February 27, 2023
Psychological safety is the key to creating a safer workplace where employees can bring up concerns and problems before they become disasters. This week Tim and Junior explore the link between psychological safety and physical safety for organizations where lives are on the line.
(02:24) Tim shares a personal experience about his time managing the Geneva Steel Plant.
Safety protocols were not followed and a critical accident happened. The life of a worker was lost.
(11:26) The Duty of Care and the fundamental hazard categories.
In 1788 British Parliament passed The Chimney Sweepers Act which established a legal and a moral obligation to keep each other safe in the workplace. Frameworks have evolved around this duty and we've identified four fundamental hazard categories. They are chemical, biological, ergonomic and physical. We've used that framework for more than 200 years to make the workplace a safer place by identifying and removing hazards in these four categories.
(28:36) Passive observation vs active participation.
When we engage in an activity we do so on a spectrum of passive observation to active participation. During activities where safety is at risk passive observation enhances that risk. Passive observation is more likely to occur in environments with low levels of psychological safety.
(36:18) Toyota production lines and the andon cord.
Toyota's introduction of the andon cord is a great example of what it means to "stop the line". The andon cord enabled anyone on the production line regardless of position, title, or authority, to stop the line by pulling the cord. The main concern for Toyota was quality assurance. We can apply this same concept to safety. Anyone on the job, regardless of position, title, or authority should be given the power to "stop the line" at any moment and not be punished for it.
Ebook - Breaking the Chain of Command: Achieving Physical Safety through Psychological Safety
Webinar - Breaking the Chain of Command: Improving Physical Safety through Psychological Safety
0:00:01.9 Producer: Welcome back, Culture by Design listeners. It's Freddy, one of the producers of the podcast. Today's episode is titled Breaking the Chain of Command: Achieving Physical Safety through Psychological Safety. Now, you may have seen our webinar event with the same title earlier this month, I want you to know that Tim and Junior took the time to record this podcast separately, this is not a recording, but fresh content on the topic. And if you are joining us for the first time, there are a lot of concepts here, so what we've done is we've created an e-book with all of the visuals from this topic and the webinar that you can download at leaderfactor.com, we'll include a link to that and all other relevant links to this episode in the show notes at leaderfactor.com/podcast. Thanks again for listening. Thank you for your reviews. Enjoy today's episode on improving physical safety through psychological safety.
0:01:05.0 Junior: Welcome back, everyone to culture by design. I'm here with Dr. Tim Clark, and today our topic is breaking the chain of command achieving physical safety through psychological safety, the BLS data that we're gonna go over today and a few other statistics is astounding.
0:01:19.9 Junior: So while we start, here's a question for you to chew on for just a minute, how many people do you think die every day due to unsafe and unhealthy working conditions? That's the question we're gonna start out with, and we're gonna answer it in just a few minutes, additionally, at the end of today's episode, we're gonna talk about a brand new e-book that we just published and will give you details regarding where to find that for free, many of you know Dr. Clark as an organizational anthropologist, some of you know him as an Oxford trained social scientist, you've got a lot of titles to him, but probably a few of you know of him as the plant manager of Geneva Steel. That was your title. Once upon a time. Wasn't at Tim? Yeah.
0:02:00.4 Tim: It's a little known secret. I did do that, I was in manufacturing for several years, and I was the plant manager at Janes deal for five years, and so I have some manufacturing experience, and I think that'll be relevant to our conversation today.
0:02:18.7 Junior: You to... Tim, explain what your job was and what the environment was like.
0:02:24.2 Tim: Sure, well, I was a plant manager of what is called a fully integrated steel production plant, this was the last remaining fully integrated plant still operating West of the Mississippi river, so we had a plant that was about 1600 acres enclosed, and so integrated means that you run the entire process, so you create coke from call, you use that Coke as a primary fuel in the blast furnace to take iron ore and melt that into pig iron, and then you take that liquid pig iron and you process that further burn the carbon out at alloys make it into steel, and then you pour into Ines, you roll the in gets into hot roll bands or steel plate, or we made spiral weld pipe, all kinds of products, and then you ship it out, so it's the entire process. So I had the opportunity to manage that plant for five years, that integrated facility, as it was like going into a megaton realm. It was other worldly. It's hard to describe the scale of that place, we had our own railroad, we had our own little hospital, we had our own fire station, we had our own security, it was just self-contained world, so I hope I'm painting a little bit of a picture to help you understand what that was like?
0:04:07.3 Junior: 1600 acres is a lot of acres. Your own railroad, that's a big operation.
0:04:13.0 Tim: Yeah. It is.
0:04:14.0 Junior: I wanted to invite you to share a story that you've shared with me and others about safety and about blast furnace, about some of the things that you experienced. And maybe a few of the things that maybe you wish you didn't have to experience. Can you tell us one of those stories... Yes.
0:04:33.2 Tim: Well, first of all, you've gotta envision that this is a heavy manufacturing environment, there's machinery, massive machinery that's moving all of the time, it's a very dangerous, hazardous environment. Well, first of all, let me just tell you how blast furnace works. A blaster is a big oven that is about 150 feet high, it's a big cylinder and it's lined with refractory brick, it's just a big oven, and you take these hopper cars and you run them to the top on a track and they pour out Hiro or pellets into the top of the oven to the blast furnace, and those iron ore pellets, they slowly melt and they work themselves down and then pigeon liquid pig iron comes out the bottom, so these hopper cars are constantly going up, unloading, coming back down. And one day, a maintenance worker was down in the bottom of a hopper car doing some maintenance, doing some repairs, and according to the safe job procedure that maintenance worker was to ensure that that hopper car was what we call locked out, meaning that no one could operate that car, and it was his job to make sure that it was locked out, the operator on the other side, his safe job procedure said you need to visually inspect that hopper car to make sure that it's empty and that it's ready for operation, both the maintenance worker and the production worker violated their safe job procedures, and so what happened was the production worker pull the lever and down came 15 tons of iron ore pellets on to the maintenance worker and he was killed almost instantly.
0:06:33.3 Tim: Later that afternoon, I had to accompany several other leaders at the company and go to the home of this maintenance worker and inform his wife that he would not be coming home that night. That's an experience that I'll never forget, that happened on my watch, we lost a maintenance worker because of that accident, and that changed my life in many ways, and it helped me understand the connection... Well, it helped me understand safety better, and that's what we're gonna talk about today, but you have to understand, and then in a heavy industrial environment, safety is a religion, we preach it every day, but we don't practice it as well as we sometimes preach it, and that's what we're going to talk about today, so that's a bit of a so-brain example, it's an experience from my own life, a defining experience that I will remember forever, and hopefully it will be instructive to you as we go through this discussion today.
0:07:38.3 Junior: I appreciate you sharing that, Tim, and I can only imagine what that must have been like going to that home and... No wonder. It's stuck with you. So back to my original question from earlier, to everyone listening, what was your guess... How many people do you think lose their lives every day due to unsafe and unhealthy working conditions, the most recent number from the UN estimates that 7500 people die every day due to unsafe and unhealthy working conditions, 7500, it's an incredible number, and that's not an annual number, that's a daily number. So that rolls up to 28 million deaths from occupational accidents and work-related diseases each year, 28 million is a big number. So you think about Tim's experience and going to that home to inform that man's wife, that's one... So multiply that by 7500. That's a single day. Imagine 7500 of those conversations happening. Not that all share a similar context, but think about that number in that scale, so that number, the 28 million, that's more than road accidents, war violence and HIV AIDS combined. That's a big number. Yeah, it's incredible. Another 374 million workers sustained non-fatal injuries and accidents in the workplace, so Tim, this is not a solved problem.
0:09:03.8 Junior: Is it?
0:09:04.5 Tim: No, it's not. Well, 28 million deaths per year, 374 million injuries, many of which are permanently disabling injuries, so the scale of this is something that we have to reflect on to just try to absorb a little bit... It's astonishing. No, it is not a solved problem. Junior, that's correct.
0:09:31.5 Junior: And I would invite everyone listening to reflect on that number, how does that make you feel? And the next question is, what's the trend... Are these deaths going up or down, and recently they've been going up, the BLS data from 2021 showed the fatalities were up 9%. That's amazing, 9%. So this is something that's clear and present, and depending on who you are and where you work, these numbers may or may not be top of mind, I think that perhaps a lot of the audience doing knowledge work is a little bit detached from some of these numbers, if you're in certain industries, what we would consider high hazard industries, you may be a little bit closer to these numbers and feel this maybe your organization has lost someone or has lost people recently, and this is close to home, but for those of you for whom it's a bit distant, put yourself in the shoes of those that are working and dealing with this on the day-to-day and what that must be like. So part of what we wanna get across is that this is a preventable solvable problem, there are things that we can do, and part of it has to do with the way that we look at safety, how we define safety, and some of the behaviors and practices that we implement inside our organizations that it face value, may not seem like they have a lot to do with these numbers, so in order to set the context, let's go ahead and cover a little bit of history, Tim, safety at some point wasn't a thing at all of them physical safety wasn't an issue, it was not on people's minds over time, it suddenly became a thing, and this was probably a very long time ago, which we realized, You know what, we probably don't wanna lose our lives working, and over time, we've come from not very caring very much at all, to carrying a whole lot, and one of the transition period was in the late 1700s in England, where we stumbled into this idea of duty of care.
0:11:26.7 Junior: Can you give us a little context on duty of care?
0:11:29.7 Tim: Sure. So Junior, if we go back in our time machine to the first industrial revolution, and we're in London and we're looking around, What does it look like? What do we see? We see smoke to everywhere we go, their smoke, it's black and smoky, why? Because the entire economy was driven by call... It was a coal-fired economy, now, this was the time that mass production was brought into the world, mechanization textiles, and so if we looked around, we would see chimneys everywhere where we had factories, we had chimneys everywhere, and we had chimney sweepers that would clean out the chimneys, they sweep out the chimneys, in some cases, they were constricting boys as young as four years old to work with them under very dangerous working conditions and for long hours. And so finally, British Parliament called time out and they said, This isn't right. We can't do this. We've gotta change something. And they pass the chimney sweepers active 1788, which by the way, you can look up online and read the full text of the lots there, it's very interesting, out of that law, that chimney sweepers Act came this concept that you refer to junior, the duty of care.
0:12:46.5 Tim: It's a legal and a moral concept, it's very simple, it basically means that we have a responsibility to keep each other safe in the workplace, we have a stewardship to look after each other, and so we took that concept, we applied it and we've been applying it ever since for more than 200 years, we've been applying a concept of a duty of care, but as you can imagine, what were we focused on... We were focused on physical safety, it was all about the physical, and we were transitioning from a paradigm of not valuing human life to value in human life. So before the first industrial revolution, if you go back centuries and you look at history, how did many societies of value human life when they were engaged in production... When they were building things, well, human life was expendable, it was fungible, it was commoditized flesh, that's what it was, the person, the individual was a unit of production, and we didn't think of them in any other sense, so this changed gradually, and so now we value human life, what does that mean? That means that we need to remove hazards from the workplace, and it needs to be a continuous process, and so...
0:14:12.2 Tim: What did we do? We created a framework, identifying for fundamental hazard categories, chemical, biological, ergonomic and physical, and we've used that framework for more than 200 years to make the workplace a safer place by identifying and removing hazards in these four categories, so Junior. That's kind of what we've been doing for the last more than 200 years.
0:14:39.9 Junior: It is, and our definition of safe has changed, so our criteria for success in 1788 may have been to not die, and if people didn't die, we were successful, but that definition of safe has changed, it's matured and that's part of our discussion today, so we introduced this fifth hazard category on top of the ones that I mentioned, which is psychosocial or psychological, so it introduces another domain, another lens through which we can look at safety. We recently conducted a webinar, we ask participants to respond to this statement, psychological safety has been incorporated as part of your organization's physical safety system, and the results were pretty interesting, only 30% agreed with that statement. 24% were neutral, 35% disagreed and 10% strongly disagreed. So we can see just in that data alone, that this is not something that's been normalized inside our organizations of today, it's something that is improving, but we still have a long way to go. So safety, what is it... If the definition has changed, how has it changed? It has become more holistic. So I want you to envision in your mind's eye to circles, two concentric circles that represent the two domains of safety, one is visible, so tangible elements of safety, your physical body, on the other side, we have invisible what we can't see.
0:16:13.0 Junior: It's everything else, it's your emotions, it's your feelings, it's your thoughts, it's everything else that doesn't fall into that first bucket, which may arguably Be More... And in order for us to become good at safety, we need to process both and be good at both at the same time, and the relationship between these two is really the crux of today's conversation because there is a relationship between them, and if we understand that and understand the mechanisms by which both improve and we're going to be successful and decrease those numbers that we talked about in the beginning.
0:16:52.6 Tim: Well, that's true, Junior, and there's a sequence, there's a cause and effect relationship here, if something has triggered mental or emotional or social fear, than your ability to mitigate risks in the physical world are compromised. And that's what we're gonna talk about. So the psychological safety has a direct bearing on the physical safety, and in sequence, we need to enable the psychological safety first, so that people can be in a state of vigilance and attentiveness to look at the physical environment, identify and remove hazards in all of these categories. And so we're gonna talk about how those two worlds, the physical or the visible and the invisible are connected.
0:17:45.8 Junior: So the traditional approach that we've taken to safety is pretty straightforward, it's been managed through the hierarchy based on our normal default reporting relationships and the established chain of command, so the word chain we use in the word chain, we use in the title breaking the chain of command, achieving physical safety through psychological safety. So what we're saying very early on today is that the traditional approach is insufficient, the chain of command is insufficient, the best approach is to give authority to the individual to break that chain of command, to stop a process, to stop a system. To refuse to comply with a direction or a procedure that they've been given if they think that a hazard is there, but a few things have to be true in order for this to work, in order for the individual to be willing to break the chain of command to raise the hand to not comply, to do these things, to ask a question, to give a penetrating comment, and no one can force you as a sovereign individual to do what you don't feel safe to do or what you don't feel as safe for others. So we need to enable people to break the chain of command, so if we go into psychological safety for a moment and talk about it as a mechanism, first of all, it's definition, we define it as a culture of rewarded vulnerability.
0:19:09.6 Junior: So think about that for a moment, as it pertains to what I just shared, and physical safety, stopping a process or breaking the chain of command asking a question, raising your hand is an act of vulnerability, and the way that that active vulnerability is handled will determine whether or not that person does the same thing in the future, or whether people generally will raise their hands and stop a process, if Psychological safety isn't there, that active vulnerability is punished, you can be assured that over time people will stay quiet, and that can become very, very dangerous. So in order to increase psychological safety, here's the mechanism, we need to model vulnerability and we need to reward vulnerability, so why as a person... Show acts of vulnerability. I ask questions, I put myself out there. I reward people when they do that. If I hear a question, a great question, let's find the answer. If I wanna decrease psychological safety, what do I do is the opposite mechanism, I withhold, I abstain from acts of vulnerability myself, and I punish the acts of vulnerability of others... That's a stupid question. Don't ever ask that again, and it can be subtle, we're not gonna talk about the spectrum today, but it's pretty interesting, and that low psychological safety, the punished vulnerability.
0:20:25.3 Junior: Sure. Here's a fear response. Why is that fear response... What we wanna stay away from them.
0:20:31.2 Tim: Well, the fear response... Let me make a distinction that I think is really important to understand. So for example, when something triggers a fear response in a human being than what happens, it engages neurologically, your amygdala, and what are you going to do, you're going to begin to release stress hormones beginning with adrenaline, and then you're gonna go to cortisol now for an immediate threat, this is a very, very good thing. Right, you're gonna go into a flight or fight response, and you're gonna have generally keener century perception, your hearing gets better, your eyesight gets better, you have a sudden burst of strength and STEM, and those are all good things that come out of a traditional fear response based on an immediate threat. Short-term, immediate threat, but that's not what we're talking about here, we're talking about long-term fear, not short-term fear based on a neurological fear response with adrenaline and cortisol, we're talking about long-term fear in the environment, so if I'm in an environment and my vulnerability is consistently punished. Then what do I do? I learn to retreat and withdraw, I learned to recoil, I learn to go into a mode of self-preservation and loss avoidance, and that makes sense.
0:22:09.4 Tim: So if I'm in that mode, the long-term consequences of being in that fear-based environment are debilitating, because what do I stop doing? I stop actively looking at the physical environment around me, identifying hazards or potential hazards or dangers or risks, and then trying to do what I can to remove those I am cognitively and emotionally compromised. That's the point. So if you're in an environment where there is fear in its long term, we're not talking about an immediate threat, right, but we're talking about the culture of punished, vulnerability, Junior that you just mentioned. If you live and work in that environment, again, it compromises your ability to create a safer physical environment... That's the connection that we're trying to make today.
0:23:10.3 Junior: I wanna share another poll that we did in the recent webinar, and before I do that, think about this, if there's fear present, what do people do with errors and mistakes, did they put them on the table, do they bring them to the forefront or do they sweep them under the rug. They sweep them under the rug. So here's the question, what percentage of errors and mistakes do you believe employees hide in your organization? And mind you, this is a global audience across virtually every industry, and here's what they had to say, there were no responses between zero and 40% non-shocking, not a single person reported fewer or less than 40%. So 50%... We have 19% of the responses. So 19% of those responding said that 50% of errors and mistakes they believe are hidden in their organization, 60%, 13, 70% of mistakes, 12%, 80% of mistakes, 15% of people said that 80% are hidden. And we have Respondents at 90%, and we also had a few votes and 100%... That's amazing. This was the most startling data that came from the webinar and all of the polls that we did, in my opinion, no one said between zero and 40%, that stunned me.
0:24:36.3 Junior: So everyone reported past 50%, imagine if it were just 50, one in two mistakes is hidden, one or two errors is hidden. Now think of the industries that are responding here to him, think about Geneva again, think about heavy manufacturing, how do those mistakes that are being hidden translate into the real world, they translate sometimes all the way down to casualties they do in a literal sense. It's a scary thing.
0:25:07.6 Tim: And so what this means, Junior, is If we translate this, this helps us understand why we commit unforced human errors again and again and again, and if we keep doing it, maybe it's a near miss and a near miss... And a near miss, but at some point, it's gonna a direct hit and someone is going to go down with a serious injury or perhaps even a fatality, the connection is unmistakable. A third are saying that 70% of mistakes or more are deliberately hidden, now think about what a mistake is or an air... In the world of safety, a mistake and air is crucial information that we need... We need to analyze it, we need to do root cause analysis, we need to understand why we had this kind of cause and effect relationship, we need to go back and we need to put a corrective action in place so that it doesn't happen again. So if we're deprived of the information related to an error or a mistake, then there's a high chance we're gonna make that mistake again. And that's exactly what happens.
0:26:25.4 Junior: I also wanna call out the relationship to knowledge work for just a second, so if we remove ourselves from physical safety for just a moment, notice that we're not talking about physical errors or safety errors in the question, we're talking generally broadly errors and mistakes. So think about that in the context of knowledge work, what opportunities are we missing, what innovation is not happening because these mistakes or the errors aren't being reported, or we don't have good information... The feedback loop is broken. Think about how much opportunity lies in the response to this question, What would happen if instead of 50%, we said 10% or 5%, what if we got all the way down to zero where the culture surrounding this was so strong that all of the airs and mistakes were reported, how much better off with that organization be not just from a physical standpoint, from an innovation standpoint. So that's one of the places that my mind goes when I see this data, is that the application is broader than just physical safety, so for those of you not super concerned about physical safety, this still has very much to do with you.
0:27:36.3 Tim: I appreciate your bringing that up. Junior, that's an extremely relevant point, if you're a knowledge worker and you're not... Your work environment is safe, you don't worry about these things that other people worry about in an environment where there are physical hazards and chemical and biological and ergonomic out, that's not even part of what you worry about every day, but this question, as you said, Junior, does not, it does not distinguish between or among categories of mistakes, it's any mistake, and what we're saying is that a lack of psychological safety drives mistakes underground every kind of mistake. And so if a large percentage of those mistakes are being driven underground, think about the unintended adverse consequences, as you said, Junior innovation, and there's a whole host of other consequences and consequence categories that we haven't even talked about, so this is relevant to knowledge workers as well.
0:28:36.6 Junior: Let's go into a few patterns that we see across organizations, some that are doing very well, others that aren't doing so well, and we're gonna talk about what we call the danger zone. So think of a spectrum, I think of a line in your head, on the left side, we have passive observation, on the right side, we have active participation, the safety systems that are broken down for the safety systems that are poor performing, those organizations that we have, where we have the most fatalities, where we have the most errors are characterized by passive observation, low psychological safety, that becomes the mode of performance of anyone inside that system that sees that their vulnerability is going to be punished, and so that's where you get a lot of silence. That's where you get a lot of mistakes being pushed underground, that's where you get a lot of deference to the chain of command, and instead of breaking it, we follow it to the T or we say nothing, and so we just sit back or quiet, we don't bear responsibility, we don't believe that the accountability lies with us, the accountability lies up the chain somewhere someone else's issue, and that's where we start to have a lot of breakdown, and on the other side, we have active participation where I feel like it's my responsibility.
0:29:54.0 Junior: I'm going to engage of my own volition, I'm gonna look around and I'm gonna see an error or I'm gonna see a risk, I'm gonna see a hazard, and I'm gonna raise my hand and say, Hey, there's this thing over here, I saw this. I bear some responsibility for this, I wanna pass the information along, I wanna take action, whatever the case may be, and so as people move from active participation to passive observation through the punished vulnerability of organizations and leaders, the whole system takes on more risk. Why is that? Because safety, by nature is interdependent, it's not one person's responsibility, the one person who's responsibility you may think it is, is not even there or may not even have all of the information, and so we all assume responsibility, so if we don't and we turn into complacent people, that can become very dangerous for an organization.
0:30:48.3 Tim: Junior, I think a great illustration of that is, when you get in your car and you get on the road and you start driving as tones, you get in the car and you start driving on the road, you have entered an inter-dependent safety system where your safety depends on others and their safety depends on your behavior.
0:31:09.0 Junior: So then you ask the question, Well, is passive observation really a big deal who cares? Think about when a driver decides to get on a mobile device and focus on that and is trying to do that at the same time, that driver loses their focus on the road, the vigilante, the attentiveness, the defensive posture, and that can turn very easily and quickly into complacency and negligence and result in an accident, so you can see, just get out on the road, you have entered an inter-dependent safety system, we all depend on each other, and so you can see that passive observation really is dangerous. It's not benign. It's dangerous. Next, we're gonna talk about the three safety systems, so we've got three that we wanna talk about today, breakdown, preventive and predictive. You can probably assume, which ones are good? Which ones are bad? Which one's neutral? So break down bad, we assume static conditions, we run all the way to failure, we wait till something breaks and then we move into reaction, we either fix the issue after the fact or it's never reported and we do the same thing again and experience the same air breakdowns, a bad deal, breakdown system is run until your tires are and you have an issue, to go back to the car and road analogy, that's break down.
0:32:37.4 Junior: Don't wanna do that. Preventive, we assume static conditions, we go as long as we can just barely short of failure, so we see the threads on the tires, they haven't blown quite yet, but we're gonna go as long as we can go, we're checking periodically based on useful life, if the tires have 50000 miles on them. We think they're gonna go for 55, we check it 55. And then we go into predictive systems, we're assuming dynamic conditions, we continuously monitor performance based on real-time data, we detect early signs of fatigue failure, which we're gonna get to in a second, and then we adjust, we fix and we correct. Immediately, what's the primary difference between these three systems, it's in the way that we collect, analyze and respond to the data, is it reactive, is it preventive, the timing of the gathering of the data and then the action regarding the data is pretty interesting, if you think about a timeline, most of what happens in a breakdown system is post-accident or post-problem, so the flurry of activity happens after the alarm bells went off to tell us that something went wrong, not that some things might go wrong or could go wrong on the contrary in the predictive system, the flurry of activities happening before we ever have a problem, so that hopefully we get the problem...
0:33:58.3 Tim: Yeah, let me give an example. Now, there are some things in life where we run deliberately in a breakdown system mode that we do that on purpose. Yeah, I'll give you an example where I do that, and you may say that's wrong. You should become more preventive or predictive, but I run a breakdown system with my printer, I don't change the ink cartridge until I run out of ink because it's just more beneficial for me to replace the cartridge rather than try and pay attention to time and usage data. And try and figure out when I need to replace the cartridge, because replacing a cartridge just takes a second. Does that make sense? I deliberately run my printer to break down until it runs out of ink and then I replace the cartridge, that's probably okay in that situation, but in an interdependent safety system where the stakes are high and the margin of air is low, and people could be injured or even killed, then we do not apply that same logic, so I just wanna point out that there are different areas in life where we run to break down and we do it on purpose, but not in a physical safety system where humans...
0:35:18.5 Tim: And their lives are at stake. I just wanna make that distinction.
0:35:22.4 Junior: No, it's helpful, I appreciate that. So two things when it comes to breakdown systems, signs of breakdown always precede break down, so if you think about your printer is probably gonna be bathed, say Ink low. In most systems, we're gonna have some sort of indicator, some sort of data that's telling us, Hey, you know something to watch out for here because something's coming, then we have early detection, but along with that it detection is intervention, so we're gonna see a sign for breakdown or the one will exist, then we need to detect it, and then we need to intervene because of it. So Tim, you introduced me to the idea, or not the idea, I guess, but the... And in cord, I had never heard of the... And in court, I'd seen the cords and buses before that you can pull, that stops the whole thing, but I'd never heard specifically about Toyota Production, what's the... And the... And in court.
0:36:18.4 Tim: That's a tool that they developed for the Toyota production system years ago, and it's like a rope that they would run alongside an assembly line, and anyone, any worker on the line could pull that cord at any time and stopped the line. The point was, what were they looking for? They were looking for production problems, and in production you're always focused on three variables, three factors you're focused on through put, you're focused on yield and you're focused on quality, and so they train the workers and the maintenance side as well, production and maintenance. To look for potential problems, signs of a potential problem related to throughput or yield or quality, and then pull that cord because if you just let it go, it wasn't gonna get better, it was gonna incur more costs, it's gonna be more costly if you waited... So pull the court now, let's fix the problem as early as we possibly can, we may see some early warning sign, it gets our attention, so pull that core, that's where the and in cord originated. But now, we've adopted that same concept in the world of safety and in safety, we're basically saying the same thing, if you see anything, you're not gonna pull a physical cord, but if you see anything that indicates some kind of danger, some kind of risk, some kind of hazard, you're going to stop the line, figuratively speaking, and you're going to point out your concern and you're going to address the concern before you go on, so that's the whole concept, is to break the chain of command and stop the line.
0:38:06.9 Tim: And so we've adopted and we've applied this concept to physical safety environments to stop the line.
0:38:14.1 Junior: One of the things that I like about that analogy is that the cord runs along the entire line, there's not one single Checker or QA person at the end of the line that bears sole responsibility to pull some lever, it's anyone in any piece of the line can pull that, and so it shared responsibility, again, it's interdependent, so here's the problem though, if you don't have psychological safety, if you think that your vulnerability will be punished and pulling the cord is definitely an active vulnerability, are you going to... You're probably not going to engage in early intervention, you're probably not gonna pull the end in court as it were, you're probably gonna stay quiet, you're probably gonna leave it be... You're probably going to let that thing just go down the line and hope that someone else takes care of it, drawing in psychological safety, we wanna pull in stage four challenge or safety. This has everything to do with what we're talking about today. If an organization does not have challenge or safety, if A team doesn't have challenge or safety, it's very unlikely that we're going to do well in this invisible domain of safety, it...
0:39:21.7 Junior: Or on the physical side as well, safety generally will probably be poor if we don't feel safe to challenge the status quo.
0:39:30.9 Tim: That's really true Junior... So if we just go back through very briefly the four stages of psychological safety, stage one is inclusion, safety, feeling included and accepted, having a sense of belonging, stage two is learner, safety feeling that you can engage in the learning process without fear of being embarrassed or marginalized, Stage Three, contributor safety, being given an opportunity to make a meaningful contribution with an appropriate level of autonomy and control, and then finally, this is what we're talking about, Stage Four, challenge your safety, feeling free and able to challenge the status quo or fear of repercussions. Now think about this, stopping the line, breaking the chain of command and stopping the line, Polina and cord is an act of vulnerability that relates to stage four, challenger safety, it is a challenging behavior, if you stop the line, you're drawing attention to whom... To you, it all comes your way, you're taking a risk, you're breaking the chain of command, and so what we're saying is, unless there's a threshold level of stage four challenger safety, who is going to engage in that early intervention behavior to stop the line, if that psychological safety does not exist at that level, that challenger safety level, then essentially, if you're at the top of the chain of command, you're asking everyone to muscle through the fear or most people are not going to do that.
0:41:08.1 Tim: So I hope that that relationship is clear, stopping the line requires stage four, challenger safety.
0:41:17.3 Junior: So let's talk about fear. If you don't have a challenge or safety or a high degree of challenge or safety, chances are there's probably some fear in the environment, and fear-based environments make two feet layers when it comes to safety, the first is that they are only treating symptoms, they're not looking at root causes, we see the issue after the fact, and we don't go pre-accident to look at in a penetrating way, most of the time what is happening beforehand, it's causing this issue because that is often a very vulnerable thing to do. An organization sometimes don't have the tolerance for it, or people don't give accurate enough data or speak up enough such that we can identify the root cause. So that's number one. Number two is that we continue to make the same unforced errors over and over again, because we're not focused, we're not vigilant, we're not ready, we don't feel like it's our responsibility. And so the fear compromises the entire system, so think about fear and its relationship to safety, both in the invisible and the visible front, fear is our worst enemy when it comes to safety, you can think about, if I'm an employee inside an organization and I feel like I'm gonna get hammered if I raise my hand and point something out, I am never gonna do that, and the person next to me is not going to do that either, and so you can see how that translates all the way down the line.
0:42:47.2 Junior: Think of some of the biggest catastrophic failures that we've had in organizations over the years... Over hundreds of years... And this is true organizationally, it's true politically, it's true across the board. When we've had high degrees of fear, the outcomes are almost never good, and they're not sustainable either, if there is some measure of success, eventually it will break and the system will degrade, it will become so broken that people will no longer tolerate it at some point.
0:43:20.7 Tim: Yeah, Junior, think about these relationships, think about stopping the line, if you're a nurse and you need to challenge the surgeon that didn't wash their hands, or that may be using an un-sanitized instrument, are you willing to challenge the surgeon, think about the flight attendant that needs to challenge the pilot for something, think about in a manufacturing environment, the crane operator that needs to challenge the shop floor foreman because they identify something that could be a potential hazard, so that challenging behavior that goes up the hierarchy is very frightening for many people. And so what do we do if fear pervades the environment, then we create exaggerated deference to the chain of command, and we don't do that, we're not going to stop the line, and yet to become a progressively safer work environment, we need people that are empowered and feel confident to stop to line.
0:44:30.4 Junior: So a couple of key relationships for us, psychological safety allows the continuous removal of hazards, whereas fear ensures the continuous preservation of hazards, silence is the enemy of psychological safety, so to summarize the logic, let's go down two chains, the first bad, red, low. Psychological safety starts with fear, that's the first ingredient in a breakdown unsafe system, because what happens after fear, silence, we move into a mode of passive observation on the left side of that spectrum that we talked about, that moves into a breakdown system, which moves into decreased safety and that decrease safety can show up a whole host of ways, but it's part of what contributes to that 7500 a day number.
0:45:18.5 Junior: On the other side, we have blue psychological safety, good, psychological safety is our first input that translates into a Speak-up culture in which we actively participate, that translates into a predictive system and then to increase safety with fewer hazards, fewer risks, fewer fatalities, fewer injuries, and so our invitation today is to build your safety system on a foundation of psychological safety, so at the beginning, we talked about the definition of safety and how it's changing... This is how it's changing, psychological safety is becoming incorporated into our safety systems, and not just as an ancillary small component, but as the foundation, it's upstream from almost everything else, or perhaps it is upstream from everything else, it's the first input. If you have low psychological safety, the chances that you have high physical safety are low, especially over a long time horizon, the safest systems, both in the physical domain and the intangible domain have high psychological safety. So, Challenger safety, stage four, if you haven't heard of Challenger safety before, if you're brand new, we would encourage you to go and listen to the psychological safety series, specifically the stage four episode, where we talk about challenger safety, because that will translate directly into helping you become proficient enough to incorporate some of these attitudes and behaviors into whatever system you find yourself in, and it could be that you're in manufacturing, and this is very much part of your day-to-day, it could be the year in health care...
0:47:02.6 Junior: The same thing is true. It could be that you're in government or a non-profit, could be that your private sector technology and you need to move at an alarming rate because the conditions are changing so fast regardless of your domain, these principles are relevant and will help you improve your systems.
0:47:23.1 Tim: Junior, I just wanna go back to, you laid out the causal chain, well, two chains, one begins with fear, the other begins with psychological safety, and that really is the entire point, physical safety is about culture, and culture is all about psychological safety, and so if you get the inputs wrong at the beginning, you can't fix it downstream, as you said, you gotta go up stream to fix it, you gotta go back to that first input.
0:47:48.6 Junior: So all of today's content, some of the principles that we've shared, some of the models, the spectrums that we've talked about that are sometimes hard to visualize, have been visualized for you in an eBook that's downloadable for free on the website. We will go ahead and put a link to that in the show notes, and this will be made available if it's not already for you, and we encourage you to share it, if there are people in your network that you feel like would find this valuable. Share both the podcast and the e-book, and as always, thank you so much for listening, we appreciate you and all that you do, and a special shout out for those of you that are in high risk industries that deal with these things all day, every day. What you do makes a difference, think about the psychological components of what you do and the relationship that they have to your physical safety systems, and with that... We will catch you in the next episode. Tim, thank you for your time today.
0:48:46.6 Tim: Thank you, Junior.
0:48:54.1 Producer: Hey Culture by Design listeners, you made it to the end of today's episode.Thank you again for listening and for making culture something that you do by design and not by default. If you've enjoyed today's episode please be so kind to leave us a review it helps us reach a wider audience and accomplish our mission of influencing the world for good at scale. Today's episode show notes and other relevant resources related to today's topic can be found at leaderfactor.com/resources and with that we'll see you next episode.