The Pursuit of Success & Averting Drift into Failure – YT vid from Sidney Dekker

Here’s a 30 min YT presso from Sid Dekker on complex system failures and drift.

Some extracts:

· “this fascination with counting and tabulating little negative events, as if they are predictive of a big bad event over the horizon, is an illusion”

· “We should be doing something quite different if we want to understand how your complex system is going to collapse and fail”

· “You go, oh, that’s really good, because we pursue excellence and we hold our people accountable for excellent outcomes, and excellent outcomes is the same as zero errors, and zero screw ups, and zero order missed days … whatever your KPI might be. This, is an invitation to a big blowup just around the horizon”

· On DuPont, “DuPont [is] very, very safe, supposedly, right? And these guys killed four people in a gas release in LaPorte, Texas, not that long ago … Now, the issue is how have they been managing their safety, their errors. It’s in the picture for you to see”

· “If you look around, you will see that what they’re concerned about is little bugs. Please take care, sorry, please take extra precaution when driving and walking … And so, this focus, this obsession on .. mishap free days doesn’t predict disaster at all”

· “Great example, right, Macondo. Did you know that these guys had more than six years, six years of entire incident and injury free performance on this boat … “

· In aviation “something really interesting, which is the airline that seems to be less safe, actually won’t kill you. So, the airline that reports more incidents, has a lower passenger mortality risk”

· “Now, what’s fascinating, so we replicated this data across various domains, construction, retail, various other domains, and we see that there is this inverse correlation between the number of incidents reported, the honesty, the willingness to take on that conversation about what might go wrong, and things actually going wrong”

· “Is the team taking past success as a guarantee of today’s success? In a dynamic complex system, that is an extraordinarily bad idea .. because past success is not predictive of success today”

· “If we want to understand, in complex systems, how things really are going to go badly wrong, what we shouldn’t do is try to gleam predictive capacity just from the little bugs, and incidents, and the error counts that you do”

· “No, we need to understand how success is created”

· “much more goes right than goes wrong. And this is probably true for all the work that we do. Much more goes right”

· “And then when things go wrong, then we do postmortems, then we send in the hoards to try to find out what happened, but we can learn from what goes right. Now, my claim is going to be that not only should we be doing that because there’s lots of data to learn how things go right, but also because for us to know how things will really go wrong, we need to understand how they go right”