Posts Tagged ‘resilience’

Resilience Engineering has emerged from an approach towards accident modeling and prevention that is based on answering the question, “What makes for sustained safety and success?” The idea being focusing only on what went wrong is important but may give only half the picture.

This all sounds well and good and makes so much sense one would wonder what is so special about this approach. How else would one look at accidents? Turns out in the history of accident modeling one of the first models used took a very different approach, a very personal one. It is an approach that leans towards shame and blame should failure occur and is alive and well in certain areas of the management world.

Don’t Hit That First Domino!

Herbert Heinrich developed the Domino Theory of accidents in 1929 while working at Travelers Insurance. The model has 4 components or dominos and the idea was the damage that resulted from an accident could be analyzed in terms of a series of events that cascaded like a set of dominos. The dominos are:

  • Genetics
  • Individual personality and/or character flaws
  • The Hazard
  • The Accident

“Bad seed” might be the best way to describe the genetic or ancestral contribution to accidents.  The individual is doomed, in a way, before they get started so it would be best to just not hire them.

“Bad habits” would sum the second point where the individual is innately predisposed in day-to-day behaviors to engage in risk-taking activities. Think, “strong urges.” An example would be having the urge to surf the web indiscriminately.

“Risky behavior” is synonymous with the hazardous activity, e.g., surfing the web without antivirus protection and downloading a Trojan horse that takes over one’s computer.

The crashing of a site by having one’s computer unwittingly participating in a denial of service attack would be an example of the damage caused by all 4 dominos falling.

The idea behind using this model would be to remove the dominos or space them far enough apart so that they could not have a chain reaction. For example, pre-screen and avoid hiring anyone who has those bad genetics or predisposition. This avoids the problem completely. If you do hire a person with the undesirable character traits then don’t let them work in areas where their flaws would play out in the work place and cause an accident, e.g., deny them the ability to surf the web at work.

You can see this takes a rather dim view of human nature. It also has another major shortcoming, i.e., failure to take into account the dynamics of the situation and the broader view required to actually determine what causes failure.  Is it that simple? Is my computer participating in a denial-of-service attack simply my responsibility alone? Should I be punished since I must be defective?

Unfortunately, this approach can be very tempting for a manager to use when the heat is on to find out what went wrong in a situation, especially a complex one. On April 14, 2011, Frank Krakowski resigned as the head of the FAA’s Air Traffic Controller Organization because of a series of events where controllers were asleep in their towers.

“Heads must roll!” would be the simple way to sum up the so-called solution to the situation. I have to believe most people know that Krakowski’s resignation had little effect but human nature intensely wants to play into the domino model. Find the bad guy and punish him or root him out! And if you can’t get to the bad guy soon enough then punish the guy who hired him!

The thing to keep in mind in all this is resilience engineering is about determining what it takes to work safely in a complex environment. The air traffic control situation is a very complex socio-technical problem. Simplistic solutions just don’t cut it. Aaaaah! But they feel so good, and for a brief moment give a shot of narcotic allowing one to drift away and pretend to be in control.

In the next blog we’ll look at the next evolutionary step in accident modeling and see what it has to offer.

Resilience Engineering #2: Drift

by Gary Monti on June 14, 2011

Last week introduced resilience engineering and started with two critical concepts, robustness and resilience, with robust systems being unchanged but pushed to provide performance in a challenging environment and resilient systems adapting to the challenge and evolving.

This week we’ll look at the costs that can accrue with robust systems and the potential for introducing a potentially dangerous behavior called drift. Before getting to drift a little background information will help.

Resilience engineering is especially useful in resource-limited, constrained situations; situations where trade-offs must be made almost on an ongoing basis. One such trade-off that must be considered is how far to push the current system in terms of both technology and people vs. making necessary changes.

The Importance of Time Horizons

The distance to the client’s, customer’s, senior manager’s, or any other powerful stakeholder’s time horizon has a big influence on whether or not a robust or resilient approach is used. A client situation that had very real consequences might help explain. The client firm wanted to purchase another company. Due diligence was performed. However, it was constrained by shortsightedness. The client wanted to enter the market and generated emotionality regarding the issue. As the urge to purchase increased so did the shortsightedness.

The financials looked fine. The concern for the client was the physical plant, comprising four locations. The shortsightedness mentioned earlier won out and the purchase went through. The entire situation ended up slowly turning into a nightmare ending with the client selling at a very reduced price several years later to get out of the situation.

The Cost of Robust Behavior

What had occurred was a classic case of the seller making the company look enticingly resilient while actually working it in a robust manner. A simple metaphor for the situation is brakes on a car. Imagine you want to buy a used car and you ask, “Do the brakes work?” Truth be told; the answer is, “Yes, they always have.” Sounds good. But what if a different question were asked, “How much life does the braking system have left in it?” That might yield a totally different answer, e.g., the rotors/drums need replaced, the hydraulic fittings are corroded and will need replaced if a wrench is put to them, etc., etc. In actuality the braking system is on the verge of failure and an additional $1,000 or more is needed to make needed repairs…and the repairs can’t be piecemeal, the entire system needs replaced at the same time. However, if the purchaser is satisfied with the fact the car has always stopped well in the past then the issue of overuse, of being pushed beyond a safe limit, will be missed and the dreams of where this car can take him will continue. This overuse of the braking system to the point where it is close to being a safety issue is called drift. Formally,

Drift is the incremental movement of a system towards, and eventual crossing of, a failure boundary. This all occurring while belief is maintained that all is well.

Using the brake metaphor, the seller had let the system (physical plant) drift towards failure while increasing performance pressure in order to be able to say, “See, it is giving the desired results.” In the previous blog it was mentioned there was a cost associated with this behavior. In this case it was an insidious cost. Money that should have gone into maintaining the physical plant was shifted towards the bottom line.

The seller pushed the system to perform in a robust manner, i.e., continue generating profit and have them falsely increase by siphoning off money needed for the physical plant to maintain and adapt to the increasing performance pressure.

This made the purchase look that much more enticing causing the client, only looking at the bottom line and blinded by emotionality, to pay too much, essentially taking a mortgage to cover profits extracted by the seller – profits that really weren’t profits but maintenance dollars. On top of that the needed repairs and equipment costs still needed to be incurred.

Another issue was inability to grow since there was no resilience. With the assumption that the plant was fine the belief that current systems could be integrated into the changes envisioned turned out to be bankrupt. Not only did current systems need work, they were close to obsolescence.

Probably enough said for such a dark and dreary topic. Next week we will look at a brighter story, a story where a firm split but did it amicably through a resilient approach.

Project Reality Check #14: Death of a Project

by Gary Monti on March 22, 2011

The death of a promising project is jarring. It may open the door to opportunity. It may also lead to more problems. Which path is illuminated depends upon what the stakeholders, including team members, choose to do with the pain.

Grieving

The stages of grief – denial, anger, bargaining, depression, and acceptance – are known by many. What isn’t commonly known is individuals have the ability to refuse to go through them and simply stay stuck at one stage. This can be seen at funerals and wakes.

There are those who lack any significant response and their turn in the pit of unfairness of life will come with some other event. Others are shattered and will need time to put the pieces back together in a way that puts the loved one’s death in perspective by incorporating something of the deceased’s spirit in moving forward in a significant, positive way. Still others who experience grief simply want to go “back to sleep,” get through the situation, and return to a monotonous sense of security that can be shortsighted, numb, and insensitive causing a walling off to occur along with stunted growth.

Keep the somber images above in mind when doing lessons-learned on a promising project that somehow failed, and failed dramatically to everyone’s surprise. There is nothing magical about lessons learned. If they are to be beneficial each stakeholder and team member involved must put some piece of themselves into the process and risk being transformed.

Robust Lessons Learned

What can help is changing the way lessons learned are performed. This can be done through resilience engineering (RE), steeped heavily in chaos and complexity theory. Two concepts from RE that help are “robust” and “resilient.” They can be used as lens for placing value on contributions to lessons learned.

Traditionally, a robust approach is used. Here “robust” means the ability for the system, as it is, to respond to change, especially threatening change. The overall structure of the system does not necessarily change. As is, the system changes tactics based on the threat being projected. This sounds pretty good. There is a trap present, though. An example may help.

Imagine a downsized company with resources stretched thinner and thinner having avoided major catastrophes on the last few projects. It is natural for phrases such as “best of breed, lean-and-mean, etc.” to start getting bandied around. With the lessons learned from each project a growing sense of false confidence can develop, one that leads to a “going to sleep” as to how close to the edge the team actually is. Suddenly – BANG! –  a high profile project starts falling apart and a chain reaction of failure sets in moving at the speed of sound. What makes matters worse is nothing turns up when doing root cause analysis to determine where a fix is needed. No matter how hard everyone tries, workarounds have no impact or the workarounds make matters worse.

A Paradoxical Approach: Resilient Lessons Learned Ahead of Time

A better approach to lessons learned on the previously successful projects would be through resilience. As used here, resilience asks and answers the questions, “What is the nature of success? How can we sustain it? How close to the edge are we? Can we adapt? If we do, how must we change our structure and the way we do work?” Done properly, this approach to lessons learned helps puncture the false confidence and leads to a more sober, positive approach to building for sustained success. In the example this would lead to addressing human capital well in advance of the catastrophe. The paradox, then, is lesson learned would be performed BEFORE the next high profile project began in an attempt to avoid the catastrophe.

In closing, there is one key difference between the robust and resilient approach. Rather than root cause analysis the resilient approach examines the socio-technical complex present in the organization. It looks to see where everyone is “drinking the Kool-Aid” and a collective march towards the edge is occurring while everyone believes success is just understood to occur.

Project Reality Check #10: Personal Resilience

by Gary Monti on February 22, 2011

Staying centered in high-risk situations is a key project manager characteristic necessary for success. Asked once by a project manager, “What do I do when dealing with an uncooperative person on my project?” the answer given was, “The same thing you do when the person is cooperating.” As you can guess, the challenge to that answer was pretty immediate. So why believe the advice is sound?

The Paradox

There actually is a paradox at play. As a question it can be expressed as, “Should I change behaviors based on what is happening or should I stick to the initial focus?” The correct answer to that question is, “Yes.”

When the Zen master D.T. Suzuki came to the West one of the first things he addressed was the difficulty associated with staying centered with all the distractions present. Looking at this from a project management perspective the solution to such a situation can be broken into two categories of action needed: Internal and External.

Internal Activities

Every day the project manager’s primary activities include:

  • Keeping one’s eye on the goal(s);
  • Maintaining the same level of awareness of risk when things are going okay as much as when they aren’t;
  • Thinking about alternative situations and outcomes along with the underlying assumptions needed to make them true and realistic, e.g., imagining what would happen if the housing market collapsed;
  • Fleshing out options based on the possibility of some aspect of those alternate universes, e.g., determining what constraints on the financial market are needed to forestall the collapse.

External Activities

With a clear focus on the desired goal the project manager observes behaviors and takes note of variances from expected performance. Types of behaviors shown fall into two broad categories:

  • Win-win where stakeholders and team members work interdependently. Maintaining the integrity of the project comes first even if personal sacrifice is involved. There is the belief the individual will do well by contributing to the overall successful achievement of project goals, e.g., a committed team member.
  • Win-lose where antagonism or complete independence is the order of the day. Individuals focus on themselves first-and-only at the very best or on inflicting some sort of damage on the project at the worst, e.g., a competitor.

The Solution: Resilience

Resilience is the ability to continue functioning while adapting to a changing situation. It could be restated as staying consistently with the internal activities while shifting with the external ones.

Sticking with the belief everything is simple, I’ve found the following series of questions and taking appropriate action helps:

  1. Where am I? This isn’t so much a geographic question (although when on the road for long stretches it is). It is more in line with the physical, emotional, and spiritual space presently occupied.  What value do I bring to the situation and why would anyone work with me in this current state?
  2. Am I aware of what the project needs right now? This leads to a subset of questions, “What is? What should be? What’s the gap? What shall we do?”
  3. Do I see the constraints present? Monitoring the environment is an ongoing activity. Do I know how they affect the project?
  4. Can I empathize? It usually takes a team.  Can I accept people as they are, even the difficult ones?
  5. Can I formulate a plan? This is where the internal and external activities begin to converge. The internal activity “thinking of alternate situations/outcomes” can be used to generate a range of options.
  6. Can I state the plan and seek commitment without engaging in emotionality? Letting go of reactivity is very powerful. Can I stay with that and simply state to others what is needed without putting any emotional bait on the table or biting on bait others may put in front of me?
  7. Can I accept the limits of the commitments? This is where resilience is both tested and strengthened. It requires viewing myself both as separate from the work at hand and being more than what life does to me, positive or negative.

Sometimes you get the elevator, other times you get the shaft. The idea is to build resilience, think, and keep moving to get more of the former and less of the latter.

Flexible Focus #4: The eight frames of life: Health

by William Reed on June 3, 2010

Is your lifestyle enhancing your health, or are you unwittingly planting seeds of your own demise? Do you have a comprehensive way of engaging your mind and body for health, or do you get around to it when you can? The Mandala Chart can help you address this challenge, and get positive results in the process.

The key word for health is radiance. Radiant health shows brightness in your eyes, and an aura of light around your skin. It shines through in your laughter and in your step. Radiant health is attractive and contagious. Its energy is a sustaining force for life and vitality.

The quality of radiance is easy to sense, but difficult to measure. Sickness is easier to measure than health, but health is far more than the absence of sickness. Health is the vitality of mind and body, the evidence of life energy.

Health care is a burgeoning issue for people in all nations. It affects those who do not have access to clean water, adequate food, or basic health services; and it affects those who suffer from excessive intake of processed food and chemicals in the environment. It also affects healthy people who still must bear the costs of general health care. It affects our family, our friends, and the people we work with.

There is more information today about health and wellness than anyone could possibly master in a lifetime. The range of options for health and wellness is a virtual smorgasbord, a glutton’s choice. Often even specialists cannot agree on what is right. Perhaps the answer is to find what is right for you.

This is where the Mandala Chart can help you create your own customized vision of health. What works for one person may or may not work for you. With so many alternatives to choose from, it is no easy task starting with a blank sheet. The Mandala Chart simplifies the process by putting it first in an 8-frame perspective, just as we did with the 8 Fields of Life. The important thing is to see them all in the context of the whole, and not get lost in the details and dictates of individual pieces of the puzzle. Do not succumb to the syndrome of the specialist, who proclaims that although the operation was a success, the patient died.

Of course with the Mandala Chart you are free to create and choose your own categories. However, it is often easier to start with a template and then customize it through your experience.

Here I suggest 8 categories you can use for Health: Food, Movement, Breathing, Sleep, Skinship, Resilience, Humor, and Love. Download a Mandala on Health template featuring each of these categories, so that you can begin to create your own customized approach to a healthy lifestyle. I selected these categories because they are broad enough to contain both traditional and alternative approaches to health. They have all been demonstrated to have an impact on our health and well-being, and each of them can be connected to the keyword radiance.

Remember that no one pattern fits all. The results you get depend on the actions you take. Health is ultimately a combination of your genetic predisposition, the cumulative effects of your lifestyle and discipline, and your mental attitude. All of these combine to make the difference, so it makes sense to take a comprehensive approach.

Without recommending any particular health method or system, here are some of the factors to consider when you incorporate these elements in your lifestyle.

  • Food: The quality and quantity of what you eat, food combinations, preparation, diet, cuisine, as well as your enjoyment and beliefs about food.
  • Movement: How you use and treat your body, the quality and frequency of your movement, how you practice, enjoy, and improve, as well as the mind-body connection.
  • Breathing: The quality and depth of your breathing, how you use your breath in movement and speaking, as well as the connection between breathing and awareness.
  • Sleep: Your sleep patterns and comfort, regularity, depth, and quality of your sleep, short naps, dreams, as well as relaxation and recovery.
  • Skinship: Connection to your environment and to other people, hygiene, sensory experience, sexuality, as well as your aura and radiant energy.
  • Resilience: Your ability to survive experiences unscathed, to make a comeback physically and mentally, as well as your spirit of continuous engagement.
  • Humor: Laughter as a sign of a relaxed attitude, an open heart and a positive spirit, as well as the ability to enjoy life and make others feel good.
  • Love: Taking good care of yourself and the ones you love, the spirit of giving and protection, as well as the power of healing.

The frames of the Mandala are can be used in several ways. In printed form it is a framework for note taking or brainstorming. In the eMandala Chart you can attach web links or notes for further reference. Even the blank frames in the template serve as a mirror for reflecting on your own goals and issues related to health, and can also trigger topics for conversation or further study.

The important thing is to use the Mandala as a zoom lens for flexible focus, rather than a container for checklists and information. For this reason it is useful to start with a key word or image, such as radiance, which illuminates each of the 8 frames under a common theme, and integrates them with a single synergistic image. Also make use of the Principle of Interdependence, by bringing positive ideas, influences, and people into your life.

The same process can be applied to each of the other fields of life, gradually giving you greater mental clarity and leverage for action, through the power of flexible focus.