hell of a lot of money.
00:27:08.060 --> 00:27:09.337
Yeah, yeah, that's some big jack.
00:27:09.686 --> 00:27:13.100
And I think a lot of us would make decisions better with $60 million,
00:27:13.900 --> 00:27:18.980
even in today's dollars, and access to the best engineers or analysts on that
00:27:18.980 --> 00:27:20.726
particular topic, right?
00:27:22.102 --> 00:27:26.110
And stuff. So we have lots and lots of stuff.
00:27:26.812 --> 00:27:30.992
So we wanted to come back. You asked me, well, and this is going to go back
00:27:30.992 --> 00:27:34.181
to, we're trying to stimulate our friends.
00:27:34.663 --> 00:27:40.592
Yeah. That, you know, in a time of turbulence and change where the value of
00:27:40.592 --> 00:27:47.372
pursuing safety is in decline, the attention and willingness to invest in efforts to improve safety.
00:27:47.372 --> 00:27:51.506
In fact, it's the opposite, are faster, cheaper.
00:27:52.197 --> 00:27:55.820
Who gives a damn about what consequences play out along the way?
00:27:56.174 --> 00:27:58.524
We have to move fast and we have to move cheaper.
00:27:59.186 --> 00:28:03.268
And so how do we stand up for safety in this period of turbulence?
00:28:03.859 --> 00:28:05.212
We all need to pull together.
00:28:05.929 --> 00:28:10.660
And as you asked at the beginning, how do I deal with it and how do I personally get frustrated?
00:28:11.275 --> 00:28:16.284
Well, Voltaire said it for me in the 1700s.
00:28:17.018 --> 00:28:24.268
Mon Dieu, gardez-moi de mes amis. Quand à mes ennemis, je m'en charge.
00:28:25.132 --> 00:28:31.548
Dear, dear God, protect me from my friends. I can contend with my adversaries on my own.
00:28:32.888 --> 00:28:36.730
Beautiful. Thank you, my friend. We all need to pull together.
00:28:37.822 --> 00:28:42.466
And that is synthesize. Put safely and effective first.
00:28:43.802 --> 00:28:51.579
Build the momentum for continuous energy investment, re-energizing, revitalization.
00:28:51.933 --> 00:28:54.722
We are in a period of desperate need for revitalization.
00:28:55.323 --> 00:28:59.596
That requires innovation, that can draw on the science base.
00:28:59.926 --> 00:29:04.310
That's going to change the science base. It's going to expand the science base.
00:29:04.692 --> 00:29:08.750
We need to do it together because we are like the sharp end operator.
00:29:09.017 --> 00:29:12.892
We got to pull off something when we're under constraints. They're tying one
00:29:12.892 --> 00:29:17.121
arm behind our back, and they're trying to cut us off at the knees at the same time.
00:29:17.759 --> 00:29:22.990
We got to show a way, get some tools in there to show we can still dance,
00:29:23.204 --> 00:29:24.905
and we can help them dance too.
00:29:25.265 --> 00:29:30.992
Because we all are part of the balancing act that creates and sustains safety
00:29:30.992 --> 00:29:32.879
while we do things effectively.
00:29:33.355 --> 00:29:36.422
And that's always been the case, and it will always be the case. Thank you.
00:29:40.947 --> 00:29:45.629
And there you have it. Part two, finito, complete, terminar.
00:29:45.629 --> 00:29:47.627
It's over. We've done it.
00:29:48.178 --> 00:29:50.589
And thanks for hanging in there and listening to both parts.
00:29:50.589 --> 00:29:54.053
I know it's made a difference. It's a very interesting conversation.
00:29:54.308 --> 00:29:58.755
And I kind of hope it does rock a boat. I'll be good with it rocking a boat.
00:29:59.196 --> 00:30:02.759
But more importantly, I hope it builds a pretty strong case for we're better
00:30:02.759 --> 00:30:05.819
collectively together than we are separate.
00:30:06.486 --> 00:30:10.381
And I think that's a really important message. And that's not coming from me, baby.
00:30:10.770 --> 00:30:15.066
That's coming from Professor David Woods, the Ohio State University, the man.
00:30:15.664 --> 00:30:19.599
He's been around along 47 of the 50 years. That's a long time,
00:30:19.599 --> 00:30:21.010
dude. That is a long time.
00:30:21.428 --> 00:30:24.439
Learn something new every single day. Have as much fun as you possibly can.
00:30:24.439 --> 00:30:26.789
Be good to each other. Be kind to each other. Take care of each other,
00:30:26.789 --> 00:30:29.993
even the least among us. And for goodness sakes, be safe.
00:00:00.417 --> 00:00:04.697
You and I as veterans, it hit me right off the bat because the guy's going,
00:00:04.697 --> 00:00:07.383
well, I've been around since blah, blah, blah, blah, blah happened.
00:00:09.212 --> 00:00:13.177
And LinkedIn, I just went, well, I've been around for 47 of those damn 50 years.
00:00:14.929 --> 00:00:21.425
And I think you're right. I have a different perspective on what's gone on in those 50 years.
00:00:21.971 --> 00:00:25.006
And you've been around for a lot of those 50 years.
00:00:25.355 --> 00:00:30.283
So we should reflect a little since people wanted to do this and we're doing it I thought in a very,
00:00:31.114 --> 00:00:35.967
they were undercutting would be the fair word undercutting where we stand rather
00:00:35.967 --> 00:00:41.057
than empowering us to go further and do better it was undercutting everything
00:00:41.057 --> 00:00:45.503
and that's really the last thing we need in a time of change and challenge.
00:00:58.643 --> 00:01:02.278
Pre-accident investigation podcast. It's me, Todd. How are you?
00:01:02.632 --> 00:01:07.653
This is part two of the David Woods conversation. If you've not heard part one,
00:01:08.170 --> 00:01:12.363
you know, I'm of mixed minds, but it's probably worth going back and listening
00:01:12.363 --> 00:01:15.443
to first because it kind of sets the story.
00:01:15.783 --> 00:01:19.292
It builds the case for what part two talks about.
00:01:19.467 --> 00:01:23.133
But if you're in a hurry and, you know, you got a lot of crap going on and you're
00:01:23.133 --> 00:01:26.438
super busy and important, and many of you are, I realize.
00:01:26.763 --> 00:01:28.720
You're fine jumping in here as well.
00:01:29.051 --> 00:01:34.573
He is a great podcast guest for a bunch of reasons. One, Professor Woods is
00:01:34.573 --> 00:01:38.153
just smart. Every time he talks, I have pages of notes I take down.
00:01:38.495 --> 00:01:43.569
Just the way he phrases things makes me think. I hope you feel the same. I bet you do.
00:01:44.074 --> 00:01:47.783
Secondly, he requires very little feeding and maintenance. I mean,
00:01:47.783 --> 00:01:50.866
he'll take off, baby, and he'll go.
00:01:51.290 --> 00:01:56.623
And I like that because he has lots to say and he's thought a lot about this,
00:01:56.623 --> 00:02:03.241
a bunch about this. So this is kind of a very interesting and very important conversation.
00:02:03.849 --> 00:02:08.493
And I have to tell you, I don't want to ruin the ending because it's good,
00:02:09.115 --> 00:02:13.904
but it really ends in a way that I think it probably must end and should end.
00:02:14.368 --> 00:02:16.295
And it's the right thing to do. You know me.
00:02:16.928 --> 00:02:21.593
My theory is the meaning of life is good work done well for the right reasons.
00:02:21.593 --> 00:02:23.819
I've said that to you guys a million times.
00:02:24.417 --> 00:02:30.013
This kind of builds that case beautifully. And I think you'll appreciate it immensely.
00:02:30.518 --> 00:02:34.064
And it's a great conversation. It's very important. For a part two,
00:02:34.500 --> 00:02:37.286
this is killer good. That's how good it is.
00:02:37.928 --> 00:02:40.912
I'm having a good time here. I hope you're having a good time there.
00:02:41.342 --> 00:02:45.364
There's much for us to share. And I kind of want to jump right into this because
00:02:45.364 --> 00:02:52.354
there's so much information for you just to chew on and think about and enjoy.
00:02:52.679 --> 00:02:56.149
Yes, if you're not enjoying this, we're doing it wrong. It should be pretty fun.
00:02:56.544 --> 00:02:59.498
I mean, that's the whole goal is to learn something and have a good time.
00:02:59.910 --> 00:03:04.166
You know, it's about professional development. And that, my friends,
00:03:04.560 --> 00:03:10.005
that is something that we've been on a journey together for a long, long time.
00:03:10.377 --> 00:03:15.706
So without much further conversation, and I promise you, I don't have a lot more conversation.
00:03:16.281 --> 00:03:20.849
Let's hear part two of the talk that the three of us are going to have,
00:03:21.134 --> 00:03:23.426
Professor Woods, myself, and you.
00:03:23.885 --> 00:03:28.434
And it's going to be on what do we do with this information and how do we move
00:03:28.434 --> 00:03:32.784
forward as a community of people who are directly involved in safe,
00:03:32.784 --> 00:03:35.185
reliable operations. That's our goal.
00:03:41.140 --> 00:03:44.296
Because the other thing that's happened is the world keeps getting more complex.
00:03:44.818 --> 00:03:51.761
So those old things that kind of work some don't work so well anymore or the impact isn't so great.
00:03:52.092 --> 00:03:56.109
And that's why I'm always talking about, especially in patient safety,
00:03:56.109 --> 00:04:00.005
is can you produce an order of magnitude effect?
00:04:00.690 --> 00:04:06.338
I'm looking for 10 times an effect, not a percent. Yes, you could do a study for a percent effect.
00:04:06.881 --> 00:04:10.091
Usually they want us to give them a few percent effect. Right.
00:04:10.567 --> 00:04:14.419
Right. And we're like, no, I'm looking for an order of magnitude of fact,
00:04:14.419 --> 00:04:21.074
given the nature of the systems that change and the potential harm as our systems grow in capability.
00:04:21.399 --> 00:04:25.579
The harm when they break goes up by orders of magnitude, too.
00:04:26.272 --> 00:04:30.533
That's what I've said to you before When things go wrong now,
00:04:31.214 --> 00:04:36.561
The potential for harm When things go wrong Is at least two orders of magnitude
00:04:36.857 --> 00:04:42.799
Bigger than the maximum impact Of our traditional safety initiatives We did our initiative,
00:04:43.459 --> 00:04:49.220
They let us do it And they gave us reasonable funding Within the normal organizational constraints.
00:04:50.039 --> 00:04:54.609
And it was pretty successful It would be a percent improvement Not an order
00:04:54.609 --> 00:04:55.729
of magnitude improvement.
00:04:55.729 --> 00:05:00.389
And we're looking at harm that is two orders of magnitude. And as I said to
00:05:00.389 --> 00:05:03.499
you last time, measles is a simple example.
00:05:03.667 --> 00:05:08.834
And by the way, when I talked to you last time, we're now in the seventh month,
00:05:09.467 --> 00:05:11.799
right? And we have set a record, right?
00:05:12.339 --> 00:05:15.199
We are way past the max number.
00:05:15.759 --> 00:05:19.190
We're way on our way to three orders of magnitude. We might hit,
00:05:19.579 --> 00:05:22.836
we're definitely going to hit two and a half orders of magnitude in measles cases.
00:05:24.779 --> 00:05:32.849
As a canary in the coal mine on how the exposure to harm is increasing at the
00:05:32.849 --> 00:05:35.402
same time that our systems grow in capability.
00:05:35.728 --> 00:05:37.231
How will we break that cycle?
00:05:38.697 --> 00:05:42.256
Well, the irony is we can rock the boat with a science base.
00:05:43.509 --> 00:05:48.222
But it is kind of the answer in a way, right? Or it's a vital part of the answer.
00:05:48.851 --> 00:05:54.662
Yes. I mean, we have to have a generalizable set of what goes on.
00:05:55.869 --> 00:06:01.359
Because the normal context and pressures and constraints in which we do practical
00:06:01.359 --> 00:06:03.311
safety programs, they're very narrow.
00:06:03.590 --> 00:06:05.860
We get lost in the details of every setting.
00:06:06.295 --> 00:06:08.286
And it's driven very reactively.
00:06:08.849 --> 00:06:12.919
Even the, you know, the, our proactive, we get proactive successes,
00:06:12.919 --> 00:06:14.858
but it's hard to sustain.
00:06:15.217 --> 00:06:19.889
It's hard to have them organically multiply. It's a uphill climb each time we
00:06:19.889 --> 00:06:22.897
pull one off and that doesn't scale.
00:06:23.263 --> 00:06:26.670
And we've seen that when, if you take the long look, you go, yeah.
00:06:27.117 --> 00:06:32.999
So I want to go back to this issue of everything in the human experience pretty
00:06:32.999 --> 00:06:35.244
much is encompassed in the label safety,
00:06:35.859 --> 00:06:39.159
success, failure, reward, harm, fear, blame, responsibility,
00:06:39.159 --> 00:06:44.301
ethics, courage, disaster, heroic saves, the drama of the very near miss, right?
00:06:44.746 --> 00:06:47.765
It covers the C-suite. It covers regulatory policy.
00:06:48.509 --> 00:06:52.949
It goes all the way down to people who have to operate critical systems under
00:06:52.949 --> 00:06:56.868
enormous pressures to do amazing things at the sharp end.
00:06:57.488 --> 00:07:02.669
We cover a new technology that can do more and extend human reach,
00:07:02.669 --> 00:07:06.273
human vision, human action to new scales and distances.
00:07:06.911 --> 00:07:08.786
They have an enormous range of things.
00:07:09.512 --> 00:07:16.609
But in the end, you know, a mantra for proactive safety that I articulated 26
00:07:16.609 --> 00:07:24.269
years ago, been in print 21 years, is this our fundamental obligation as safety people, right?
00:07:24.269 --> 00:07:28.199
If you're engaged in creating safety, our fundamental obligation is to create
00:07:28.199 --> 00:07:32.645
foresight about the changing shape of risk before harm occurs. Mm-hmm.
00:07:33.774 --> 00:07:38.083
This came out first in the patient safety movement around 2000,
00:07:38.083 --> 00:07:43.024
and then very significantly in the Columbia space shuttle accident.
00:07:44.655 --> 00:07:54.843
And so now those two things, this huge encompassing of human systems issues and this obligation,
00:07:55.450 --> 00:08:01.847
for foresight about the changing shape of risk, means we've got a lot.
00:08:02.347 --> 00:08:06.625
I mean, what scope? I mean, what fun we get to have over the years, right? You and me.
00:08:07.234 --> 00:08:09.873
All the places we get to go, all the things we get to interact,
00:08:09.873 --> 00:08:13.803
all the scary places we've been, right? That's what we talk about over beers.
00:08:14.903 --> 00:08:19.837
Who went to the scariest place and came out alive?
00:08:20.875 --> 00:08:28.763
The so the key is building science base but that science base is about it has
00:08:28.763 --> 00:08:31.762
these funny constraints on it how do you do,
00:08:32.598 --> 00:08:36.543
lab how do you do what science people when people say science they usually think
00:08:36.543 --> 00:08:41.753
of lab experiments and definitive results with laws and you go big laws to hold
00:08:41.753 --> 00:08:43.215
everything up yeah i'm with you,
00:08:43.846 --> 00:08:48.920
and well when safety encompasses so much of human experience you have to look at the real world,
00:08:49.574 --> 00:08:54.393
and how do you and are you understanding human aspirations are you understanding
00:08:54.393 --> 00:08:57.793
why we build technology why we operate in certain ways why we're willing to
00:08:57.793 --> 00:09:02.563
invest in some aspects more automation less people maybe sometimes we should
00:09:02.563 --> 00:09:04.458
grow human expertise and have
00:09:04.847 --> 00:09:08.123
and maybe that's a better investment in the long run sometimes,
00:09:09.103 --> 00:09:11.244
always be one way or the other right.
00:09:12.462 --> 00:09:18.896
The and and and so you end up with this thing of we can't really do what our
00:09:18.896 --> 00:09:21.046
social norm of what science is.
00:09:21.046 --> 00:09:25.076
We have to do something that looks at the real world. So all of those practical
00:09:25.076 --> 00:09:28.716
experiences you and I have been in, we've treated we were just joking about
00:09:28.716 --> 00:09:32.182
it as research opportunities. Right. We're not just helping them.
00:09:32.634 --> 00:09:36.924
Each time we do it, we're going, I'm looking for patterns and understanding,
00:09:37.499 --> 00:09:40.886
whether that's at the sharp end, whether that's about the technology or the
00:09:40.886 --> 00:09:46.178
human technology interaction. whether that's about the organizational beliefs, how do you move them?
00:09:46.636 --> 00:09:49.388
How do you change their models and biases?
00:09:50.227 --> 00:09:55.286
I mean, another one is that makes this hard and different than usual areas of
00:09:55.286 --> 00:10:00.016
science is how do you do science when the people trying to do the science are
00:10:00.016 --> 00:10:02.887
part of the processes the scientists are trying to study?
00:10:03.445 --> 00:10:06.394
If you're trying to understand safety, you're influencing safety.
00:10:06.748 --> 00:10:12.076
You can't study it without being related to the process that's trying to build
00:10:12.076 --> 00:10:13.834
safety or sustain safety.
00:10:14.142 --> 00:10:16.220
You're studying how it breaks, right?
00:10:16.551 --> 00:10:21.398
You're part of the thing you study. You're not an outside objective observer.
00:10:21.538 --> 00:10:24.556
You're in something that's changing all the time.
00:10:25.172 --> 00:10:31.419
So the third thing is creating safety is about all kinds of skills,
00:10:31.791 --> 00:10:37.196
but they're all about balancing competing interests, right? In a changing world,
00:10:37.196 --> 00:10:39.165
not a state, not a category.
00:10:39.531 --> 00:10:44.146
It's about rebalancing how activities need to shift relative to goals,
00:10:44.146 --> 00:10:51.519
how goals need to shift relative to risk, how resources need to shift relative to uncertainty and risk,
00:10:52.406 --> 00:10:54.865
and new technology and new opportunities.
00:10:55.753 --> 00:11:01.791
It's a dynamic balancing And it's very hard To get organizations In today's world,
00:11:02.633 --> 00:11:06.216
That's why I use a lot of military examples Because they have to be good at
00:11:06.216 --> 00:11:12.953
balancing Dynamically Otherwise they lose Even if they start in the best position And they stay there.
00:11:14.177 --> 00:11:18.356
The best position doesn't stay best because there's somebody else adapting to.
00:11:19.074 --> 00:11:26.474
And so that gets us to this current situation we've been talking about of people
00:11:26.474 --> 00:11:28.704
looking back at 50 years and saying,
00:11:29.291 --> 00:11:34.374
yeah, it's just a lot of noise, a lot of labels, not much progress. Sloganeering.
00:11:34.852 --> 00:11:38.589
Pre-scientific sloganeering, right?
00:11:39.222 --> 00:11:43.414
And I think we want to blow away any confusion That there is,
00:11:43.414 --> 00:11:46.774
in fact, fantastic progress And,
00:11:47.834 --> 00:11:52.567
that the world keeps changing And that progress is necessary And needs to be,
00:11:53.190 --> 00:11:55.036
sustained and sped up even,
00:11:56.086 --> 00:12:01.174
And that it's easy, given the pressures Limited resources, huge variety of situations
00:12:01.174 --> 00:12:06.413
And distractions we have to face in safety It's easy not to know a lot about what we know,
00:12:07.734 --> 00:12:08.627
It's hard to keep up.
00:12:08.952 --> 00:12:12.290
It's hard to be part of this. It's hard to synthesize.
00:12:14.149 --> 00:12:17.574
God, that's interesting. You know that's an incredibly interesting thing you
00:12:17.574 --> 00:12:19.257
just said. That's remarkable.
00:12:20.894 --> 00:12:24.894
I mean, so we're getting a little bit to some of the punchlines.
00:12:24.894 --> 00:12:30.834
One is got to put effective and safe, safe and effective up front in order to
00:12:30.834 --> 00:12:34.594
be viable in both the short run and the long run, to be adaptive both in the
00:12:34.594 --> 00:12:35.754
short run and the long run.
00:12:36.374 --> 00:12:42.494
That are put faster, cheaper first assumes a stable world. Right.
00:12:43.325 --> 00:12:47.784
Where it's just a quick race. But when the landscape changes and the rules change
00:12:47.784 --> 00:12:52.784
and the destination changes and the trophy at the end changes, you got to adapt. Yeah.
00:12:53.974 --> 00:12:59.342
So what I want to highlight with you and encourage everybody is to spend some
00:12:59.342 --> 00:13:05.462
more time investigating, arguing, challenging, revising, extending, limiting.
00:13:05.462 --> 00:13:09.002
I'm not even going to say the scope of what we know is more limited than we
00:13:09.002 --> 00:13:10.678
thought, building more.
00:13:11.061 --> 00:13:15.362
But I want to give a couple examples that we have generalizable findings that
00:13:15.362 --> 00:13:19.744
are both concrete to guide how to work in a particular situation.
00:13:20.069 --> 00:13:23.610
Right. One general generalization doesn't apply everywhere.
00:13:23.964 --> 00:13:30.251
But it applies in lots more places. In fact, the reason we know it's a generalization or a law even,
00:13:30.790 --> 00:13:35.732
or a theorem even more that we can prove, is because we see it in many different
00:13:35.732 --> 00:13:40.102
settings play out, even though there are differences because of the unique features
00:13:40.102 --> 00:13:42.627
of those settings or the layer at which we observe it.
00:13:43.461 --> 00:13:49.816
And so I want to give one, right? It's really simple. It's a short paper under 4,000 words.
00:13:50.170 --> 00:13:52.185
It's a synthesis of syntheses.
00:13:52.800 --> 00:13:58.642
It's called the Command-Adapt Paradox Paper And it was written in frustration,
00:13:59.002 --> 00:14:04.372
I admit it Because people kept coming back and saying Well, what about compliance?
00:14:04.372 --> 00:14:09.572
And how much pressure for compliance should we be putting on our subordinate
00:14:09.572 --> 00:14:15.992
managers and personnel To just comply with the policy, to comply with the plans,
00:14:15.992 --> 00:14:17.605
to comply with the rules?
00:14:18.372 --> 00:14:22.314
And I kind of went, oh my God Are we re-litigating this again?
00:14:22.633 --> 00:14:26.012
How many times have we re-litigated this? Why are we doing this?
00:14:26.012 --> 00:14:29.942
This is an example of us We're in the washing machine going around and around
00:14:29.942 --> 00:14:33.186
again I'm tired of getting an ounce in your head off the wall You know,
00:14:33.985 --> 00:14:38.482
And so I reviewed the papers and syntheses To remind people about the basics
00:14:38.482 --> 00:14:45.339
And tried to summarize the synthesis of the syntheses You know, in plain, plain terms,
00:14:46.280 --> 00:14:51.074
compliance says there's plan and conform we often turn the plan into automation
00:14:51.074 --> 00:14:53.251
to try to make sure there's conformance right,
00:14:53.899 --> 00:14:59.554
right and the pressure to plan to behave by plan and conform reduces adaptive
00:14:59.554 --> 00:15:06.717
capacity this is laid out and a variety of things and i went through them in a ways like.
00:15:07.744 --> 00:15:12.844
Here are i had it up but anyway you should go look at it and i'll put the paper
00:15:12.844 --> 00:15:14.614
i'll put the paper in the notes for this.
00:15:14.614 --> 00:15:20.291
You know, it's like one of the findings, one, two, three, four, finding one.
00:15:20.645 --> 00:15:23.048
Okay. Well, the, the modern, right.
00:15:25.120 --> 00:15:30.494
There will always be surprised to challenge your plans. The modern date on that
00:15:30.494 --> 00:15:32.882
is in the 1980s on that finding.
00:15:33.387 --> 00:15:39.190
How far does it go back? It goes back to 1836 in Clausewitz.
00:15:40.741 --> 00:15:49.615
Another one is people outside models of work are miscalibrated.
00:15:50.684 --> 00:15:56.584
Your model of how someone else confronts the world is not the same of the model
00:15:56.584 --> 00:16:00.249
of the person confronting uncertainty, complexity in the world.
00:16:01.909 --> 00:16:08.434
That model confusion really dates back to again, some developments and papers
00:16:08.434 --> 00:16:12.660
and findings in our 50-year history.
00:16:13.832 --> 00:16:18.168
But you know how far it goes back? It goes back to 1890.
00:16:19.892 --> 00:16:24.347
William James, and he called it the psychologist fallacy.
00:16:25.067 --> 00:16:30.393
When the person studying human behavior substitutes their model for the situation,
00:16:30.944 --> 00:16:34.456
for the person's model of the situation, they have to act it.
00:16:35.136 --> 00:16:38.767
And he says, your job is to discover the model the person brings,
00:16:38.767 --> 00:16:42.287
not because it's right, but because they'll behave according,
00:16:42.287 --> 00:16:44.853
that model will influence their behavior.
00:16:45.387 --> 00:16:48.272
And then you can start to see what they're missing, what they're getting right.
00:16:48.568 --> 00:16:51.320
And you'll see that both of your models are wrong.
00:16:52.069 --> 00:16:56.767
Both of your models are incomplete and the risk of miscalibration exists,
00:16:56.767 --> 00:17:00.467
whether the person acting in the world and the person trying to understand the
00:17:00.467 --> 00:17:01.891
person acting in the world.
00:17:03.048 --> 00:17:09.267
And that's in Behind Human Error. That's in the 1983 paper at the Bellagio,
00:17:09.887 --> 00:17:14.792
the first formal official meeting on going behind the label human error in 1983.
00:17:16.287 --> 00:17:21.237
Those were, that fundamental is there. And that comes out in how we deal with
00:17:21.237 --> 00:17:24.767
hindsight bias and the techniques and a whole bunch of different things.
00:17:24.767 --> 00:17:26.335
And we can go on and on in there.
00:17:26.989 --> 00:17:31.331
Very quickly, we see research coming out. And again, we could date it earlier,
00:17:31.575 --> 00:17:37.833
but 1986, Lucy Suchman, plans are resources for action. Plans aren't specifications of action.
00:17:38.359 --> 00:17:41.348
All right. And then we go through how that developed.
00:17:42.153 --> 00:17:47.694
And what that means and what you end up with, oh, and that plans are necessary
00:17:47.694 --> 00:17:51.084
to recognize anomalies and surprise, right?
00:17:51.084 --> 00:17:54.304
If I don't have a model of what's typical, what's supposed to work,
00:17:54.304 --> 00:17:58.625
how things usually work, how we usually handle disruption and variation,
00:17:58.811 --> 00:18:01.464
I can't recognize anomalies, right?
00:18:01.464 --> 00:18:04.914
And therefore, I can't revise models. I can't revise tactics.
00:18:04.914 --> 00:18:06.764
I can't learn new strategies.
00:18:07.037 --> 00:18:10.560
I don't understand and diagnose the anomalies and where they come from.
00:18:11.202 --> 00:18:16.234
So learning and change comes from recognizing anomalies And to do that,
00:18:16.234 --> 00:18:21.651
I need a baseline of typicality that comes from plans So plans help me revise,
00:18:22.364 --> 00:18:27.075
And that's an old finding Eisenhower said that one in the 1950s.
00:18:27.944 --> 00:18:33.394
As well as scientists in the 80s and 90s So that led us to the idea of It's
00:18:33.394 --> 00:18:39.121
not plan and conform, it's plan and revise But revision isn't freelance,
00:18:39.578 --> 00:18:43.414
So then we run through what's the interaction between, right,
00:18:43.414 --> 00:18:46.569
what do we want to achieve? How are we trying to achieve it?
00:18:47.167 --> 00:18:52.826
Variability, surprise, and opportunity will arise outside the boundaries of that scope.
00:18:53.268 --> 00:18:58.132
And how do we revise relative to that? How do we recognize, revise,
00:18:58.319 --> 00:19:03.286
reframe, revitalize, right, head in new directions?
00:19:03.594 --> 00:19:06.544
And we've seen that now that we've lived decades in this.
00:19:06.544 --> 00:19:11.184
We see that over and over again Where safety programs, safety innovations Were
00:19:11.184 --> 00:19:16.884
turned into programs The programs, these were all fights The programs eventually
00:19:16.884 --> 00:19:18.646
were widespread in the industry,
00:19:19.335 --> 00:19:22.630
Even transferred to other industries And then you go and look.
00:19:23.384 --> 00:19:27.820
A while later, and you recognize they're not fit for purpose anymore.
00:19:28.473 --> 00:19:33.781
They're not doing the job. They've lost vitality, right? They need to be revitalized.
00:19:34.182 --> 00:19:38.744
Some of those were the successes in teamwork at crew resource management.
00:19:38.744 --> 00:19:43.782
And then you go into places that have crew resource management or other teamwork programs and you go,
00:19:44.419 --> 00:19:47.604
yeah, but when you actually look at the organization closely,
00:19:47.604 --> 00:19:52.221
you're finding a lot of breakdowns in teamwork, a lot of working across purposes,
00:19:52.581 --> 00:19:57.144
a lack of synchronization over different organizational boundaries within,
00:19:57.144 --> 00:19:58.644
you know, within the organization.
00:19:58.644 --> 00:20:01.416
And you go, there's not great teamwork here, guys.
00:20:01.851 --> 00:20:05.954
You need to revitalize the program and expectations around this.
00:20:05.954 --> 00:20:11.657
And it become routinized and rote and fine and a distraction.
00:20:12.034 --> 00:20:16.376
I get to go off and take my team training, but nothing effective came from it.
00:20:17.022 --> 00:20:21.824
So we have to re-energize the pursuit of safety We have to revitalize That should
00:20:21.824 --> 00:20:27.204
be seen as a basic in safety Not only do you need to You're in a place of.
00:20:28.984 --> 00:20:33.427
Re-energizing, revitalizing safety We want to do this before bad accidents happen
00:20:33.747 --> 00:20:38.324
But down the road, it's not one and done It's a phase And then you're going
00:20:38.324 --> 00:20:43.164
to have to re-energize and revitalize And some of that will be on different aspects,
00:20:44.144 --> 00:20:49.074
That weren't critical before And, you know, were okay to handle With the other
00:20:49.074 --> 00:20:52.934
programs you had But now needed to be more the focus and central thing Because
00:20:52.934 --> 00:20:53.994
the world keeps changing,
00:20:54.693 --> 00:20:59.167
So anyway, so if somebody comes and says to you, it's all noise and it's pre-scientific,
00:20:59.735 --> 00:21:03.024
read the Command-Adapt Paradox paper, right?
00:21:03.024 --> 00:21:06.904
It synthesizes lots of research. It encompasses a broad set of things,
00:21:06.904 --> 00:21:10.904
and it ends up with an actionable strategy, and it's being carried out.
00:21:10.904 --> 00:21:15.524
Guided adaptability is being used by pragmatic people working with everyday
00:21:15.524 --> 00:21:20.344
organizations like Dave Provan and Bethleh and their book coming out on this,
00:21:20.785 --> 00:21:25.713
and they're turning it into practical action so that you can meet those demands.
00:21:25.992 --> 00:21:28.889
Do it now, do it fast, and don't cost me money. That's right.
00:21:29.624 --> 00:21:31.095
And make it better, make it better.
00:21:31.904 --> 00:21:36.134
What a great conversation. Thank you, my friend. Well, the other ones,
00:21:36.134 --> 00:21:41.244
I mean, there's other ones I want to mention quickly to remind people of this
00:21:41.244 --> 00:21:42.829
before we bring it to a close.
00:21:43.724 --> 00:21:48.164
Just to highlight to people, I already mentioned the fluency law and now that
00:21:48.164 --> 00:21:50.440
goes back to the psychologist fallacy.
00:21:51.349 --> 00:21:56.028
But the fluency law and all that stuff is critical to our analysis of how things
00:21:56.028 --> 00:21:58.048
go right and how things can go wrong.
00:21:58.645 --> 00:22:02.388
You have to go in and understand how people are adapting. And to do that,
00:22:02.388 --> 00:22:06.134
that's where in resilience engineering, we said study how things go right. Why?
00:22:06.511 --> 00:22:10.198
Because people are doing fluent adaptations to make things go right.
00:22:10.198 --> 00:22:12.129
So go study how things go right.
00:22:12.558 --> 00:22:17.088
So make sure you understand the fluency law. It's critical out there in the
00:22:17.088 --> 00:22:19.780
last 25 years of how we pursue safety.
00:22:20.308 --> 00:22:24.858
And forget the big labels and arguments over this And putting numbers on it,
00:22:24.858 --> 00:22:28.980
whatever There's a fundamental law, right?
00:22:29.236 --> 00:22:34.958
Now, it's an empirical law But we can derive this from some first principles
00:22:34.958 --> 00:22:39.545
That gives it extra strength It's not just empirical that we see it a lot It
00:22:39.777 --> 00:22:41.676
kind of has to work this way Right.
00:22:42.958 --> 00:22:46.808
And so then when you understand it You can make use of it in a variety of settings
00:22:46.808 --> 00:22:50.628
To help understand and direct your action and also understand how sometimes
00:22:50.628 --> 00:22:52.045
people get on the wrong track.
00:22:52.702 --> 00:22:56.468
The other one is, this one came, there were some things anticipating it,
00:22:56.468 --> 00:23:00.911
but it was first, the label was first used in 98, it's the law of stretch systems.
00:23:01.513 --> 00:23:05.621
Every system is stretched to operate at its capacity as soon as there is some improvement.
00:23:06.638 --> 00:23:10.318
When a new form of technology comes along, the capabilities will be exploited
00:23:10.718 --> 00:23:13.291
to achieve a new intensity and tempo of activity.
00:23:13.925 --> 00:23:20.029
The statement of the law is actually a paraphrase of an after-action report from a U.S.
00:23:20.319 --> 00:23:27.708
Military operation that was Kordsman, Anthony Kordsman, summarized the use of
00:23:27.708 --> 00:23:30.682
new modern military technology in the Gulfs.
00:23:31.618 --> 00:23:35.454
To do more, do it faster in more complex ways. It didn't make the work on the,
00:23:36.054 --> 00:23:37.580
sharp end operator easier.
00:23:38.160 --> 00:23:41.364
It enabled them to do more, do it faster in more complex ways.
00:23:41.364 --> 00:23:45.811
What did that mean? You could do more. It was good. A capability also meant it was riskier.
00:23:46.578 --> 00:23:49.132
Things could go wrong. When they went wrong, harm was bigger.
00:23:49.312 --> 00:23:52.533
Right. And some of that were friendly fire incidents.
00:23:53.642 --> 00:23:58.994
So notice this highlights how everybody's adapting and how when people say we're
00:23:58.994 --> 00:24:05.324
going to improve the system in this way, I'm sorry, but that's not what's going to happen.
00:24:06.008 --> 00:24:09.824
Do I know what's going to happen? No. What I know is what we think is going
00:24:09.824 --> 00:24:11.774
to happen is not what's going to happen.
00:24:12.554 --> 00:24:17.144
Because people are adaptive. And what they'll see as an advantage is different
00:24:17.144 --> 00:24:19.013
than what we thought it would be.
00:24:19.517 --> 00:24:24.234
We'll think more narrowly and linearly. They'll see it relative to their goals.
00:24:24.234 --> 00:24:26.124
Remember that psychologist fallacy.
00:24:26.443 --> 00:24:31.464
They'll see it in a new light. And they'll go, look what this will do for me.
00:24:32.156 --> 00:24:37.104
And that means maybe it won't do something so good for a different role at a
00:24:37.104 --> 00:24:40.103
different layer of the operation or organization.
00:24:40.798 --> 00:24:44.694
And we see this in the adaptations around AI coding.
00:24:46.414 --> 00:24:51.144
We just see it all the time in all of this. one that is really,
00:24:51.144 --> 00:24:56.054
really important and has been there since 19.
00:24:56.054 --> 00:25:01.230
I first said it in 83 at the Bellagio meeting, and then it's in the 94 Behind Human Error, is how,
00:25:01.843 --> 00:25:05.934
hindsight, knowledge of outcome changes your perspective and changes your ability
00:25:05.934 --> 00:25:11.224
to understand what happens when people confront situations with uncertainty and risk.
00:25:11.912 --> 00:25:15.499
And so I gave it a new name a few years ago, the novelty inequality.
00:25:16.109 --> 00:25:20.994
I think this is a mathematically provable situation. I have not found a partner
00:25:20.994 --> 00:25:23.644
to help me pull off a mathematical Bayesian proof.
00:25:24.997 --> 00:25:30.001
Well, you know, I've always argued with Bayes. Now I want to use Bayes to help me.
00:25:30.334 --> 00:25:33.820
I haven't quite found a way to do this. Bayes is kind of intransigent.
00:25:33.820 --> 00:25:37.460
You know, I'm not sure I'm on your side, Dave. You've criticized me so much.
00:25:38.990 --> 00:25:44.610
But the novelty inequality, when you're in a situation facing uncertainty and
00:25:44.610 --> 00:25:51.662
risk, the potential novelty in front of you is much, much greater than the known novelty,
00:25:52.179 --> 00:25:54.379
that's determined after the fact.
00:25:55.182 --> 00:25:59.472
Right. Afterwards, we can hone in on this is exactly what was different.
00:26:00.064 --> 00:26:04.520
This is exactly where the rules didn't apply. This is exactly the surprising
00:26:04.520 --> 00:26:08.951
nature. This is exactly what needed to be adapted relative to normal practice.
00:26:09.578 --> 00:26:14.400
But beforehand, you're not sure There's multiple forms This was shown in the
00:26:14.400 --> 00:26:18.120
hindsight cartoon That Richard Cook came up with And we used in the patient
00:26:18.120 --> 00:26:23.840
safety movement In the 90s Based on the Behind Human Error book Trying to explain what this,
00:26:24.666 --> 00:26:30.691
meant And literally the cartoon used It's in the 2010 book You can see,
00:26:31.418 --> 00:26:36.810
The range of uncertainty factors And trade-offs that the Sharp end person confronts
00:26:36.810 --> 00:26:43.620
In the face of uncertainty and risk versus the after-the-fact analysis can hone in on only a few.
00:26:44.007 --> 00:26:47.860
And as I always joked about Three Mile Island, they had 10 minutes to make a
00:26:47.860 --> 00:26:53.684
decision for a situation they had not been trained for and didn't know even could exist. Right.
00:26:54.950 --> 00:27:03.120
When the after-action analysis took six months and $6 million of the best engineers
00:27:03.120 --> 00:27:08.060
in the field and $60 million in 1980 terms is a hell of a lot of money.
00:27:08.060 --> 00:27:09.337
Yeah, yeah, that's some big jack.
00:27:09.686 --> 00:27:13.100
And I think a lot of us would make decisions better with $60 million,
00:27:13.900 --> 00:27:18.980
even in today's dollars, and access to the best engineers or analysts on that
00:27:18.980 --> 00:27:20.726
particular topic, right?
00:27:22.102 --> 00:27:26.110
And stuff. So we have lots and lots of stuff.
00:27:26.812 --> 00:27:30.992
So we wanted to come back. You asked me, well, and this is going to go back
00:27:30.992 --> 00:27:34.181
to, we're trying to stimulate our friends.
00:27:34.663 --> 00:27:40.592
Yeah. That, you know, in a time of turbulence and change where the value of
00:27:40.592 --> 00:27:47.372
pursuing safety is in decline, the attention and willingness to invest in efforts to improve safety.
00:27:47.372 --> 00:27:51.506
In fact, it's the opposite, are faster, cheaper.
00:27:52.197 --> 00:27:55.820
Who gives a damn about what consequences play out along the way?
00:27:56.174 --> 00:27:58.524
We have to move fast and we have to move cheaper.
00:27:59.186 --> 00:28:03.268
And so how do we stand up for safety in this period of turbulence?
00:28:03.859 --> 00:28:05.212
We all need to pull together.
00:28:05.929 --> 00:28:10.660
And as you asked at the beginning, how do I deal with it and how do I personally get frustrated?
00:28:11.275 --> 00:28:16.284
Well, Voltaire said it for me in the 1700s.
00:28:17.018 --> 00:28:24.268
Mon Dieu, gardez-moi de mes amis. Quand à mes ennemis, je m'en charge.
00:28:25.132 --> 00:28:31.548
Dear, dear God, protect me from my friends. I can contend with my adversaries on my own.
00:28:32.888 --> 00:28:36.730
Beautiful. Thank you, my friend. We all need to pull together.
00:28:37.822 --> 00:28:42.466
And that is synthesize. Put safely and effective first.
00:28:43.802 --> 00:28:51.579
Build the momentum for continuous energy investment, re-energizing, revitalization.
00:28:51.933 --> 00:28:54.722
We are in a period of desperate need for revitalization.
00:28:55.323 --> 00:28:59.596
That requires innovation, that can draw on the science base.
00:28:59.926 --> 00:29:04.310
That's going to change the science base. It's going to expand the science base.
00:29:04.692 --> 00:29:08.750
We need to do it together because we are like the sharp end operator.
00:29:09.017 --> 00:29:12.892
We got to pull off something when we're under constraints. They're tying one
00:29:12.892 --> 00:29:17.121
arm behind our back, and they're trying to cut us off at the knees at the same time.
00:29:17.759 --> 00:29:22.990
We got to show a way, get some tools in there to show we can still dance,
00:29:23.204 --> 00:29:24.905
and we can help them dance too.
00:29:25.265 --> 00:29:30.992
Because we all are part of the balancing act that creates and sustains safety
00:29:30.992 --> 00:29:32.879
while we do things effectively.
00:29:33.355 --> 00:29:36.422
And that's always been the case, and it will always be the case. Thank you.
00:29:40.947 --> 00:29:45.629
And there you have it. Part two, finito, complete, terminar.
00:29:45.629 --> 00:29:47.627
It's over. We've done it.
00:29:48.178 --> 00:29:50.589
And thanks for hanging in there and listening to both parts.
00:29:50.589 --> 00:29:54.053
I know it's made a difference. It's a very interesting conversation.
00:29:54.308 --> 00:29:58.755
And I kind of hope it does rock a boat. I'll be good with it rocking a boat.
00:29:59.196 --> 00:30:02.759
But more importantly, I hope it builds a pretty strong case for we're better
00:30:02.759 --> 00:30:05.819
collectively together than we are separate.
00:30:06.486 --> 00:30:10.381
And I think that's a really important message. And that's not coming from me, baby.
00:30:10.770 --> 00:30:15.066
That's coming from Professor David Woods, the Ohio State University, the man.
00:30:15.664 --> 00:30:19.599
He's been around along 47 of the 50 years. That's a long time,
00:30:19.599 --> 00:30:21.010
dude. That is a long time.
00:30:21.428 --> 00:30:24.439
Learn something new every single day. Have as much fun as you possibly can.
00:30:24.439 --> 00:30:26.789
Be good to each other. Be kind to each other. Take care of each other,
00:30:26.789 --> 00:30:29.993
even the least among us. And for goodness sakes, be safe.
SEARCH PAST EPISODES
Search past episodes of PreAccident Investigation Podcast.
Disclaimer: The podcast and artwork embedded on this page are from Todd Conklin, which is the property of its owner and not affiliated with or endorsed by Listen Notes, Inc.
EDIT
Thank you for helping to keep the podcast database up to date.