Hi, this is Rob Fisher. Welcome to my next installment of Robservations. These snippets are intended to give you my perspective on what I’m seeing out there in safety and quality as I travel around the world working with leaders. They’re also meant to provide you with information that you can share with your team. Todays Robservation tries to answer the question many leaders ask me: “Why won’t they just stop!?”. Sometimes after an incident, an organization uses hindsight bias – or knowing what they know now – to predict what someone should have done before to try to understand why an incident occurred. Using this bias, to hear them say phrases like, “They should have known better.”, “Everybody knows you don’t do that!” “If only they would have stopped, we wouldn’t have this issue right now!”, or “How could they have missed that risk?”. You can go back to Sidney Dekker’s Field Guide to Understanding Human Error to understand that people do what they do, at the time that they do it, for reasons that make sense to them at the time. We now understand that as systemic drivers change around this person on this task at this time, individuals will tend to react to those changes based on very predictable personality tendencies. Different people with different personality tendencies see and manage risk differently and have different potential limiters for stopping and seeking out help. When organizations believe that just telling people, “When you’re unsure or it’s unsafe, stop and get help” and they believe that’s an effective process, they fail to take into account that different people define “unsure” differently. When an organization turns over the definition of “unsure” to an individual, they shouldn’t be surprised when different people don’t stop and either seek out help or don’t seek out help. What they may fail to realize is that the systemic driver that created the condition that forced the individual to recognize the risk needs to be dealt with by the organization. You can see here just how much the reasoning varies for what makes it difficult for people to stop and seek out help for different personality types. On the one hand, we have personalities that are faster paced and don’t want to interrupt the rhythm of the task; while on the other hand, some personalities don’t feel like they have enough information to stop work. If we define “unsure” in a way that credibly characterizes the risk, more people will stop and seek out help. But here is my Robservation: they are stopping. They’re thinking about it, and they tend to think about it long enough to convince themselves and maybe even their whole crew, that either the risk doesn’t exist or that they have mitigated the risk without realizing that this mental model actually has an error rate of closer to 10-50%. You can define “unsure” by telling someone that when you find yourself Outside Of a Procedure, a Program, a Process, a Parameter or a Situation as you expected it to be – What we call OOPPPPS – your error rate is elevated as high as 50%, and the only way to reduce that error rate is to stop and seek out help from an independent source. Give us an example of when you discovered that you were outside of – or OOPPPPS – and how you intentionally stopped to seek out help. Thank you for contributing to this episode of Robservations. We’ll see you next time and remember: intentional leadership starts with you.

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