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Dive into another captivating conversation with us as Gareth Lock returns to The Safety Guru! Tune in as Gareth dives deep into navigating organizational learning through storytelling and discusses creating an environment of shared trust to encourage vulnerable and productive structured debriefs. Gareth’s profound insights and compelling examples will unveil the hidden layers of organizational growth. Ensure you don’t miss this insightful episode!
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Hi, and welcome to The Safety Guru. Today I’m very excited to have back on our show Gareth Lock from the human diver. He’s an author. He’s brought a lot of experience from his 25 years in the Royal Air Force, to oil and gas, to many different industries, including diving. But my favorite is his branding around Counter-errorism. So, Gareth, welcome back to the show. Tell me a little bit first about Counter-errorism and your journey into safety and diving.
Eric, thanks very much for inviting me back in. As we know from the last time, there’s just so much to talk about this stuff, and I’m really quite passionate about sharing my knowledge and that journey that’s there. So, the whole piece about Counter-errorism in diving is just recognizing that we’re all fallible. My first idea about the diving business was the fallible diver. And people are like, That’s really negative. We know that humans are fallible, so why not make it a human diver? It’s like, Yeah, okay. And so, it’s both sides of what I would say that the bow tie that some of your listeners might know about is the prevention piece and then the mitigation afterward and recognizing that human error is normal, the first principle of human and organizational performance. I’ve got a really broad experience and operational background in aviation, research and development, flight trials, and procurement systems engineering. Left the Air Force in February ’15, set up my own business, and worked in oil and gas and health care and software teams. But my passion is really about trying to bring this stuff into the, predominantly the sports diving space, but now starting to work with military and scientific and commercial dive teams as well because people are people.
We’re all wired the same way, and we all behave broadly the same way. So, the knowledge is easily transportable. As long as you can have an open mind and say, you know what, that’s the context and the behaviors that lead to error outcomes, let’s see how we can bridge that into whatever space that I’m working in.
Excellent. And then today, a topic we’re going to touch on is organizational learning, something that is a very, very powerful and important concept that is really at the crux of safety, but more specifically around the power of storytelling when it pertains to learning. So, tell me a little bit about some of the work you’ve done around learning and listening to stories.
Yeah. So, one of the challenges in any environment is getting lessons to be transferred from one person to another. And the difference as well between lessons identified and lessons learned. People will experience something, they’ve gone wrong. They then need to take a little bit time to reflect and unpack what’s just happened. And there’s almost an altruistic need to share that story beyond yourself. Organizations or domains mandate or regulate reporting. So, aviation, there is an obligation that said, you had an event, you are to report. Now, actually, would it be nice if we could actually get people to share those stories voluntarily? They get that out there. And for that to happen, we’ve got to have both a psychologically safe environment, so we know that we can make those mistakes, but also, we’ve got to have a just culture that recognizes that we’re all fallible. And there is this gray line that sits between acceptable and unacceptable behavior. So, in the diving space, where my real interest in human factors and diving came from in 2005, where I had a near miss. Diving had a close call. I recovered from the situation. I got back to the UK, and I said, well, how do I report this?
Because that was my military aviation background, I had a near miss. Let’s share it. I found it really difficult to do that. So, since 2005 and now, really, it’s been about trying to create an environment where people can share stories and tell stories. I’m doing a Masters’s degree at Lund University, and one of the things that I’m looking at there is where people share stories. What are the barriers? What are the enablers? Who will they share with? Why won’t they share? And so, as I’ve gone through the literature, there is a couple of reasons. Organizations would like stories to be shared, and incident stories to be shared, because they believe that they, as an organization, can learn and improve. But for that to happen, the person who’s been involved in the story has to have some value to do that. Now, that value could be internal, so we unpack it. We got a cathartic approach to sit there and go, Wow, okay, that was close. What happened? What was the context? What led to that? Because actually, I don’t want that to happen again. But that’s potentially counter to what an organization wants, where they’re looking at much bigger things, or often they’re counting stories, and they’re not actually listening or reading the narratives that are there.
And so, there are two conflicts between storytelling following incidents. And that work from Santa in 2008 just looked at actually frontline railway engineers, operators, and trackside engineers. They tell stories to keep themselves and their buddies safe. My research in the diving space has shown that people share stories in a close, trusted group because they don’t want it to go further. Even though organizations talk about having psychological safety or a just culture in place, there’s often a fear that people will be ridiculous for being stupid. And if we can’t recognize and can’t accept fallibility, then the stories that get shared are not complete. So, it’s a huge opportunity, but we’ve got to create almost a theater to be able to tell those stories.
That is a very interesting point. And I know when you talk about stories, there was some research I was reading recently from Harvard around retention, and we retain stories considerably better than statistics. Difference at the end of the day in terms of what you do remember to the tune of 33 % versus 73 % of what you’re doing your members. So substantial differences. So how do you create that environment? How do you create this setting? So, what you describe in diving, to me, sounds like a group of buddies together, sharing maybe after work. And so, it’s more social learning, but it’s not necessarily embedded in the organization.
Absolutely. So how do you do it? You create an environment where people can share, where you have a structure of a debrief. So, in some of the original work from Gary Klein with Firefighters, how do they make decisions in uncertain environments? Time pressure, incomplete information. And what he noticed was that they would finish their shift, and they’d clean up their gear, and then they’d go and grab a brew, and they would talk about what they heard, what they smelled, what they felt, what was going through their mind. And that was as a team. And so, what was happening is they were sharing and creating shared mental models within their teams. And that then helped them make decisions in uncertainty. And it helps pass on tacit knowledge. So, the environment is critical. There has to be a level of trust. And you’ve got to have a norm of doing a debrief. And that’s what I’ve been trying to bring into the diving space, having a structure for a debrief because often people don’t know how to tell a story. And that’s, again, what’s come out of my research is that novice divers, especially, they’re lacking in two things.
One is they don’t know how to tell a learning story to get a point to cross. And the other thing is actually they often don’t know what they don’t know. So, it’s that bit that they don’t know they’ve had a near miss because they have got more concept of what right, wrong, good, bad looks like. And as a consequence, they’re not even looking at where things are. When we get to, I’m going to say, the more mature area of the diving space, we talk about instructors. Now we’ve got credibility, we’ve got the reputation, we’ve got litigation involved. And in that sense, instructors won’t tell their near-miss stories because there’s this fear of, oh, look, there’s an important instructor. Hang on a minute. I’m supposed to be doing some training with him, and he’s talking about mistakes that have happened. It’s like, Yeah, they’re human, too. That’s no different than surgeons. The society holds surgeons on a pedestal of excellence. Police officers operating in dynamic, uncertain environments. It’s really difficult to tell a multi-actor truthful story because people will be able to play the news clips back or the body cam stuff back and go, hey, look, you missed that, and you missed that because they don’t understand human fallibility.
So, this bit, how do you create an environment? It’s leaders, peers, role models that and you can start in small groups and build shared trust or psychological safety. But for a start, you’ve got to know where something has gone wrong. And I recently wrote about near misses, were you lucky, or were you good? But often, near misses are treated as successes rather than failures because we got a good outcome, even though we were really close. And so, we just move on, pat in the back, off you go. It takes a very different mindset to sit there and go and ask that question, were we lucky, or were we good? Oh, yeah, we were good. All right. What do we do that we can replicate the next time and the time after that? Oh, yeah. Actually, we were pretty lucky then. All right. So, let’s look at what we missed and build those stories and then share them as it goes. And the problem with stories is that they get modified and changed because of the way that our memory works. We embellish certain factors, and we hide other ones because we don’t have that side of psychological safety, that security to show our vulnerabilities.
Very interesting. When you mentioned you talk about storytelling debriefing, a scenario that comes to mind is the approach that the US Army has used around after-action reviews, which are originally intended to be essentially storytelling from multiple different perspectives to walk through. What do we go through, whether or not there was something good or bad as an outcome, but really trying to look at what we plan and where was it different than what we expected it to look like? Is that something similar what you’re describing?
Yeah, totally. This needs to get into the habit of running a debrief. So often, debriefs or after-action reviews are run when something has gone wrong. Now, if you don’t perceive that something has gone wrong, why are we running this debrief? And it just then loses its value, and people then lose get out of the habit of doing it. Whereas actually, if we frame the debrief and we can put something in the show notes, a link to a debriefing guide that I use, and it follows the word debrief. And so, the key learnings that are in there are internal learning. What did I do well and why? What do I need to improve on, and how am I going to do it? And the E is the external learning, the team. What did the team do well and why? And what did the team need to improve, and how are they going to do it? And the why and the how questions are the most important because we can make an observation about something that went well or we need to improve, but it takes a lot of thinking to say, why did that go well?
Or how are we going to make that improvement? And then the final part, the F of the debriefing framework, is about fixed files or follow-up. So, you’ve done an activity, you’ve briefed it, you planned it, you briefed it, you’ve done it, you’ve debriefed it. Now that you’ve identified some lessons, what are you going to do with them? And that’s the difference between lessons learned and lessons identified. Many organizations have got loads of lessons identified, but far fewer lessons learned. And the lessons you’ve learned are where you’ve looked at something, you’ve put something in place, and you’ve measured its improvement. Or actually, you realized that that intervention didn’t work, and so you’ve learned that that didn’t work. So, the difference between lessons learned and lessons identified is, did a change happen afterward? And that’s a huge piece.
It is because a lot of times, like you said, organizations learn the same thing over and over and over because the change is not embedded. It’s just something on a policy document that says thou shalt do it this way, which may or may not solve the problem or may or may not be operationalized.
Absolutely. And that takes strong leadership. I was recently involved in a major review, and the accountable individual, the duty holder for this, wouldn’t sign off the actions or the recommendations as being complete until they’d actually been completed and put in place. Because one of the parts of the review that we picked up was that there were recommendations made in previous reviews that never actually got fulfilled. And it was like, hang on a minute, these were not directly contributor entries towards the event, but they did recognize that hang on a minute, we’re not very good at learning here because we capture this stuff, and we don’t fix those things that are faulty or failed.
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I love your storytelling approach to learning. How do you disseminate that across an organization so that the divers that get together, they can do that casually? How do you make sure that that same insight gets cascaded to groups that can’t be there physically?
So as a direct example, what I put together is a documentary called If Only. And that looks at a diving fatality through the lens of human factors and just culture. And I’ll send you the link for that as a human diver or slash, If only. And I was really fortunate to get involved with the widow of the diver and the dive team, three members of this, three surviving members of the dive team. So, we flew out to Hawaii, and we had a face-to-camera work, we re-enacted it, and we shot about five and a half hours of video. And then that was reduced to 24, 25 for 25 minutes, and then I added some other stuff. And the editor said, Look, you’re going to have to make it shorter than 20 minutes. I’m like, what do you take out? I don’t know. So, I created this 34-minute documentary which has been downloaded thousands of times. And that then goes out. And I know that people in the non-diving space have looked at this and gone because the failures are multiple within the system. And often, it’s about psychological safety, decisions, inability to speak up, drift, about equipment not being set up correctly, which carry across many other domains as well.
So, to me, the ability to share engaging, emotional, sometimes really quite powerful stories to get across there. So that’s one way. The blogs that I write, I often start a blog with a story because people… When you open it up, and you go, what’s going to happen next? You started off with, and the diver was on so and so, and this, and you go, Right, what’s happening next? And you’ve got to put a hook in there, and then you’ve got to stitch the theory into the story so that it becomes a learning lesson, and they can relate to the individual. There is a really powerful bias of distancing through differencing, and this sits not just at an individual level but an organizational level as well, where we will look at somebody or some organization and go, They’re different to us. We wouldn’t make that mistake. And you sit there and go, yes, you would. From the diving side, I put together under pressure the book that I published, and there’s another one called Close Calls, which is a similar story. Mine’s got theory woven in and out. Close Calls is just stories from names across the industry.
And people like to read them. The hard part is, does it actually change people’s behavior? Because ultimately, that’s what we want to do, get people to think differently and understand the context in which they were. Not to turn around and say, I wouldn’t do that as an outcome because the outcome is too late. What we’re trying to do is spot the context developing and sit there and go, oh, I recognize this, and I can see where the trajectory is. But that’s really hard to get across. And even when you’ve got known stories, so there’s a paper I read recently from Dylan and Tinsley, or might be just big Dylan on their own, talking about using lessons from Challenger to get the ideas across. And what they did was they created a scenario of an aircraft that needed to fly some spares to a remote location, but the temperature was low, and the oil seals might leak on the engines. And if the oil seals broke, they’d need to shut down the engine. They’d probably ditch, and then the crew might not survive the ditching. And what was really interesting was that even though the story was told as if it was Challenger, the people didn’t recognize it was Challenger.
And still, about 70 odd % of people went, Yeah, we’ll launch. Off you go. So even when you’re given a narrative, we often can’t make the connection because it’s just the way our brains are wired, unfortunately. So, it has to be really visceral. It has to be that’s me, and I would do that.
Interesting. And I’ve seen this many times in organizations. When you talk about small group sharing their mistakes, part of it is there is camaraderie, people know each other. Is there a way that you seem to extend this so that people don’t say that won’t happen to me? I wouldn’t make that silly mistake. To really overcome that element, to recognize that, yes, as humans, we’re all bound to make those mistakes.
So, I’d say probably US Forest Service with their lessons learned center that they’ve got. And I think the important bit is to get away from the individual’s this erroneous performance and look at the context and the error-producing conditions which are there. And that’s why I was referring to earlier understanding what goes into a good learning story is understanding what sets somebody up for failure in this scenario they’re in. Because, by definition, if we knew what the outcome of the event would be, we would have stopped it.
So, this bit about, Right, think about all those bad things that are going to happen. Yeah, well, how am I going to spot them? I don’t know the significance of those. So, what we have to do then is actually, what can we tell in terms of the situation developing that I will encounter? And then sit there and go, this is the system or the situation changing. Okay, that’s a flag. Not, I won’t make that mistake. It’s, I’m now in a situation where I’m more likely to make a mistake. Can I raise my game? Is this something that’s a flag that says, look-out.
Interesting. So, move it away from the area itself to the context of the situation that people are in because then you’re more likely to relate, saying, that set of circumstances could happen to me as well.
Yeah, totally. And so, aviation moved from cockpit resource management to crew resource management, now threat and error management. So, there’s this expectation that the aircrew is competent to do what they need to do. We don’t need to train them more and more to do that. The threat and error management situation are. I’m potentially going into a busy airfield. The wind is marginal. Do I set up the opposite runway, ILS or approach systems, or the other frequencies? The weather forecast has got thunderstorms in the area or whatever it is. It’s a potentially confusing runway. Let’s think about how we set ourselves up for success, not failure because generally, that’s about sharing stories where you know what, the situation got away from people. So, can we get ahead of things and provide that flag that says, Whoa, that’s enough? And in the majority of high-risk industries, we have something called stop work authority. My simplistic view is that often, that’s a stop by an organization to say, I’m going to give you a card. If you think it’s unsafe, then hold this card up and stop the job. But most people don’t know that it’s all going horribly wrong until it’s gone wrong.
And then the organization says, why didn’t you stop the job? Because you could see it was there. And there are a whole bunch of social, technical reasons why people find it hard to say stop because there are goals that are around there. So, if we can start to say, Let’s look at the conditions that are around us, then that’s actually easier to raise a flag.
Yeah. And also helps people understand where I am entering dangerous territory. Your example about maybe this confusing runway. There have been some runways where there’s been more than one flight that almost landed not on the runway but landed on another airplane that was taxing. But you know which airports those are. So, you could be on high alert if you know, okay, I’m approaching San Francisco is one of them, I believe, has come up a few times and say, okay, on this approach, here’s what I need to pay extra attention to.
Yes. And so, we’ve got a limited capacity to pay attention. So, in that bit that says, actually, here’s the high-threat situation. I’m now going to not quite ignore the other things, but I’m going to point my attention. And one of the things I try to get across in my training is we’ve got a limited capacity to pay attention. So, it’s not that people weren’t paying attention because often the response is, Pay more. We can’t pay more attention. What we can do is focus it somewhere else. So, what we’re trying to do is, what’s the threat that we’re encountering? And that comes from understanding the near misses that are out there and the context that’s encountered.
So, Rich, topic. To me, organizational learning is probably one of the most challenging parts of safety that we keep talking about. Hardest one to do. But I love your angle in terms of sharing stories, trying to learn on a regular, continuous basis, just so that people reflect and think through the stories. And then how do you disseminate those stories through scenarios on the context as opposed to the individual and the error that they made? I think these are very powerful concepts that hopefully help organizations move from learning the same thing over and over to learning and actually embedding that change.
Totally. And what I would say from my experience as well as people are more likely to share a context-rich story than a closed narrative story which is focused on the individual. So, if you can get more context, more system if you can get multi actors in there, there’s a paper out there looking at when an incident report has got multiple narratives, then people are more likely to look at systems causes than a single narrative which is a synthesis by the investigator who will have their own perspective. And often, it’s about compliance, noncompliance. And so, people will look at that and say, here are the recommendations which are focused on fixing the person. Whereas actually, if you have multiple actors and you can hear the conflict and the different ideas, and when you’ve got six actors involved in an incident, expect six stories. It’s not because they’re lying; it’s because they’ve got different perceptions about what happened. So, if you’ve got the opportunity to share a multi-actor story, that’s the way to go about it.
So soon, we’ll be writing Hollywood scripts through those stories.
Well, we often have multiple actors in a story in a film.
But there’s some truth to the way you share stories because even in Hollywood, they say there are seven-story themes to every movie that’s sold across the board. Rags to Rich is an example. But it’s a narrative that we tend to listen to. The personas and everything else get us to associate with it and then remember that story.
Totally. And there’s a paper from Drew Ray which talks about the different safety stories and how you share them. Do you tell the outcome and then build it up on a different narrative? Do you tell one narrative where people jump to conclusions, and then then you tell the context-rich story, which then brings the learning point out? So, this goes back to what’s the purpose of the story and who’s the audience you’re trying to tell the story to, and the learning point you’re trying to get across.
Excellent. Well, Gareth, thank you very much for coming back to our show. Appreciate you sharing some of your thoughts about learning, organizational learning, and storytelling. I think it’s very powerful. Sayers of ideas to take forward. Thank you.
Brilliant. Thank you very much, Eric. I love being on it again. Thank you.
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ABOUT THE GUEST
Gareth Lock is the founder of The Human Diver, an organization set up to deliver education and research into the role and benefit of applying human factors, non-technical skills, psychological safety, and ‘just culture’ in sports, military, and scientific diving. He has published the book ‘Under Pressure’ and produced the documentary ‘If Only…,’ both focused on improving diving safety and performance by looking at incidents through the lens of human factors. While primarily focused on diving, he also works in other high-risk, high-uncertainty domains such as healthcare, oil & gas, maritime, and software. He is currently undertaking an MSc in HF and System Safety at Lund University where he is looking at the power (and limitations) of storytelling to improve learning.
For more information: https://www.thehumandiver.com/
The Debrief Guide: www.thehumandiver.com/debrief
If Only: www.thehumandiver.com/ifonly
Sanne (Santa in the transcript) – Incident reporting or storytelling? Competing schemes in a safety-critical and hazardous work setting – http://dx.doi.org/10.1016/j.ssci.2007.06.024
Klein and firefighters – Naturalistic Decision Making http://journals.sagepub.com/doi/10.1518/001872008X288385
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