Psychological Safety, Failure & Human Factors

Welcome to the psychological safety newsletter and thanks for subscribing. You are amazing. This week discusses failure archetypes, human factors, more Elon Musk, stinky fish and more.

Human Factors & Categorising Failure

In the past couple of issues, we’ve spoken about failure – how a failure can happen, and the guardrails we put in place to prevent them. I thought it would be useful to dive into the types of failure that can occur, and for this we can look at Amy Edmondson’s Failure Archetypes from The Fearless Organisation: where some failures are “preventable“, some “complex” and some “intelligent“. To expand on those:

– Preventable Failures are those that result from a practitioner neglecting to follow a process, not possessing the required skill to perform a task, or not paying attention to the task at hand. These may warrant a Safety I approach to resolution, such as implementing a checklist.
Example: putting a laundry wash on and adding bleach instead of laundry detergent. 

– Complex Failures are “unique and novel combinations of events and actions that give rise to unwanted outcomes.“* These occur in systems that are in a complex state according to the Cynefin framework. In this domain, Safety I approaches are much less effective, since the conditions required to cause the failure are unlikely to happen again in the same way. In complex states, we can only determine probabilities, not results. 
Example: a patient death in hospital resulting from a complex range of epidemiological, human, technological and process factors.
*The Fearless Organisation, Amy Edmondson, p.163

– Intelligent Failures are those that result from risks that we intentionally take. What we mean here, essentially, are experiments that we hope will turn out one way, but turn out another. In a sense, these are not actual failures – they are only failures if we fail to learn from them.
Example: launching a new product feature to market in the hope it will increase adoption, but in fact it does the opposite. 

Table 7.2 from The Fearless Organisation, Amy Edmondson, p163.

We can therefore see why it’s so important to frame failure correctly. Failure can mean very different things to different people in different contexts. With regard to intelligent failures, it’s also really important to distinguish between things that are safe to fail, or not safe to fail. More often than not, whether something is safe to fail depends on the value of the learning of the experiment. We carry out double-blind, Randomised Control Trials on real humans, where we know with reasonable certainty that the placebo group will not benefit from the treatment, and they may even die (whilst the treatment group may survive) – but we deem the value of the knowledge gained to be worth that risk.

In a recent workshop with a large pharmaceutical firm, we talked about Preventable Failures, and how, over time, the organisation has created a wealth of policies, procedures and processes to prevent them (an over-rotation on Safety-I). However, inevitably, these compliance rules have had a chilling effect on “Intelligent Failures” – because the overwhelming volume of policy makes it difficult for people to take intelligent risks. We came up with the motto, “If you’re going to deviate, do it on purpose.“. Policies can’t tell the difference between a preventable failure and an intelligent failure – but people can, and people are able to make intelligent choices about what is safe to fail.

Context drives behaviour

We should address that first term: “Preventable Failure”. It may sound like a preventable failure warrants blame on the practitioner: that “if they’d only done it this way, it wouldn’t have failed.” Not only is this a counterfactual (a topic for a future issue), but it’s not necessarily true or constructive. In my example above, i put bleach into the washing machine instead of detergent, ruining my clothes. It was certainly a preventable failure, but was I to blame?

From The HSE: Human factors: Managing human failures

To answer that, we can look to the field of Human Factors. Maybe I was just lazy or didn’t care, but more likely it was something like one of the below:

• My attention was split due to looking after children at the same time. 
• The bleach bottle looked identical to the detergent bottle.
• The detergent bottle actually contained bleach.
• The lights had failed, so I was working in the dark.
• I was exhausted from being up all night with a baby, and unable to concentrate.
• I thought I was meant to put bleach in, because the instructions weren’t clear.
• I was forced to put bleach in (I can’t think why I would do that – maybe someone had a gun to my head!)
• Or, maybe, I was simply incompetent and just had no idea what I was doing!

This isn’t to suggest that its not a preventable failure – it absolutely was – but we should resist the temptation to assign fault to an individual. It’s far more constructive to examine the whole system, all the human factors that contributed to a failure, and consider how we could instead:

• Reduce the cognitive load of practitioners
• Make things easier to use and operate correctly
• Detect signals of failure before they occur
• Provide effective training and opportunities for experience
• Ensure that people speak up if a system is difficult to use correctly
• Ensure that people won’t be punished for highlighting failure
• Ensure that people suggest ideas to make things less likely to fail
• Ensure that people feel safe and able to ask for help

We can see that, far from finding fault with an individual, the most effective way of preventing preventable failures is to adopt a human factors approach to designing systems of work, alongside the cultural practices that foster psychological safety.

Blame fixes nothing

Having read that, take a look at this, and consider “who’s at fault?” here. 

Thanks to Rob England for posting this and encouraging a lively discussion in the comments!

Psychological Safety At Twitter:

Ok, I guess we have to address the big one: Elon Musk and Twitter. This week, Elon sent a message to Twitter employees telling them they had until Thursday to decide whether they wanted to stay on at the company to work “long hours at high intensity” or leave. The message was to commit to a new “hardcore” Twitter or leave the company with severance pay. And for the employees who stay on,  “Only exceptional performance will constitute a passing grade.” Employees who criticised Musk on the company Slack channels were fired overnight by email, for “violating company policy”. In the same week, an engineer, Eric Frohnhoefer, who disagreed with Musk publicly on Twitter about the technical details behind application performance in different regions, was sacked for doing so – before Musk appeared to take his critique on board and do exactly what he suggested. 
 

All this, at the same time as forcing people back into the office whilst ending free lunches for employees working on premise, but has also locked everyone out of the offices.
 

Sergio Isidoro put it really well: “There has been 2 major themes in tech organisational development in the past years – microservices and psychological safety. Twitter is going from reference, to “case study” on both.” 

I have no doubt that we’ll see more from Elon in future newsletters. Mostly, I want to extend my gratitude and sympathy for anyone working at Twitter who’s suffering as a result of all of this, and for those who have already left or in the process of leaving. You have built an incredible platform and an amazing organisation, for which, whatever happens to Twitter now, you should be forever proud of.

If Twitter does begin to crumble, you can find me, and many other folks at Mastodon: @tom_geraghty@mastodon.online

This newsletter is sponsored by Conflux

Conflux is the leading business consultancy worldwide helping organizations to navigate fast flow in software. We help organizations to adopt and sustain proven, modern practices for delivering software rapidly and safely.

‘The Fearless Organization’ by Amy Edmondson is considered by many to be essential reading on the topic of psychological safety. In this article, Sophie Weston, Principal at Conflux, has put together some key takeaways from the book.

Psychological Safety in the Workplace

I was super pleased and honoured to be invited to speak with Douglas at Voltage Control, on their Control The Room podcast: “… most of us learn management from our managers. We learn what management looks like, we learn what management is through our own managers. And because of the way time and careers work, most of the managers that we have, certainly early in our career, are themselves fairly inexperienced, fairly junior managers. So there’s this sort of feedback loop of inexperienced managers teaching inexperienced people how to be inexperienced managers. And so we don’t always get exposed to the really, really competent managers and leaders until later on in our career. And that’s when we realize, “Oh no, that’s not the way we should do things.”

And me again! Thanks to Paul Gisby for inviting me on to the “Talking Leaders” podcast to discuss some of the myths around psychological safety, and attempting to bust some of them! 

This is a great conversation between Beatriz Datangel, Deirdre Diamond, Tennisha Martin & Keenan Skelly at SANS Cybersecurity Leadership Summit 2022, discussing psychological safety in cybersecurity teams. “We need to focus on making it safe enough for people to be themselves and add the value that they can bring.“

As regular readers might know, my first job title was “Experimentalist” – most of my early career was in agriscience and ecology. The scientist in me loves this piece from Amy Edmondson: Today’s leaders must learn to think like scientists.

Things to do and try:
Retrospectives are really powerful practices to embed and facilitate continuous improvement as well as foster psychological safety. The more we do them, the better we get at them – and the more we build psychological safety. There are so many different types of retrospective to choose from, but here’s one of my favourites – the Stinky Fish from Åsa Silfverberg at Hyper Island Original. “A stinky fish is a secret fear or anxiety about the changing world. Something that I feel insecure or unsettled about, but that I know I can’t ignore. The more I hide and avoid, the stinkier it becomes. I’ve heard lots of stinky fish over the years.“

Here’s an evolved Stinky Fish canvas from Gustavo Razzetti at Fearless Culture.

This week’s poem:

Invictus, by William Earnest Henley

Out of the night that covers me,
      Black as the pit from pole to pole,
I thank whatever gods may be
      For my unconquerable soul.

In the fell clutch of circumstance
      I have not winced nor cried aloud.
Under the bludgeonings of chance
      My head is bloody, but unbowed.

Beyond this place of wrath and tears
      Looms but the Horror of the shade,
And yet the menace of the years
      Finds and shall find me unafraid.

It matters not how strait the gate,
      How charged with punishments the scroll,
I am the master of my fate,
      I am the captain of my soul.



Paraphrased famously by leaders including Winston Churchill and Barack Obama, Nelson Mandela recited this poem to other prisoners while incarcerated at Robben Island prison, and described being empowered by its message of self-mastery.

Mission statement

The mission of this newsletter is to make the world of work a better, safer, more inclusive and equitable place. We work towards this by sharing, as widely as possible, new research and opinion, case studies, news, practices and methods related to psychological safety. 

This includes topics such as inclusion, human factors, facilitation, safety critical environments, systems thinking, leadership and management, diversity and equity, mental health, organisational dynamics, culture, ethics, and more. 

A core goal is to amplify the voices of minoritised groups and those who are less represented in this field. This includes (but is not limited to) voices of people of colour, neurodiverse people, LGBTQ+ people, women in leadership and tech, and more.

Another goal is to share insights and best practices across different domains: for example, so that those of us in tech may learn from healthcare, and those of us in education can learn from aviation.

I believe knowledge is worthless unless it’s accessible. A key principle of this newsletter is to only share content that everyone can access. This excludes content behind paywalls, research papers that are not open-access, and proprietary tools that don’t open source their algorithms (preventing us from observing how systems make decisions about us). There may be some exceptions to this principle in practice, for example, where authors are able to share original texts of papers.

Whilst this statement will evolve this over time, the core principles of equity, amplification, and progressive & humanistic leadership shouldn’t change.