10Xers

In my last post ("Lucky Breaks"), I talked about the role of luck in determining success.  Perhaps Janice Kaplan and Barnaby Marsh said it best in an article they wrote in 2018 for the Wall Street Journal ("To be successful, make your own luck"), "Luck is at the intersection of random chance, talent, and hard work."  In other words, it takes a combination of all three factors - good luck, talent, and hard work - to be successful.  As I discussed, two Italian physicists (Alessandro Pluchino and Andrea Rapisarda) and one Italian economist (Alessio Emanuele Biondo) used what is called a "toy mathematical model" (which they called their "Talent versus Luck" model, or TvL model) to show that luck plays a much larger role in determing success than perhaps previously appreciated (see their 2018 paper, "Talent vs Luck: The role of randomness in success and failure").  I wanted to continue this discussion, focusing this time on organizations rather than individuals.

I have always enjoyed reading the series of books by Jim Collins, and I particular enjoyed Great by Choice, which he co-wrote with Morten Hansen.  The subtitle for this book explains exactly what this book is about - "Uncertainty, Chaos, and Luck - Why Some Thrive Despite Them All."  Collins and Hansen completed a nine-year research project beginning in 2002 that gathered data from an initial list of 20,400 companies in a variety of industries.  Their goal was to identify organizations that performed exceptionally well, even in a world of uncertainty and chaos.  After sifting through reams of data, they identified 7 organizations that met their criteria for high-performance.  Collins and Hansen called these organizations "10Xers" because they didn't just get by, they truly survived.  Every 10X organization beat their industry competition by a factor of ten!

So how do these organizations become (and stay) 10Xers?  Are they just lucky, or are they really that good?  Collins and Hansen noted four key characteristics that seemed to set these organizations apart from their peers (shown in their Figure below):

"Fanatic Discipline" is characterized by consistency of action, values, goals, performance standards, and methods.  These organizations are relentless in their approach, almost monomaniacal in their unbending focus on their goals and objectives.  Collins and Hansen talk about something they call the "20-Mile March", using the "Race to the South Pole" by Roald Amundsen and Robert Falcon Scott as a case study.  Both teams have the same resources, arguably the same level of experience and expertise, but Amundsen's team was the first to reach the South Pole and survived, while Scott's team reached the South Pole 34 days after and died on the return journey.  What was the key difference?  Amundsen's team marched 20 miles every single day.  If the weather was bad and the team was tired, they would push on and reach their daily goal of 20 miles.  Here was the important difference though.  Even if the conditions were perfect, the team would stop every day at 20 miles.  In contrast, Scott's team frequently traveled in spurts, going as far as they could one day and then either taking the day off or going only a short way on the alternating days.  He drove his team to exhaustion and quickly used up their supplies.  Fanatic discipline means setting a goal and sticking to it, no matter what (even if it means holding back).

As an example of this "20-Mile March" concept, Collins and Hansen explained how one 10Xer, Southwest Airlines' goal of generating a profit every single year.  Between 1990 and 2003, the U.S. airline industry as a whole turned a profit in only six of the 14 years.  In the early 1990's, the industry as a whole lost $13 billion and furloughed over 100,000 employees.  But not Southwest Airlines - during that same period of time, Southwest remained profitable every single year and didn't furlough a single employee.  They did so by this fanatic discipline to their goal.  Even when things were going very well for the company, they were very deliberate about not expanding to new cities if they weren't ready.  As an example, in 1996 more than 100 cities were trying to bring in Southwest Airlines to their airports, but the airline expanded to just four cities. 

"Productive Paranoia" sounds a lot to me like the High Reliability Organization (HRO) principle of "Preoccupation with Failure".  The 10Xers considered every possible "What If?" scenario and prepared for them.  They stayed hypervigilant and attuned to threats and changes in their environment, even when things were going well for them.  They channeled fear, anxiety, and worry into action.  Collins and Hansen talk about Microsoft founder Bill Gates' famous "nightmare memo" in which he outlined all the real and potential threats that could torpedo the company's success, even though the company experienced unparalleled success.  Gates would later say, "If I really believed this stuff about our invincibility, I suppose I would take more vacations."  

Collins and Hansen noted that the 10Xers didn't necessarily make bold or daring moves.  While most leaders rely on conventional wisdom, expert opinions, or even untested ideas, leaders at the 10Xers relied upon their own creative instincts backed by empirical data ("Empiric Creativity").  Their bold moves were backed by the evidence, obtained by extensive observation and experimentation.  Collins and Hansen called this a "Fire bullets, then cannonballs" approach (which to me sounds a lot like "small test of change" that I discussed in my post, "Simplify your offense!").  10Xers would run pilots before going "all in" in order to build on proven success.

If you've read Collins' book, Good to Great, you probably are familiar with his concept of "Level Five Leadership".  Similarly, Collins and Hansen found that 10Xers exhibited "Level Five Ambition".  The leaders within these organizations were focused on the success of their organizations and not personal gain.  They channeled all of their energy and ego into the greater cause or purpose.  

Hansen wrote an article in the Harvard Business Review ("You Can Manage Luck.  Here's How.") based upon their findings from the 10Xers.  He writes, "It's not the luck you get that counts, it's what you do with it - your return on luck."  He suggests four ways that organizations can maximize their "return on luck."  First, organizations should view life as a flow of luck events (similar to the TvL model discussed in my last post).  Second, organizations should prepare for bad luck events (there's that "Preoccupation with Failure" again).  Third, organizations should spot good-luck events when they come and be prepared to act upon them.  Lastly, organizations should execute brilliantly on good-luck events.

I want to leave with one last quote from Great by Choice.  The 10Xer Roald Admundsen said, "Victory awaits him who has everything in order—luck people call it. Defeat is certain for him who has neglected to take the necessary precautions in time; this is called bad luck."  Success is a function of luck, talent, and hard work.

Lucky Breaks

Have you ever wondered how some individuals always seem to be in the right place at the right time?  Why do certain leaders get all the lucky breaks, while the rest of us have to work hard for every scrap?  There is an old adage that says, "It's better to be lucky than good".  And while that may certainly explain some things, I've honestly always believed that individuals can and often do create their own luck (see my post, "Good luck is the twin of hard work").  Rather than just being lucky, these leaders take advantage of the opportunities that present themselves.  The television star Ashton Kutcher said it best in an acceptance speech at the 2013 Teen Choice Awards when he said, "Opportunity looks a lot like hard work."  Janice Kaplan and Barnaby Marsh write (in a 2018 Wall Street Journal article, "To be successful, make your own luck") that "Luck is at the intersection of random chance, talent, and hard work...People who have a talent for making luck for themselves grab the unexpected opportunities that come along."

Whose right here?  How much does luck play into success?  Consider for a moment that the chance of becoming a CEO is heavily influenced by your month of birth (children born in June and July are less likely to become CEO's compared to children born in March or April).  Did you know that individuals with last names earlier in the alphabet are more likely to receive tenure in top ranked economic departments?  And Malcolm Gladwell discussed the well-known phenomenon that elite hockey players are generally born between the months of January and March in his book, Outliers: The Story of Success.  Of course, all of these are mere associations (not cause-and-effect relationships), but it's hard to ignore how random these findings are when it comes to explaining success.

Ben Cohen wrote an article in the weekend edition of the Wall Street Journal a few weeks ago entitled "Winners Know How to Hardness Luck".  Cohen talks about three scientists who recently won the 2022 Ig Nobel Prize in Management (these prizes were first awarded in 1991 by the Annals of Improbable Research to "honor achievements that first make people laugh, and then make them think") - Drs. Alessandro Pluchino, Alessio Emanuele Biondo, and Andrea Rapisarda, who were honored for their 2018 paper, "Talent vs Luck: The role of randomness in success and failure" (notably, Pluchino and Rapisarda won the 2010 Ig Nobel Prize in Management for their work on the so-called Peter Principle, a topic for a future post).

Pluchino and Raspisarda (who are both physicists) teamed up with Biondo (an economist) and proposed what is called a "toy mathematical model" in an attempt to model success as a function of talent and luck (which they called their "Talent vs Luck" or TvL model).  Basically, they simulated the evolution of careers of a population over a worklife of 40 years (from age 20-60) using what I call fancy mathematics!  Actually, as a non-mathematician, I was able to follow how they constructed their model fairly easily (and note, any success that I've had in mathematics is due more to luck than talent!).

They simulated a population consisting of N individuals with talent T (intelligence, skills, ability, etc), a normally distributed variable around the interval [0,1] with a given mean and standard deviation.  Individuals were randomly distributed in fixed positions within a square world.  At the beginning of the simulation, all individuals were endowed with the same amount of capital, C, which represented their success/wealth.  During the next 40 years (work life between 20 and 60 years of age), these individuals were randomly exposed (approximately every six months) to events (lucky, unlucky, or no event).  Lucky events doubled their capital with a probability proportional to their talent (i.e. the more talented the individuals were, the greater the increase in their capital), while unlucky events halved their capital.  Exposure to a nonevent did not change the individuals' capital.

Pluchino, Raspisarda, and Biondo ran several simulations, and the results were very consistent.  In general, the individuals with higher talent had a higher probability of success.  However, talent alone could not explain success by itself, as the most talented individuals were rarely the most successful.  As a matter of fact, mediocre-but-lucky people were much more successful than their more-talented-but-unlucky counterparts.  And the most successful individuals tended to be the ones with just slightly above average talent but with above average luck.  

It is a well-known fact that intelligence, as a proxy measure of talent, exhibits a Gaussian or normal distribution (the so-called bell-shaped curve with the mean at the peak of the curve).  Wealth, as a proxy measure of success, typically follows a power law (also known as a Pareto law) such that very few individuals in a population account for the greatest share of overall wealth.  In the TvL model, the 20 most successful individuals accounted for 44% of the total amout of success in the population (closely approximateing Pareto's 80/20 rule).

I've talked about something in the past known as the "Matthew Effect" (simply stated as "the rich get richer, the poor get poorer").  Meritocratic strategies are often used in society to assign honors, funds, or rewards based upon the past success (for example, a scientist's application for grant funding from the National Institutes of Health is more likely to be approved if that individual has a proven track record of successful research, as demonstrated by publications and previous grant funding).  Pluchino, Raspisarda, and Biondo test this kind of strategy using their TvL model.  Starting from the same parameters in their original model, they assigned external funds to individuals based using four different methods:

1. Egalitarian method (funds were distributed equally across the board)

2. Elitarian method (funds were distributed based upon past performance)

3. Mixed method (a given percentage of funds, or premium was distributed to the most successful individuals and the remaining amount in smaller equal parts to the remaining individuals)

4. Selective random method (funds were distributed to a given percentage of individuals who were randomly selected)

A fixed amount of external funds were distributed every five years, throughout the entire simulation period of 40 years.  Again, in the absence of these external funds, the most successful individuals were the very lucky individuals with average talent.  Surprisingly, the most effective funding strategy was the egalitarian method (distributing funds equally to every individual).  The least effective strategy was the elitarian method of distributing funds based upon past performance (which, as stated above, is perhaps the most commonly used method in our society today).  Pluchino, Raspisarda, and Biondo called the latter approach "naively meritocratic".  Notably, similar findings have been previously reported by these same investigators as well as others (for a review, see the Scientific American blog post, "The role of luck in life success is far greater than we realized"). 

So, what are we to conclude from this study by Pluchino, Raspisarda, and Biondo?  Most importantly, the old adage that it's better to be lucky than good is only mostly true.  Repeating the quote from Janice Kaplan and Barnaby Marsh from their 2018 Wall Street Journal article ("To be successful, make your own luck"), "Luck is at the intersection of random chance, talent, and hard work."  Success does not depend on just talent alone.  Rather, success is a function of talent, hard work, and luck.  With this in mind, perhaps we should reconsider some of the ways that society assigns honors, funds, and rewards.  Past performance is not necessarily a sign of future success.  I want to continue on this theme of success, talent, and luck in my next post.

The Vulnerability of Dependence

I've been reading The Daily Stoic by Ryan Holiday and Stephen Hanselman this past year.  The book is a daily devotional that couples a short passage from one of the ancient Stoic philosophers with a short explanation or example from modern times.  One of the recent passages referred to the following passage from Seneca's Moral Letters:  

"Show me someone who isn't a slave!  One is a slave to lust, another to greed, another to power, and all are slaves to fear...No servitude is more abject than the self-imposed."

The accompanying explanation from Holiday and Hanselman talks about the "Vulnerability of Dependence" - we are all addicted to our routines, our comfort, or even someone else's approval.  Unfortunately, these dependencies (or addictions) mean that we're not in control of our own lives.

The Stoic philosopher Epictetus said, "Anyone who truly wants to be free, won't desire something that is actually in someone else's control, unless they want to be a slave."  All of the things that provide us comfort - the hot shower we take every morning, the coffee we drink on the way to work, or the down comforter that keeps us warm at night when we are sleeping - can be taken away from us at any moment.  Our daily routines can be disrupted by an unexpected event.  We may show up to work and find out that our boss is leaving for another opportunity.  The doctor may tell us that we need to lose weight and drink less wine.  All of this can happen and more.

The Stoics strengthened themselves by testing their dependencies before they became too great.  For example, have you ever decided to take a break from your morning coffee for a week?  I know a couple who stops drinking wine for the entire month of November.  I have another colleague who takes a cold shower every morning.  As I wrote in the post "Hit the showers - and make it a cold one!", several ancient philosophers (not just the Stoics) practiced self-denial or voluntary discomfort in order to "quiet their appetites for material goods" and help them better appreciate all of the things that they had in their life.  Here we have the ancient version of "What doesn't kill you, makes you stronger."  

I found out that one of my former high school classmates practices the Wim Hof method, which consists of deep breathing techniques, meditation, and frequent cold exposure.  The "cold exposure" aspect consists of cold showers and ice baths.  Hof claims, "We have become alienated from nature, but the cold is capable of bringing us back to what we once had lost."  I am not suggesting or advocating for this particular method (it's personally too extreme for me).  However, several months ago I did start turning off the hot water for a few minutes at the end of my morning shower and it felt great!

My point is that we should not become too dependent on all the comforts of modern life.  Our dependence on these comforts makes us more vulnerable.  We run the risk of getting seriously off track when if or when they are taken away.  We can practice to live without these comforts through periodic self-denial and voluntary discomfort.

The Six Thousand Mile Screwdriver

We are past the middle of October, and it's definitely starting to look and feel like Autumn here in the Midwest.  Two events of major historical significance occurred during the month of October, and both have important lessons for leaders.  The first was the Cuban Missile Crisis, which took place sixty years ago from October 16, 1962 to November 20, 1962.  We've been hearing a lot about this particular crisis, as several political analysts and historians say that we are closer to a nuclear confrontation now with the events taking place in the Ukraine than we have ever been since the Cuban Missile Crisis (most of these same analysts and historians also think that we were much closer then than we are now).  Leadership during the Cuban Missile Crisis has been analyzed in a number of excellent books, including Irving Janis' Groupthink: Psychological Studies of Policy Decisions and Fiascoes, Graham Allison'sg Essence of Decision, and Robert Kennedy's Thirteen Days: A Memoir of the Cuban Missile Crisis (co-written with Arthur Schlesinger).  Hopefully, I can come back to a discussion of this crisis in the future.  However, today I want to discuss the second event of major historical significance that occurred in October, the United States invasion of Grenada, which occurred in October 25-29, 1983.

I came across a discussion on the Operation Urgent Fury , the U.S. invasion of Grenada in an article by Karl Weick (one of the early founders and thought leaders on High Reliability Organizations) in the journal Industrial Crisis Quarterly ("Mental models of high reliability systems").  The article itself was a little too technical for me, but I was fascinated by Weick's mention of something that the operational commander of the operation, Vice Admiral Joseph P. Metcalf, said at that time that was relevant to the discussion of High Reliability Organizations.  Apparently VADM Metcalf was involved with the U.S. evacuation of Saigon in 1975 and recalled that the on-scene commanders were forced to deal with "the six thousand mile screwdriver", which he defined as "the minute direction of the day-to-day operations of a field commander by higher and remote authority" (the key words being higher and remote).  In other words, the "boots on the ground" military leaders were being micromanaged by their supervisors in Washington, D.C.  

If you've been following my blog for any length of time, you will recognize the HRO concept of "Deference to Expertise" here (or in this case, the absence of deference to expertise).  It's a theme that I've come back to on numerous occasions because I thoroughly believe in it (and hopefully embrace it).  No one likes to be micromanaged.  Front-line leaders have the most up-to-date knowledge and situational awareness of what's happening on the battlefield, even with the ever present "fog of war".  Why then would a military leader thousands of miles away think that he or she could make better decisions than someone who is right there seeing events unfold directly in front of them?

VADM Metcalf was a strong believer in the concept of "Deference to Expertise".  However, he also believed that the front-line leaders at least partially controlled whether they were micromanaged from afar by the "six thousand mile screwdriver".  He wrote, "There is a natural tendency for higher authority to move down and attempt to control local actions from afar.  In this day of instant communication from and to anywhere in the world, combined with the high stakes involved, the local commander has an obligation to communicate information up if he expects to retain control.  Higher command authority must always have information, or they will remove control from the local commander."

How did he accomplish this?  Weick wrote, "To retain local control, Metcalf used situation reports, a command voice, explicit advance plans, staff warnings, and a party line to enact an environment up the chain of command that told him to do essentially what he wanted to do."  Metcalf explained further, "I organized the structure of decision making in a way that, I thought, would maximize the delegation of authority down to me, whereas below me, I delegated 'what' to do to my subordinates and they were responsible for the 'how'".  

First, Metcalf directed his staff to send at least two situation reports up to his superior officers every hour, whether there was anything to report or not.  These reports accomplished two things.  First, because they were so reliably sent twice every hour, they quickly became the single source of truth.  Conflicting information during a battle is inevitable, particularly given the "fog of war" mentioned earlier.  Regardless, Metcalf's superiors began to rely more on his situation reports to the exclusion of other, seemingly less reliable sources of information.  Second, the reports kept the staff at headquarters busy reading the reports, so that they couldn't tell him what to do (i.e., micromanage).

Metcalf assigned an experienced junior officer to man the secure phone from Grenada to headquarters in Norfolk, Virginia.  This same individual was the command voice during the entire operation.  Metcalf said, "The commander in chief and his staff always heard the same voice, a voice they knew and could relate to.  The object was to create the impression that, in fact, we were in control and knew what was going on."  Metcalf's strategy worked to perfection.

Controlling the channels of communication was important, but Metcalf also worked to control the situation through advance planning.  Operational plans were developed for the next day by 5:00 PM on the preceding evening, and Metcalf shared these plans with his superiors so that they could review his intentions in the context of his own assessment of strengths, weaknesses, opportunities, and threats.  Finally, the fact that communication equipment was limited was fortuitous in a way, as Metcalf established a party line between Grenada and headquarters.  He said, "When either my call sign or Admiral McDonald's (Commander-in-Chief, U.S. Atlantic Fleet and Metcalf's immediate superior) went out over the circuit, the line was instantly cleared.  Captains of the ships huddled around the CIC to listen in, and this particular party line came to serve a very useful function.  It conveyed our intentions to those commanders, without having me having to go over them again individually with each captain...Everyone involved in the mission decision making knew the intended plans and the pressures on local command."  

I have read extensively on the concept of "Deference to Expertise", though this is the first time that I have come across what operational leaders can do to "manage up" in order to avoid being micromanaged.  While there is more to learn about how Metcalf led during the Grenada campaign, I will save that for another day.  I would like to leave this post with a final admonition from VADM Metcalf himself: "When you are in command, COMMAND!"

"Everyone knows that quitters quit"

Several years ago, I knew someone who tried just about every recreational and sporting activity out there.  He wouldn't just try out a sport, he went "all in" and purchased all the equipment.  He had it all - we used to call him "The Gear Guy" because after trying something out, he was immediately hooked.  He would go to the local sporting goods store and purchase all the equipment needed for the activity.  When he first tried scuba diving, he bought all of the scuba diving equipment - usually the best available.  He tried rock climbing once, and then he bought all of the rock climbing equipment - shoes, harness, ropes, etc.  You name it - he had it.  Here's the thing though, he never seemed to stick with any activity long enough to get really good at it.  Just as quickly as he started one activity, he would move on to another one.  And all that gear would gather dust in the corner of his garage.

The former business executive and blogger Seth Godin wrote a book called The Dip where he talks about quitting.  Godin believes that, contrary to popular belief, the winners (at sports, business, or life in general) are usually the best quitters.  Winners quit fast, quit often, and quit without any guilt whatsover.  That doesn't seem right, though.  Or does it?

We are taught that the most successful individuals are the ones who are persistent and never quit.  The NFL Hall of Fame coach Vince Lombardi famously said, "Quitters never win and winners never quit."  Boxing great Muhammad Ali said, "I hated every minute of training, but I said, 'Don't quit. Suffer now and live the rest of your life as a champion.'"  Conrad Hilton said, "Success seems to be connected with action.  Successful people keep moving.  They make mistakes, but they don't quit."  Former U.S. President Bill Clinton said, "If you live long enough, you'll make mistakes.  But if you learn from them, you'll be a better person.  It's how you handle adversity, not how it affects you.  The main thing is never quit, never quit, never quit."

It's become a common refrain.  The actor and comedian Brad Garrett starred in the 2005 movie The Pacifier with Vin Diesel.  There's a memorable scene where one of the characters quits the high school wrestling team.  Garrett (who is plays the wrestling coach) tells the quitter, "You know why you quit?  Because you are a quitter.  And everybody knows that quitters quit."  So if all of these famous and successful people are telling us that we should never, ever quit, why does Seth Godin (who arguably is just as successful as the others) tell us that quitting is not only acceptable, it's one of the most important drivers of success?

Godin talks about a concept that he calls "strategic quitting" and notes that the most successful (athletes, business executives, entertainers, physicians, writers, researchers, etc) are notorious for focusing on the things that will help them achieve their goals to be the best.  He uses an analogy here, stating "A woodpecker can tap twenty times on a thousand trees and get nowhere, but stay busy.  Or he can tap twenty-thousand times on one tree and get dinner."  That reminds me a lot of Bruce Lee's quote, "I fear not the man who has practiced 10,000 kicks once.  But I do fear the man who has practiced one kick 10,000 times."  Practice makes perfect, and the more time that we spend practicing our craft, the better we will be at it.

When you think about it this way, Godin makes a great point.  Imagine what would have happened with my friend if he had selected and practiced just one activity.  He would have saved a lot of money on sports equipment for sure, but he would also have been a lot better at that one activity instead of just knowledgeable about all the others.

So, just like Coach Mooney (Brad Garrett) said, quitters do quit.  But so do winners.

"All progress depends on the unreasonable man"

The Irish playwright (and winner of the 1925 Nobel Prize in Literature) George Bernard Shaw wrote, "The reasonable man adapts himself to the world, the unreasonable one persists in trying to adapt the world to himself.  Therefore all progress depends on the unreasonable man."  The quote comes from his 1903 play, "Man and Superman", a four-act drama written in response for Shaw to write a play based upon the character of Don Juan.

When I first saw this quote, I really liked it, mostly because it made me think.   On first glance, one could argue that Shaw is suggesting that some individuals are particularly self-centered, which makes them unreasonable.  But then when you read the rest of the quote, he suggests that it is exactly the unreasonable man who is responsible for all of the progress made in the world.  Shaw himself could be very unreasonable at times, so maybe he is taking credit for advancing some of his political views and calling that progress?  I wouldn't know, but I want to focus more on the words and less on the individual who said them.

Mahatma Gandhi once claimed, "If you want to change the world, start with yourself."  In other words, you are the one who has to change first before you can change the world around you.  That seems a little counter to what Shaw was saying, doesn't it?  Maybe not.  The key here is to think about the world as static or unchanging for a moment.  Here, Shaw's "reasonable man" changes or adapts to the world around him (I am using the masculine pronouns to stay consistent with Shaw's quote, but the quote could apply universally to anyone, regardless of gender).  Please note here that nothing changes, except the individual's views, attitudes, beliefs, or actions.  How is that progress?  Gandhi suggests here that in order to catch up with everyone else, individuals have to be willing to change their own attitudes and beliefs.  That makes sense if we are personally behind the times and need to catch up with everyone else around us.  But what happens when we have the same views, opinions, or attitudes as everyone else? If we really want to change these prevailing attitudes or actions, we have to be a little bit unreasonable.

Shaw suggests that in order to make progress, we have to shake things up a bit and be a little disruptive (hence, "unreasonable").  I am again reminded of the leaders who I worked with in the past who challenged and pushed our organization to move out of our comfort zone and achieve things that we didn't feel were possible.  We used to feel at that moment that these leaders were pushing us too hard or being "unreasonable."  However, after we achieved some "stretch goals" and transformed the organization, we looked back at these same leaders and discovered that their "unreasonableness" was exactly what we needed at the time.

We all need to be pushed at times.  In order to make progress, sometimes we need to push our teams beyond their comfort zones.  When it comes to organizational transformation and progress forward, be unreasonable!

"I'm sorry, we are out of that..."

How many times during the last two years did you order something at a restaurant or store only to be told, "I'm sorry, we are out of that item..."?  It's incredibly unfortunate that many physicians at outlying emergency departments are being told the same thing when they need to admit a sick child to the hospital.  It's happening all over America right now as we are moving into the busiest time of year for children's hospitals with a recent surge of viral respiratory illnesses.  

Today is the last day of my week of taking care of patients on our inpatient pediatric hospital medicine service.  I always enjoy these weeks of service - it's a good break from the administrative aspects of my job and after all, I spent several years of education and training in order to be a physician.  I still love taking care of patients.  It certainly feels like Autumn outside this morning, but inside the hospital it feels like the middle of winter.  We are at the tail end of one surge of respiratory illnesses associated with rhinovirus and enterovirus D68 (see the CDC report here), and we are starting out the typical late fall/early winter respiratory syncytial virus (RSV) season a little earlier than usual this year! 

Every winter, doctor's offices and hospitals around the country see more children with respiratory illnesses.  In other words, those of us in pediatric medicine experience this every winter, and we should be adequately prepared to handle an increased number of emergency department (ED) visits and hospital admission requests.  Things are different this year though.  Our health care delivery system in this country is struggling.  We've experienced supply chain disruptions and labor shortages just like every other industry.  What's so different about children's hospitals then?  In order to answer that question, we have to go back several months to the early days of the COVID-19 pandemic, because that's when our struggles really began.

We were fortunate that, for the most part, the vast majority of children infected with SARS-CoV-2 weren't very sick.  COVID-19 was the hardest on adults over the age of 50 years, and when adult hospitals were filling up with critically ill patients with COVID-19, most children's hospitals weren't very busy at all.  As a result, hospitals around the country converted their pediatric beds to adult beds in order to accommodate the surge in adult patients with COVID-19.  Children's hospitals often sent over staff and supplies to their adult counterparts, as well as increasing the maximum age of patients that they would admit to lend a hand.  As one of my colleagues, Scott Krugman points out in an article in the Health Affairs blog "An Unexpected Shortage: Hospital Beds for Children", most of these pediatric inpatient units never re-opened, despite a drop in COVID-19 numbers.  

All of us in health care like to argue that medicine is not a business, but that is just not the case.  Health care administrators have to generate revenue and decrease costs, just like any other business.  Unfortunately, the unique calculus of health care finance incentivizes adult medicine over pediatric medicine.  Hospitals are reimbursed more for admitting adults instead of children.  As Dr. Krugman writes, "With current models of hospital and physician payment that incentivize high-cost volume adult medicine, there is a high risk of further closures of pediatric units across the country...Unless there is a dramatic change in how we pay for and prioritize inpatient care - for all age groups - the cost to organizations to care for children will exceed any community benefit and more hospitals will be pressured to close their (pediatric) inpatient units."

Two additional articles appeared within the last week or so on this issue.  Emily Baumgaertner wrote about this issue in a New York Times article last week ("As Hospitals Close Children's Units, Where Does That Leave Lachlan?").  Ms. Baumgaertner writes that the decline in pediatric beds began even before the COVID-19 pandemic, though undoubtedly the pandemic greatly accelerated the problem.  She writes, "Between 2008 and 2018 - the most recent national data available - pediatric inpatient units in the United States decreased almost 20 percent, and nearly a quarter of children found themselves farther from their nearest pediatric unit."

As community hospitals and even large academic medical centers close their pediatric inpatient units, free-standing children's hospitals will have to fill the gap in order to meet the demand for inpatient care. One of my pediatric critical care colleagues, Dr. Deanna Behrens, recently wrote an Op/Ed piece in the Chicago Tribune.  Dr. Behrens specifically addresses our current predicament that there are just not enough pediatric beds to meet the current demand.  She writes, "Here is what can happen when the system gets overwhelmed: The emergency rooms are full of children who need a hospital bed. Emergency department providers must spend time calling various hospitals to look for rooms on the general floor or in the PICU. The pediatric floor is full. We cannot transfer children who have improved to the floor from the PICU, so the PICU is full. It is more difficult to transfer to the PICU children on the floor who get sicker — because the PICU is full. Children in the emergency room end up staying for much longer than normal. Hospitals in the area and in surrounding states trade patients depending on who has which type of bed available at any given time."

It is indeed a perfect storm - critical staffing shortages, supply chain disruptions, an early respiratory viral season, and pediatric bed closures - all of which are placing an unprecedented strain on children's hospitals across the country.  But as the proverb says, "A smooth sea never made a skilled sailor."  I see these challenges as an opportunity for all of us to really take a look at how we practice pediatric medicine and improve. 

While we certainly should look at how pediatric health care is financed in this country, the reality is that the system that currently exists isn't likely to change quickly, if at all.  We need to look elsewhere for help.  First of all, pediatric health care organizations are going to have to take a leadership role in addressing the disparities that currently exist.  We have to find ways to keep children out of the hospital whenever possible.  Children's hospitals are working with local government and community organizations to address the social determinants of health.  Second, we have to continue to leverage existing technology to prevent unnecessary admissions and/or expedite discharge from the hospital.  COVID-19 accelerated several advances in remote patient monitoring and increased the utilization of telemedicine care.  While technology will require investment, if we can prevent hospitalization or shorten the length of stay when children do get admitted, it will be well worth it.  Third, children's hospitals need to develop and/or expand existing partnerships with community hospitals in order to extend their reach and provide localized pediatric expertise.  Fourth, we are going to have to change our existing models of care.  Staffing shortages aren't going to go away anytime soon, so we will have to be creative on how we design care delivery systems to provide safe, effective, evidence-based care.  I also think that children's hospitals need to build closer relationships with community colleges and universities to develop workforce pipeline as early as possible, similar to what they have done with medical schools.  Finally, we are going to have to address the concurrent mental health crisis.  We just don't have the capacity to hold kids in emergency departments or inpatient beds while they await definitive mental health treatment.  

 These next few years are not going to be easy, but I do think we will get through them and be a better and stronger pediatric health system as a result.  Dr. Behrens ended her Op/Ed piece with the following statement, which I think applies universally.  "Be kind to each other, be patient with health care providers as we work to help your children...With everyone's help, we will get through this."

I can't tell you why...

Here's a silly "Dad joke" for you.  I used to ask our kids, "Why were the Eagles better with Timothy B. Schmit versus Randy Meisner?"  They would respond, "I don't know.  Why?"  I would then respond with, "I can't tell you why".

In a recent post ("Find your way back!"), I mentioned that rock-n-roll bands are just like any other group, team, or organization in that the relationships between individuals in the group ebb and flow.  I am reminded of the psychologist Bruce Tuckman's model of group development (originally published in 1965) which refers to four key stages in the life of a group, "Forming, Storming, Norming, and Performing".  Unfortunately, some groups get stuck in the "Storming" stage, where the group can't move on to the next stage until individuals settle their disagreements and resolve their personality clashes.  Tuckman apparently added a fifth stage several years after he developed the model, namely the stage called "Adjourning" when the group (hopefully) completes its task and breaks up or disbands.  

If you read about the history of the rock-n-roll supergroup, the Eagles, you start to appreciate the concept of Tuckman's stages of group development.  Over the years, the group has progressed all the way to the "Performing" stage, at which point someone got into an argument with one or more of the other members and left the group (usually due to "creative differences" or in a few cases, outright hatred).  When that occurred, the group went back through the "Forming, Storming, Norming, and Performing" stages with a new member.  Let's take a closer look at what I mean.

The group formed in Los Angeles, California in 1971 when drummer Don Henley and guitarist Glenn Frey were joined by bassist Randy Meisner and guitarist Bernie Leadon (recently from the folk rock band, The Flying Burrito Brothers) as the back-up band for singer Linda Ronstadt.  While on tour with Rondstadt, Henley and Frey decided to form their own band, actually with Rondstadt's encouragement.  In reality, the group that came to be known as the Eagles only played live together with Linda Ronstadt once for a July concert in Disneyland (they did play on her eponymous third studio album).  Here we have a great example of Tuckman's "Forming" stage.  During this stage, members of the group are usually highly motivated and enthusiastic about coming together to discuss their mutual goals and interests.  In this particular case, "Forming" included coming up with a name for their band (I've heard several different stories on who originally came up with the name, one of which suggested that it was the comedian and actor Steve Martin, who was a friend of the band from their very early days).

In rather impressive fashion, the Eagles recorded and later released their first studio album, "Eagles", in June, 1972.  The album was an immediate success, topping the album charts at #22 with three Top 40 hits ("Take It Easy", "Witchy Woman", and "Peaceful Easy Feeling").  Had the band progressed all the way to the "Performing" stage? I actually don't think so.  It was not until their second studio album, "Desperado" that Henley and Frey began to collaborate more effectively, assuming the bulk of the songwriting duties for the band.  In addition to taking over most of the songwriting duties, the pair began to dominate as the true leaders of the band.  Clearly the group was in the "Storming" stage here, as they were trying to figure out their different relationships, roles, and responsibilities.  Meisner and Leadon had perhaps wrongly assumed that they would be the leaders of the band, given that they were veteran musicians.  However, that was not to be the case.

The "Norming" stage is the point at which all of the personality clashes and disagreements between individual group members have been resolved.  All of the members in the group at this point understand their role and responsibilities, and everyone is working toward a common, shared goal.  The Eagles, by this point in the life of the band, were starting to move in a different direction musically.  Henley and Frey wanted to break away from their country rock roots (if you listen to their first two albums, you will appreciate Leadon's banjo, dobro, steel guitar, and mandolin playing skills) and move more towards hard rock.  So, in at least one sense, they were moving into the "Norming" stage.  However, Leadon and Meisner were still unhappy with their role and level of influence with the creative direction of the band vis-à-vis Frey and Henley.  Importantly, highly functioning groups still can experience conflict, they just seem to manage it so that it doesn't have an adverse impact on the group's progress towards their goals.  Leadon and Meisner may have just simply accepted their limited influence.      

The band invited guitarist Don Felder to play and eventually join the group full time on their third studio album, "On the Border" in 1974.  The album featured a couple of hits, including the band's first of five number one singles, "The Best of My Love".  The band quickly moved to the "Performing" stage with the release of their fourth studio album in 1975, which was their first of four consecutive number one albums, "One of These Nights".  Later that same year, the band won the Grammy Award for Album of the Year and Best Song of the Year (for the song, "Lyin' Eyes").  At this point, the Eagles were international superstars.  

Unfortunately, Bernie Leadon had grown more and more disillusioned with the direction that the band was taking, and he was no longer satisfied with his role in the band.  Apparently, during one argument with Frey, Leadon poured beer over Frey's head and told him, "You need to chill out, man!"  He eventually left the band for good in December of that same year.  Here we have the "Adjourning" stage, and like most groups that experience changes in membership, the Eagles found themselves back in the "Forming" stage of group development.  The band invited guitarist and singer Joe Walsh, formerly of the band, the James Gang.  I guess at this point, the band's status as a rock-n-roll supergroup was solidified.  

The band would apparently quickly progress with the new line-up through the "forming" and "norming" stages to get back to the "performing" stage.  They released "Their Greatest Hits (1971-1975)" in early 1976, which quickly became the top-selling album of all time until Michael Jackson's "Thriller" took that distinction over in 2009.  The band recorded and released "Hotel California", one of my personal favorites, in December, 1976.  The title track won the Grammy for song of the year, but the album lost the Grammy for Album of the Year to Fleetwood Mac's "Rumours" album (another personal favorite).  

Unfortunately, once again there was trouble between the different members of the band.  Don Felder originally sang the lead vocals for the song, "Life in the Fast Lane" (which he mostly wrote), but the rest of the band wasn't happy with the sound.  Apparently, the band's manager took Felder out to lunch so that Henley could re-record the lead vocals.

During the "Hotel California" tour, Meisner started growing more disillusioned with the band and his role (similar to Leadon before him).  Apparently at one point, Meisner refused to come back on stage for an encore to sing the hit song "Take It to the Limit" (the only song he ever sang lead vocals for the group) because of health-related issues with hitting some of the high notes on the song.  Frey and Meisner got into an altercation backstage, at which point Meisner decided to leave the band.  The band replaced him with bassist and singer Timothy B. Schmit, who incidentally had replaced Meisner once before in the band Poco.

Once again there was a new member of the band, which required going back to the forming, storming, and norming stages.  Schmit would fit in well, and the band recorded their next studio album "The Long Run" in 1979 after spending two years in the recording studio.  While this album wasn't as successful as "Hotel California", it did feature several hit songs, including the song that featured Schmit as the lead vocalist, "I can't tell you why".

Unfortunately again, personalities and egos continued to clash.  The band performed at a fundraising event for then California Senator Alan Cranston.  When the Senator and his wife thanked the members backstage, Felder responded with "You're welcome - I guess."  Frey and Felder would spend the rest of the night onstage telling each other about the beating that they had planned to administer once the show was over.  Frey reportedly told Felder on stage, "Only three more songs until I kick your ass, pal!"  While that appeared to be the end of the Eagles, the band did release a live album in November 1980 ("Eagles Live") whose credits included the names of five attorneys and ended with "Thank you and goodnight."  The band broke up, and the former members pursued solo careers.  They would come back together several years later ("When Hell Freezes Over"), and they have had several different iterations over the years (with Felder coming back and getting fired again, Frey dying and being replaced by his son, and country music singer Vince Gill joining for a couple of tours).

While there is no question that the Eagles have been highly successful, like any group, team, or organization, the group has had their fair share of struggles and difficulties.  Their history provides us with a great illustration of Tuckman's model of group development, as well as providing some reassurance that in any group, there will be good times and bad times.  Lastly, and certainly with apologies to Randy Meisner, I really do think the Eagles were a better band with Timothy B. Schmit.

"Not with a bang but a whimper"

Several years ago - I think it was during the seventh grade, but I'm not completely sure - I read a fascinating book called Alas, Babylon by Pat Frank.  The book was written in 1959 and tells the story of how a group of survivors from the fictional town of Fort Repose, Florida lived in the aftermath of a nuclear war.  The title of the book comes from a biblical verse in the Book of Revelation, "Alas, alas, that great city Babylon, that mighty city! for in one hour is thy judgment come."  I remember being absolutely mesmerized (and frightened) by the book, even though it took place in a much earlier time in history.

I was just as mesmerized while recently reading a novel with similar themes called On the Beach by Nevil Shute.    Shute's book was published a little earlier than Alas, Babylon and has been made into a movie of the same name twice.  The first version was released in 1959 and starred Gregory Peck, Ava Gardner, and Fred Astaire, while the second was a made-for-television movie in 2000 that starred Armand Assante, Rachel Ward, and Bryan Brown.  The title comes from a line in T.S. Eliot's poem, The Hollow Men:

In this last of meeting places

We grope together

And avoid speech

Gathered on this beach of the tumid river.

The last line of Eliot's poem appears on the title page below the author's name:

This is the way the world ends

Not with a bang but a whimper.

The story takes place in Melbourne, Australia following a nuclear war that was largely restricted to the Northern Hemisphere.  Unfortunately, the atmosphere is polluted with nuclear fallout, and the radiation has slowly drifted south with the prevailing winds.  The end of the world is near, and the main characters are dealing with this in their own way.  *SPOILER ALERT* Interestingly, at one point the characters actually visit a few cities in the Northern Hemisphere and find a number of areas surprisingly intact, but no one is there.  It's almost as if so-called neutron bombs were used in the war.

The story was captivating for sure, but what I really found interesting was the contrast of how different characters responded to their coming demise.  Most avoided expressing strong emotions, which would be more than appropriate, given the circumstances.  And most did not indulge in self-pity.  I found that most characters accepted their fate and tried to live out their lives as best they could.

While we may never have to confront the end of times like the characters in On the Beach had to do, there is no question that we as leaders will have to confront a crisis at some point in time.  Indeed, most of us have already experienced leadership in a time of crisis during the last two plus years with the COVID-19 pandemic.  I think what I liked about this book, and what I have witnessed the past two years, is that crisis often bring out the best in all of us.  

I'm going to add this book to my growing number of post-apocalyptical and dystopian novels that I've read during the pandemic.  While the story is entirely fictional (of course, and most importantly, thankfully), like many works of fiction, there's still a lot that stories can teach us about human nature and, for that matter, leadership.  Check the book out!

Imagine the worst

A few months ago, our hospital's Disaster Preparedness Team ran a simulation in our emergency department.  The incident involved a so-called "dirty bomb" that was set-off during a large summer music festival and involved multiple casualties.  Oh, and by the way, during the event the hospital experienced a power outage.  When I first heard about the scenario, I shook my head and said, "Boy, I hope that never really happens!"  It was just like the author Lemony Snicket's "Series of Unfortunate Events".  Notably, Snicket once said that "Imagining the worst doesn't keep it from happening."  He of all people would certainly know, even though his books are entirely fictional.  While I completely agree with him, I can't think of a better way to be prepared for an unfortunate event than imagining the worst beforehand.

I've been talking about Barry Turner's "Man-Made Disaster Model" as presented in his 1978 book, Man-Made Disasters.  Turner posthumously published a revision of the book with Nick Pidgeon in 1997.  One of his most important contributions to the safety science literature is the concept that man-made disasters develop over a long period of time, during the so-called "incubation period."  I discussed his model at length in my first post, "The Failure of Foresight".  His model was based on an analysis of 84 British accident inquiry reports covering a 10-year period of time, though he focused on three events in particular (covered in my second post, "It takes hard work to create chaos!").  As mentioned in my last post, I would like to move now to a brief discussion on some of the interventions that can help prepare organizations to prevent or at least mitigate man-made disasters.

I would like to focus on two excellent articles written by Turner's co-writer in the most recent edition of his book, Nick Pidgeon.  The first article was published in the Journal of Contingencies and Crisis Management, "The Limits to Safety? Culture, Politics, Learning and Man-made Disasters", while the second article was published in the journal Safety Science, "Man-made disasters: Why technology and organizations (sometimes) fail".  Both articles speak to the importance of "safety culture" in an organization.  If organizational culture is defined (very loosely) as "the way we do things around here", then "safety culture" may be similarly defined as "the way we ensure safe operations around here."  However, a more formal definition comes from the Advisory Committee on the Safety of Nuclear Installations (ACSNI) Human Factors Study Group's third report on "Organizing for Safety" which states:

"The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures."

Pidgeon suggests that a positive safety culture is characterized by four components, most of which are consistent with the defining characteristics of so-called High Reliability Organizations (HROs).  HROs HROs are usually defined as organizations that somehow avoid man-made disasters (to use Turner's term), even though they normally exist in an environment where normal accidents can be expected to occur by virtue of the complexity of the organization and by the nature of the industry.  Here are the four components:  

1. Senior management commitment to safety (see my recent post, "Be the best at getting better")

2. Shared care and concern for hazards (for more, see "Preoccupation with Failure")

3. Realistic and flexible norms and rules about hazards (see "Commitment to Resilience")

4. Continual reflection upon practice through monitoring, analysis, and feedback systems (see "Sensitivity to Operations")

Importantly, while a commitment from senior leaders (top-down) is absolutely essential to building a positive safety culture, culture has to be built from the bottom-up.  As Turner himself stated, "Managers cannot simply 'install' a culture...viewing safety culture as a continuing debate makes it clear that it is a process and not a thing..."

James Reason (who developed the Swiss Cheese model of error) suggested that a positive safety culture consists of the following sub-dimensions:

Pidgeon emphasizes the importance of organizational learning, even suggesting that "permanent culture change may itself be best approached through processes of long-term organizational learning or 'self-design' rather than solely through management edict (decree) or imposition of external regulation (prescription)."  To build upon the quote by Lemony Snicket above (though I don't know if Pidgeon ever read "Series of Unfortunate Events"), Pidgeon suggests that a process of "safety imagination" can help overcome some of the organizational barriers to learning.  He writes, "The idea of safety imagination is based upon the principle that our understanding and analysis of events should not become overly fixed within prescribed patterns of thinking, particularly when faced with an ill-structured incubation period."

In both articles, Pidgeon shows a table that was derived from a set of teaching programs developed over several years by the U.S. Forestry Service to help train fire-fighters. Here are his "guidelines for fostering safety imagination":

1. Attempt to fear the worst (recall that one of the barriers discussed by Turner was a tendency to minimize emergent danger)

2. Use good meeting management techniques to elicit varied viewpoints 

3. Play the 'what if' game with potential hazards

4. Allow no worst case situation to go unnoticed

5. Suspend assumptions about how the safety task was completed in the past

6. Approaching the edge of a safety issue a tolerance of ambiguity will be required, as newly emerging safety issues will never be clear

7. Force yourself to visualize 'near-miss' situations developing into accidents

Safety imagination is a process of creating your very own version of a "Series of Unfortunate Events".  Just like the disaster scenario that our hospital conducted, imagining the worst possible chain of events is one of the best ways to prepare an organization for man-made disasters.  Safety imagination, as an exercise, will help extend the scope of potential scenarios that an organization could possibly face, counter complacency and the view that "it can't happen to us", force the recognition that during the incubation period, the most dangerous and ill-structured hazards are often ambiguous and withheld from view, and perhaps most importantly, suspend institutionally defined assumptions about what the likely hazards an organization will face.  

I've learned a lot by reading both The Logic of Failure by Dietrich Dörner and Man-Made Disasters by Barry Turner.  I can certainly see why they are classics in the safety science literature.  The information that these two books covered is foundational, in my opinion, for any organization that wishes to become a High Reliability Organization. 

It takes hard work to create chaos!

Last time I started a short series of posts on Barry Turner's book Man-made Disasters which is a classic in the safety science literature.  Turner wrote that "small-scale failures can be produced very rapidly, but large-scale failures can only be produced if time and resources are devoted to them."  In other words, it takes hard work to create chaos!  

While the term disaster is often used in the context of natural disasters such as earthquakes, tornadoes, fires, floods, and hurricanes, Turner uses a more specific definition that applies only to these large-scale organizational failures.  Here, a disaster is defined as "an event, concentrated in time and space, which threatens a society or a relatively self-sufficient subdivision of a society with major unwanted consequences as a result of the collapse of precautions that had hitherto been culturally accepted as adequate."  

In this context, the disasters that Turner is describing are completely man-made in origin.  They are defined less in technological terms and more in sociological ones.  Importantly, all organizations operate within a certain set of cultural beliefs, norms, and assumptions that are either formally and explicitly codified within a set of rules and regulations or tacitly taken for granted as "the way we do things around here" ("safety culture").  Man-made disasters, then, are differentiated from accidents (which refer more to random, chance events) and natural disasters (so-called "Acts of God" such as hurricanes and earthquakes) by "the recognition (often accompanied by considerable surprise) that there has been some critical divergence between those assumptions and the 'true' state of affairs."

While Turner eventually reviewed the accident inquiry reports from 84 different events in the United Kingdom, he focused on three major events:

1. Aberfan Coal Tip Slide of 1966:  Incidentally, this event was featured in episode #3, season #3 of the television series "The Crown".  A colliery spoil tip (basically, a pile of waste material - typically, shale, sandstone, and anything that isn't coal that is removed during the coal mining process) became unstable over time and slid downhill, eventually covering an elementary school in the town of Aberfan, Wales, killing 116 children and 28 adults.  

2.  Hixon Rail Crash of 1968: A semi-trailer carrying a 120-ton electrical transformer attempted to cross a recently installed automatic railroad crossing at Hixon, Staffordshire, England and was struck by British Rail express train, killing 11 people and injuring 45 people.

3.  Summerland Fire of 1973: A fire spread rapidly through the Summerland leisure center on the Isle of Man, killing 50 people and seriously injuring another 80 people.  The interior and exterior portions of the building had been designed by two different architects who didn't coordinate with each other, creating significant fire risks.  The fire was accidentally started by three boys who were smoking in a vacant part of the building.  

While all three events were quite different, Turner identified a number of similarities that he used to develop his "man-made disaster model":

1. Rigidities in perception and beliefs in organizational settings: In all three cases, the accurate perception of the possibility of a disaster was hindered by both cultural and institutional factors.  I referred last time to the concept of "bounded rationality", which is when individuals seek to make decisions that are merely "good enough" rather than the best possible decision (see also "satisficing").  Unfortunately, some important piece of information may have been left outside the framework of bounded rationality - in other words, leaders in these three cases failed to comprehend that the three accidents were even within the realm of possibility.  With the Aberfan case in particular, despite multiple reports in the past of similar colliery spoil tip slides, no one at the Aberfan site was thinking about the possibility of one.  

2. The decoy problem: Here, when some hazard or problem was perceived, action taken to address the problem took the focus away from the true problem, which ultimately led to the event.  Here, the operators and owners of the trucking company were more worried about the hazard of arcing onto the overhead electrical wire at the crossing.  They were so focused on trying to prevent this from occurring, they never considered that a long, slow-moving truck would be at risk of getting hit by a train.

3. Organizational exclusivity - the disregard of non-members: In two of the cases Turner reviewed (Aberfan and Hixon), individuals outside of the principal organizations concerned had anticipated the possibility of the accidents occurring.  However, it was automatically assumed that the organization knew much better what the risks were as opposed to an outsider's view.  

4. Information difficulties: Remember, so-called "wicked problems" lack an easy and obvious fix.  When dealing with complex situations (and wicked problems), Turner suggests that four types of information difficulties are important (see further below).  

5. Involvement of strangers: So-called strangers are those individuals who are present but are not otherwise part of the organization.  As Turner writes, "The problems created in situations where safe operation relies to some extent upon the safe behavior of strangers are intensified by the fact that the strangers are always located at the moment of danger at a site where they have a number of opportunities to manipulate the situation in ways not foreseen by those designing the abstract safety system."  As an example, during the Summerland Fire incident, when designing evacuation procedures (and even during the rescue operation), no one anticipated that parents would go back into danger in order to save their children.  These parents fought to reach their children against the flow of the crowd who was trying to evacuate, thereby creating a congested passageway and ultimately preventing people from getting out successfully.

6. Failure to comply with existing regulations: Both at Hixon and Summerland, individuals failed to comply with safety regulations.  

7. Minimizing emergent danger: Most, if not all, complex systems are non-linear.  The property of emergence suggests that multiple small, seemingly insignificant events, can interact in such a way to produce a much bigger and more dramatic event.  

8. Nature of recommendations after the disaster - the definition of well-structured problems: I mentioned this in my last post when I was talking about "After Action Reviews".  Recommendations made after the fact almost always forget that individuals operating during the crisis do so without perfect information.  Information that is relevant to the disaster may be obvious after the disaster has occurred, but that same information may have been completely hidden at the time of the disaster.  Remember, "not every failure which is obvious now, would be obvious before the disaster."  

One of Turner's most important concepts is that of the "incubation period" (see my last post, "Failure of Foresight" for an in-depth description).  Briefly, the "incubation period" is the time when certain latent failures and misconceptions or faulty assumptions about the organization's safety culture and/or rules and regulations hide beneath the surface until an inciting or triggering event sets off a chain of events leading to catastrophe.  The build-up of latent failures and faulty assumptions occur because of the discrepancy between the perceived state of the organization ("We are not in a dangerous situation") and its true state ("We actually are in a dangerous situation").  Turner cites four key reasons to explain how these latent failures lead to active failures:

1. Events go unnoticed or underappreciated in terms of their significance (recall in particular the decoy problem and the involvement of strangers discussed above)

2. Events go unnoticed or are misunderstood because of the difficulty in handling information in complex situations: Turner calls this the "variable disjunction of information" (which he defines as a complex situation in which a number of parties handling a problem are unable to obtain precisely the same information about the problem, so that many differing interpretations - and as a result, potential solutions - to the problem exist).  The information necessary to fully understand the problem available at any one point in time is dispersed across many locations and different individuals.  Variable disjunction of information is compounded further by the poor communication that often exists in the silos of these large and complex organizations.

3. Effective violations of precautions passing unnoticed because of cultural lag in existing precautions: Violations frequently occur when regulations are ambiguous or when they conflict with other goals of the organization.  The best example of this phenomenon comes from Scott Snook's concept of "practical drift" , which he defines as "the slow and steady uncoupling of practice from written procedure" and Diane Vaughn's "normalization of deviance".

4. Events go unnoticed or are misunderstood because of a reluctance to fear the worst possible outcome: When things do start to go poorly, individuals tend to minimize the danger or deny that the danger effects them.  There's no question that we, as humans, tend to assume that we are invulnerable or infallible.  We may respond to a dangerous situation with the phrase, "We got this!"  That same sense of invulnerability often prevents us from asking for help.  Just as important is the fear of "sounding the alarm" too prematurely - we don't want to look foolish or incompetent.  Lastly, we frequently assume that someone else has made the call for help (a form of the "Bystander Effect").

I want to leave this discussion with a final quote.  The French writer Victor Hugo said, "Great blunders are often made, like large ropes, of a multitude of fibers."  The most important take-home message from Barry Turner's "Man-Made Disasters Model" is the concept of the incubation period.  These events do not occur all of a sudden, but rather there is a set of long-standing issues that create the conditions favorable to a catastrophic event.  Here is the time where we as leaders need to intervene.  Next time, we will discuss how to do that.