Preoccupation with failure: The organisation complacent with success, and workers assume ‘each day will be a bad day’. The organisation rewards employees for self-reporting errors. Reluctance to simplify interpretations: Employees are rewarded for questioning assumptions and for being sceptical of received wisdom. At Deepwater Horizon, for instance, more engineers and managers may have raised concerns about the poor quality of the cement and asked for further tests. Sensitivity to operations: Team members continue to communicate and interact, to update their understanding of the situation at
Preoccupation with failure: The organisation complacent with success, and workers assume ‘each day will be a bad day’. The organisation rewards employees for self-reporting errors. Reluctance to simplify interpretations: Employees are rewarded for questioning assumptions and for being sceptical of received wisdom. At Deepwater Horizon, for instance, more engineers and managers may have raised concerns about the poor quality of the cement and asked for further tests. Sensitivity to operations: Team members continue to communicate and interact, to update their understanding of the situation at hand and search for the root causes of anomalies. On Deepwater Horizon, the rig staff should have been more curious about the anomalous pressure tests, rather than accepting the first explanation. Commitment to resilience: Building the necessary knowledge and resources to bounce back after error occurs, including regular ‘pre-mortems’ and regular discussions of near misses. Long before the Deepwater Horizon explosion, BP might have examined the underlying organisational factors leading to previous, less serious accidents, and ensured all team members were adequately prepared to deal with a blowout. Deference to expertise: This relates to the importance of communication between ranks of the hierarchy, and the intellectual humility of those at the top. Executives need to trust the people on the ground. Toyota and NASA, for instance, both failed to heed the concerns of engineers; similar...
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