Notes on Kevin Lacy’s article. It of course if very well written and yet he also gets key points exactly right. Kevin has come to many of the same conclusions as I have independently. He say’s, “The time when you had a drilling foreman who has seen everything and knows what to do in every situation is long gone.” This is so true and yet another reason we need a due process system like FORECAST, BROADCAST, and SIMULCAST that add confidence to systems. He says, “The challenge with process safety and well control now is that the major incidents are so infrequent that there is a general sentiment that these things don’t happen, or won’t happen”. Yes, this is endemic and a part of the problem that proclaims, “The Ends justify our means”, while the process oriented better approach is, “The Means justify (constrain and improve) our ends”. This outcome bias is used to fuel a culture of Injustice as Kevin’s latter comments describe clearly. “The public reaction to Macondo was standard: blame the individuals, and write new processes (along with hiring new frontline people to enforce them). But I believe the response needs to be deeper than finding a scapegoat and finding a process gap.” Yes! I am glad to have a friend in Kevin that sees this clearly because we seem to be a scarce commodity in the world at this time. And thankfully Kevin goes on, “The lesson I take from this is that there are three necessary parts to building a process safety culture. One is leadership, one is the actual process or standards, and then there is the culture itself, how we work. Those three things should work together dynamically and reinforce each other.” Here is where I can clarity something that Kevin almost get perfectly right and that is that the third component isn’t “culture” and yet it is confidence. Confidence that the processes in place will lead to the best outcomes so that all personnel believe in the process and focus on the task closer at hand ensure the processes succeed. This confidence must be developed and protected at all costs. This confidence is the measure of the culture. This confidence feeds the “positive improvement feedback loop” that makes the process improve and the outcomes improve. This is what Kevin wrote, “Those three things should work together dynamically and reinforce each other.” My opinion then of the three things is: 1. Leadership at every level is focus on the precursors of the consequences of risk and they are vulnerabilities and exposures that become hazards. This is means versus ends focus. This is HOW versus WHAT focus. This is journey versus destination and beginning versus end focus. This is AFFECT versus EFFECT focus. This is measurement of AFFECT and that is leadership defined and that leadership focus must be instilled at every level of leadership and with the self-leadership of “how we think and act”. 2. Processes. This become almost in the subconscious yet our focus is on evolving vulnerability and exposures that exist in the system we are creating in the earth; we are replacing natural perfect barriers on top of oil and gas with our man made barriers to blowout. Dynamic focus (leadership) should be the conscious focus of at least one person during process of executing the plan yet the dynamic assessment of current vulnerability and exposure of our barriers must be broadcast back to all people involved in the process. 3. Confidence in the processes. And this creates culture. The culture is developed as confidence in its processes and a “how” versus “what” mentality is developed and focuses on. Culture isn’t a part of the process and yet culture is developed and maintained by the process. The details are the vital part of the reinforcement of belief in the process that is gauged as, “confidence”. This is our cultural measurement. The safety culture is measured and protected through confidence in it. In order for people to have confidence they must truly think and more important “believe” that the processes will actually improve outcomes or else they will not see the processes as worth, “the pains we are taking.” Kevin writes that we must ask tough questions about our processes like, “Why was it not being used?” This is a measurement of the key precursor of consequence of a safety culture and Kevin must be strongly applauded for seeing this subtle key truth.
Kevin also addresses the true root cause of the quickness of drifting into an Unjust Culture that focuses on outcomes and blames the tail or the frontline workers for the outcomes instead of blaming the leadership by saying, “the rugged individualism prevalent in the American psyche.” and I will add that this also makes it easier to blame others because we feel less connected to them and this is culturally acceptable; yet it isn’t and that mentality must be moved away from steadily. We must be more responsible and not less. We must use our heads and not chase our tails. We must be more focused on our own internal locus of control and less on the external locus required to blame others for our own shortcomings of our own processes. We have to admit we do not know it all before we can even come close to learn and move in the right directions.
Kevin goes on to a key point in discussing what I consider the uselessly distraction of looking to probabilities to measure risk by writing, “…it is very common for drilling managers to say ‘this won’t happen’. I have sympathy with this. What they really mean is, it’s highly improbable. And they’re right, it is highly improbable. In fact, it’s very difficult even to put a probability on it…” My contention is that simply by focusing on the outcomes necessary to constrain probability to any useful measure we affect the outcome adversely and the whole focus is distracting from the definition of all true leadership is in the first place; closer to home at the precursors to consequence. Kevin goes on and says, “This creates a kind of vacuum in terms of what to focus on…” Kevin nailed exactly the point. We must focus on the origins of risk and the precursors of consequence and not our outcomes, our processes and not the effect they are having as long as we believe in them and this requires confidence. We should not ignore that the worst outcomes are possible and the best and yet we must learn, establish and then focus on processes that we are confident in and not allow ourselves to drift into outcome orientation on the small scale of focus or the larger scale of performance metrics. Engineers should never be exposed to the toxic distraction of costs while involved in the drilling of the well. This is outcome alone and if they are not already diligent to process and time pressuring them will create worse and even the worst, outcome. MBAs that think opposite of this must be kept away from them! If we establish processes we are confident in and guard that confidence with improvements and focus on the right things, because our focus drifts, our safety culture will be better and stronger and the best they can be at every moment in time. Kevin says, “It’s a subtle but profound shift in thinking.” Kevin goes on to compare well containment to the airline industry and says we are “three orders of magnitude off” and points to a point I’ve been making for three years about how the NPT test must be signed off on by the engineer that designed it, by writing this, “They (airline industry) don’t ever allow a single person to be the sole agent in a set of actions that could lead to system failure.” Yep!
Kevin also mentions “feelings” and not sending mixed messages. Again this is key. Culture is all about “feelings” and yet we put the “cart before the horse”. The feelings of a great culture “follow” the “forms”. This means the actions follow the processes that define how we do things. The key feeling in our process is “confidence”, and if we have it, we reinforce it and if we don’t have it we “game” it.
Kevin concludes with some key points, “Very few people intentionally make mistakes but they may not follow a process, or they may not know about it, or, over time, process corner-cutting is reinforced when nothing bad happens right away. This is how process deficiency propagates.” Kevin and I only differ mainly in one key point and that is that confidence in the system is the key measure to manage in the overall process of creating and maintaining the safety culture. The precursors to eroding confidence or confidence building should be focused on. Precursors being the things he mentioned like pointing to good outcomes as proof that shortcuts drifted into do not result in bad consequences. This is corrosive to confidence and yet if the vulnerability to this is properly and completely understood they can be clearly detected and managed.
Of course it all goes back to leadership’s responsibility to direct focus closer to home, at the origins of risk, on the process and not the outcome, and on the means, and not the ends, and if that is done there will be less drifting into looking at outcomes and assuming a good outcome means the corner cutting doesn’t matter, in the first place. Leadership, process, and confidence are the process. Culture is the byproduct. We must manage culture at its origin and that is leadership. We must manage culture by managing confidence. Not as simply seen, this is confidence versus arrogance and improvement versus deterioration. The mindset of the leader is one of confidence, humility