LONDON PARTNERS’ FOCUS GROUP

ATHENS FEB. 2020

LEADERSHIP: NAVIGATING THE FUTURE
 Human Performance Principles – key concepts

• Human Performance is like a religion without a bible

• A principle is dependable & predictable – it is always true
• People do what makes sense to them…at that moment…in the context of that work….that we
helped them create
• Safety is not the absence of an accident, but is the presence of capacity (by design & not luck!)
• Success comes from making it easy to do the right thing and hard to do the wrong thing
• The principles are really much more directed at leaders, not the workers/operators
• The principles are not aimed at what to do, but help what to avoid
• Human Performance facilitates alignment of workers, systems and the organisation

Shell International Trading and Shipping Company

 #1 – People Make Mistakes
• Error is normal…..therefore error is never causal
• Error is part of being succesful
• Errors are not choices – errors become a choice in retrospect
• If you can’t remove error, therefore you must defend against the inevitability of error (i.e.
Fail Safely = error tolerance)
• Error without significant consequence is the closest thing to “leading indicator” data

• Creative, adaptive, smart & experienced workers keep the normal variability of your operations
in check all of the time
• Workers can fix giant operational problems in real-time and still trip on the floor
• People are exceptional problem solvers but not exceptionally reliable
• We build systems that expect perfection and are surprised when workers are not perfect
• Asking people not to make errors is not an effective strategy
• Error is directly connected to operational complexity
• The more rigid a procedure is written, the greater the potential to require variance from it
• Near Miss reporting is a symptom of system weakness
Shell International Trading and Shipping Company
 #2 – Blame Fixes Nothing
• Blame is emotionally important….not operationally important
• Blame makes error a choice in retrospect
• Blame takes up emotional and intellectual space with little added value
• Blame misdirects resources and strategies
• Blame is the opposite of encouragement
• Deterrence by Blaming is not effective
• We think bad things happen to bad people – we want to think the best about people (we judge in
retrospect). Test this by looking at historical investigation report content.
• We think we can fix the problem by fixing the person who failed – Name, Blame, Shame &
Retrain. We sometimes send the whole organisation not to do what the offending worker did
• The quickest way to blame is to investigate what should have happened vs what did happen
• Mistakes are not choices and errors are not a conscious decision to fail – error is an unintended
deviation from an expected outcome
• One of the most difficult aspects of event recovery is to help remove self-blame
• Our move towards blame & punishment has drifted towards negativity with positive intent
• Don’t find blame - fix systems (if a worker gets killed the family don’t feel better if the worker
Shell International Trading and Shipping Company

made a mistake. The worker is dead & blaming the worker for being dead helps no one).
 #3 – Learning and Improving is Vital
• Organisations have two choices – learn & improve, or blame & punish
• Learning is a deliberate improvement strategy
• Knowing how work is done is difficult (work as imagined vs work as done)
• Workers are the experts, the profound users of the work process
• Workers always complete the work design
• Defences are placed in systems, tested in systems & strengthened in systems by
learning how successful work is done

• Learning may be the most powerful safety & reliability tool you have
• Learning takes effort, deliberate resourcing and courage - is the org open to honest feedback
• Only knowing more makes your organisation better
• The higher up the further away from awareness of workplace hazards – the lower you are the
further away from influencing the work systems
• Waiting for failure to occur is too late & reactive – learn while operations are normal
• The enemy of learning is knowing – you will not ask important, relevant questions. Be curious,
be smart, be humble
Shell International Trading and Shipping Company
 #4 – Context Drives Behaviour
• Workers do what they do for a reason, and the reason makes sense to the worker given
the context
• Complex systems don’t lend themselves to traditional metrics
• Local rationale is information to be discovered, not to be weaponised
• The environment in which work occurs mainly determines workers’ behaviour & actions

• Individual behaviour is influenced by organisational processes and values

• Management is in the business of directing workers’ behaviour (grocery store example)
• Organisations create context – make it easy to do the job right & difficult to do the job wrong
• Design for error. Context is not an accident – its part of how work is done
• BBS assumes workers have unlimited power & self-discipline to make safe decisions
• BBS is the doubt that org context & systems have the ability to influence worker actions
• Ask “what failed” vs “who failed”
• Additional insight: ‘Outward Mindset’ (Arbinger) – to shift behaviour requires shift in mindset
• Fixing people is cheaper and faster to implement – fix the context is sustainable & effective
Shell International Trading and Shipping Company
 #5 – How You (Management) Respond to Failure Matters

• You have two choices – getting better or getting even

• You can blame & punish, or learn & improve, but you can’t do both
• You create the feedback system you have
• Managers shape how the organisation learns by their reaction to failure
• Every aspect of improvement is contingent on leaders’ deliberate decision to get better

• Leadership is present at all levels in the organisation

• People are watching closely to see what type of information you welcome and what you don’t
• We purposely learn to improve – event response should be deliberate and purposeful also
• Leaders play a special role in creating robust and stable organisations
• Leadership’s response to failure in communicating commitment to reliable & stable performance
• Leadership can provide an environment where it is safe to fail and learn
• Embrace the red and fear the green

Shell International Trading and Shipping Company