The Situation

The alarming trend called out for immediate attention. In the past two months, the company had experienced more safety incidents than in the past two years. What was going on? Was this the result of the recent acquisition? The previous year’s reorganization? A lapse in safety training? Or was it just a blip on the radar?

When experiencing such a downward trend in safety, organizations often conduct postmortems to uncover the root cause. These gatherings are not unlike others held to diagnose product failures, identify reasons for cost overruns, or learn from mistakes made in project execution. Whatever the focus, the intent is to find, fix, and hopefully learn from the mistakes of an undesirable event.

What Usually Goes Wrong

Here’s the catch. Successful postmortems require a problem-learning process before they get to problem-solving. To successfully problem-learn, we must recreate the system that enabled the undesirable outcome—all the bits and seemingly insignificant pieces. Then we can answer these two key questions of postmortems:

1. Why does it make perfect sense that what happened, happened?
2. What was the understandable thinking that fueled the unfortunate decision?

Answering those questions should be easy, but it never is. As I often ask, “Wouldn’t your processes work great if it weren’t for all the people in the room?”  

The First Issue

As Todd Conklin, internationally recognized expert in safety performance and author of the book Better Questions, noted, “The pressure to fix is stronger than the pressure to learn.” Humans don’t like not knowing, so we often fool ourselves into believing that we know something—like identifying a symptom of a problem—to compensate for what we don’t know—like a thorough understanding of the system that produced the problem.

The Second Issue

When you’re in a workshop with twenty-four other folks—including your peers, your boss, and a high-level VP—you will absolutely be highly motivated to look good in front of them. The larger the group, the stronger the drive. You will be poised to defend yourself and those who report to you when others lead with questions such as this: “Why didn’t you shut off the value as the protocol stipulates?” At that moment, you can safely assume that some of your defense mechanisms will swing into action.

The Third Issue

Aside from these predictable (understandable?) human behaviors, waves of biases will wash over the meeting room. Examples include the following:

• Recency Bias: Quickly recalling and overemphasizing recent experiences at the expense of older experiences
• Hindsight Bias: Claiming you knew all along what would happen
• Confirmation Bias: Seeking information that supports your idea of what went wrong

The Challenge

My challenge was ascertaining how to redirect a group who was used to knowing the answers. They were highly motivated to look good in front of their peers and poised to leap into solution-talk. How could I create an atmosphere of learning? Of exploration? How would I change the questions playing in their minds?

To mitigate those factors, I chose role-playing. I asked the leaders in the room to role-play the person(s) involved in the incident. Role-play is a powerful tool known for reshaping attitudes and perspectives. It also increases empathy (walk a mile in another’s shoes), lowers stress (stress negatively impacts memory function), and changes your frame of reference.

The Better Question

It’s now two years later, and I am sitting with a key member of the twenty-four who was part of the group who gathered two years ago to address this issue. Rather than share my perspective on the outcome, I wanted to share his experience of the role-playing. I thought that would be more helpful than relaying what I saw and did. I’ve edited the conversation slightly for brevity and clarity.

What do you recall about the mindset of the attendees?

From the moment everyone knew the VP would be in the meeting, they wanted the perfect answer ready to defend themselves. I’ve got to defend my side of the business. I want to be prepared to defend whatever we are delivering from our perspective.

Before the investigation started, some leaders had already collected some facts. To them, it was simply an operator who didn’t follow the process. That was the end of the investigation, and now they just wanted to act. For some people, the solution was to fire the person who didn’t follow the process. Bring a new one in, they said. Others wanted to give the person a warning, give them a tough time, forgive them, move on, and hope it wouldn’t happen again. For others, the solution was making the process more complex—adding more steps. So now it’s not as easy to follow the process. And when you look at those three solutions—fire them, forgive them, make the process more complex—is that really what will prevent the incident from happening again? I don’t think so.

Tell me about what you recall from your role-play.

In real life, I was the lead investigator for the safety scenario you asked me to role-play. I had the information from the investigation. But to role-play, I had to put myself in the shoes of the operator. When I entered that mindset, I became aware that to do a certain thing or check another thing before I did something else was not so easy. I had to remove my own bias about what I thought had happened, and I also experienced what having others interview me would be like.

Did you have a strategy when you started role-playing?

No. I didn’t have time to come up with a strategy. You told me I was going to role-play just ten minutes before I took the stage. It was kind of an emergent thing. But it was interesting. The more I responded, the more I started to get a sense of what the operator had experienced.

We spent part of the first day of the workshop learning about changing mindsets and the different kinds of questions to ask. What were you aware of as you answered those questions during your role-play?

I was very aware that the workshop participants were asking me more curious questions. They seemed to be trying to paint a picture of what happened instead of finding blame.

They were not asking questions such as, “Why didn’t you just check this or follow that?” Those are typical questions asked in an investigation. And there is a big difference between being asked those kinds of questions versus “Hey, did you notice that? Did you think about that?” kind of questions.

If the questioning is an interrogation of the operator, that person won’t be mentally ready to have the kind of conversation we need to problem-learn. We need to be able to walk in their shoes.

You shared that you had investigated this incident before our two-day workshop. What will you do differently the next time you investigate a project failure or safety incident?

Two things resonated with me. First, I felt like the role-playing exercise helped me stay in the context of where the operator was at that time—all the little things that were happening. On the first day of the workshop, you talked about the need to understand how they are playing the game versus simply keeping score. I need to find out what it was like for them to be playing the game. That will allow me to read between the lines, to listen with the mindset of what led that person to think that not following the process was okay.

Second, if I were to do this investigation again, I would ask different questions. I would be more curious. I would ask questions that helped me repaint how they were playing the game rather than keeping score of what they were or weren’t doing. Clearly that person did something, consciously or unconsciously. But to prevent it from happening again, I need to discover what that is. And to do that, I need to ask different questions.