Commander's Intent

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Finishing

tkern@convergentperformance.com (Jefe, Global War On Error) — Sat, 30 Jan 2010 14:24:00 +0000

Talking about finishing seems vaguely inappropriate this time of year when everyone is using the turn of the New Year to set new goals and begin new courses of action. But a couple of observations over the past holiday season brought the subject forward for consideration.

The first was the abnormally large number of college and professional football teams that folded like a house of cards under pressure during the final days and weeks of the 2009 season. Out of respect, I won’t name the teams, but living just south of Denver, one Orange and Blue clan comes to mind. I don’t use the word “quitters” very often, but I’m not able to come up with a better term to describe what I witnessed down the stretch of the 2009 season, when several college and professional teams seemed to lie down in front of the competition.

When it comes to finishing things, I live in a glass house, so the stone I throw shatters my world as well. Like many of you, I use the New Year to set new goals and adjust my course. Each January, as I write my latest New Year’s goals, I take a look back at how I performed on the previous year’s objectives. This year I discovered I had achieved just one of eight goals I set for 2009 – and even that one – which was finishing my new book Blue Threat - was a two time “rollover” from 2007.

It’s not so much that I mind not achieving every goal I set. If I did I would be probably be setting my goals too low, but 1 of 8 is a .125 batting average, and no one stays in the big leagues long with that kind of performance. So my big questions is “WHY?” Why do good athletic teams fade down the stretch? Why am I batting .125 on well thought out and presumably achievable goals? Why don’t people finish well?

At the risk of mixing too many sports metaphors, let’s turn to baseball, or more specifically to two moments in professional baseball history. It was the fifth inning of Game 5 of the 1968 World Series, and my beloved Detroit Tigers were down three games to one to the St. Louis Cardinals, when speedster Lou Brock decided he did not need to slide at home plate when trying to score from second base. Tiger catcher Bill Freehan took the throw, blocked home plate, and the fastest man in baseball was called out as he tried to dance around the tag. Detroit won by scoring three runs in the seventh inning, and went on to take the last two games to win the Series.

Fast forward two years to the 1970 Major League All Star game – a meaningless competition to showcase the game’s best players. With the score tied 4-4 in the seventh. Pete Rose is on second base when Jim Hickman lined a single to center field. Amos Otis fielded the ball cleanly and came up throwing. As Rose rounded third, Coach Leo Durocher waved him home at full speed. As Rose neared home plate, he started to crouch for his patented head first slide, but seeing the catcher come up the third base line to block his slide, Rose changed his tactics and crashed headlong and under full power into Fosse, dislocating Fosse’s shoulder – an injury the Cleveland Indians’ catcher would never fully recover from. The umpire signaled “safe” (the throw went over Fosse’s head) and Rose’s team won the game by one run.

Why didn’t Lou Brock slide during a critical game of the World Series? Why did Pete Rose intentionally collide with Ray Fosse in a meaningless All Star game? More to the point, why do some of us finish stronger, and more often than others? I know the answers lies in words like planning, perseverance, prioritization and overcoming procrastination. But it seems like there is something more elemental, but I just can’t put my finger on it. I would greatly appreciate any thoughts the readers might have on the subject. In the meantime, I am making a personal committment to a .750 completion batting average as one of my 2010 goals. I'm not betting my next month's paycheck on that one, but we need to hurry, because if the Mayans have it right, we may only have two more New Years to get it all done!

Aviation professionalism: Why we can’t go back to basics

tkern@convergentperformance.com (Jefe, Global War On Error) — Wed, 11 Nov 2009 19:26:00 +0000

Recently, we've heard a lot about a lack of professionalism in all sectors of aviation. Professional pilots landing on taxiways, drunk in the cockpit and overflying destinations while playing with their laptop computers. It has been a bad few weeks, but these high visibility outcomes are very likely just the tip of a much more dangerous iceberg.

On November 4th, FAA Administrator Randy Babbitt said “there is an extreme need to refocus on professionalism" citing the "sad example" of the crew who "lost total situational awareness" and overflew their intended destination with an airliner full of passengers. "I can't regulate professionalism," he lamented. "With everything we know about human factors, there are still those who just ignore the common-sense rules of safety." A year ago, U.S. Air Force Chief of Staff General Norton Schwartz echoed a similar concern following an embarrassing string of incidents in his organization related to nuclear weapons handling. In a speech in October 2008, General Schwartz, said "We collectively need to back a little bit toward something called compliance. We must, do the right thing and do the right thing right. That's as simple as it gets."

Administrator Babbitt and General Schwartz both point to the key aspect of this challenge and any potential solution – it revolves around personal integrity, accepting responsibility for our actions, and a willingness to hold ourselves and our peers to professional standards. But these are not simple fixes because words like integrity, responsibility and standards are not standard issue in modern society.

The way we never were

There has been a lot of discussion in aviation circles in recent weeks about a need “to get back to basics.” That won’t work.

Our society (in general) and aviation specifically, has never been really serious about compliance. We pay lip service to trite phrases like “an uncompromising commitment to safety” but then go about business as usual, with frequent errors and casual violations. The attitude seems to be “so far no harm, therefore no foul” – and no real need to change.

According to the Josephson Institute of Ethics, a non-profit think tank that has measured the ethical fitness of American youth since 1992, "the hole in the moral ozone seems to be getting bigger — each new generation is more likely to lie and cheat than the preceding one." In short, the gene pool from which we draw our pilots (and maintainers, support personnel, dispatchers, managers and executives) is in a state of moral decay. Administrator Babbitt called the recent events of unprofessional behavior "bumps in the road." But if the only fix is another call for a "return to professionalism," the road ahead will get rougher and more lethal.

The noncompliance problem is not getting better, it is getting worse. In the not too distant past, the pilot error/violation accident rate was blurred by other causes such as improper maintenance, component failure or weather. Now that the engineering and systems flaws have been aggressively addressed, the last flaw standing is the so-called “professional pilot.” To add to the problem, advances in technology have made the modern cockpit so error tolerant that a pilot can make literally hundreds of errors and commit scores of violations without serious consequence. Experience – once the great teacher – now teaches pilots that errors and violations don’t really matter. Unwittingly, we may have engineered ourselves into a culture of noncompliance.

The real reason a back to basics approach won't work is that we can’t go back to a place we have never been. If we are to seriously address the most foundational remaining cause of compromised safety, we must go forward to the basics, to create a cadre of professionals that don’t wink at noncompliance and who are willing to admit that we have some heavy lifting to do. Professional ethics is not a core skill for aviators, but it needs to be. Contrary to popular opinion, ethics is neither instinctive nor intuitive. It must be taught and learned until a common baseline is established and peer to peer accountability kicks in for real.

Although accurate self assessment and leveraging negative feedback are not core skills sets in most pilots, we all need a cold slap of reality if we hope to turn this around.

- We are not so good that an occasional violation of the sterile cockpit procedure is OK – ever
- We are not so good that we can take flight planning and preparation briefings for granted
- We are not so good that we can fly in a physiologically impaired state – either fatigued or from playing too close to the bottle to throttle time line

Maybe we are not so good – period.

Or perhaps, as a collective, we don’t have the moral fiber it will take to tackle this challenge at all - in which case, we are begging the regulator to step into our ethical vacuum. The first step must be overcoming the denial of the problem. Let’s face facts, far too many so called professionals operate on the fringes of compliance. There is a simple answer to this problem. Ethics for all - a serious train up of why compliance matters and how to engage in peer to peer empowered accountability. In the meantime, it is well past professional midnight and time for every aviator worth his or her salt to “man up,” look in the mirror, and then each other in the eye, and demand that we act like the professionals the world believes us to be.

A Shaky Alliance

tkern@convergentperformance.com (Jefe, Global War On Error) — Sat, 02 May 2009 13:56:00 +0000

Most of us live and work in a world where safety and security is primarily provided by others. Even those of us who fly airplanes, fight fires or work in other so-called high risk industries are surrounded by devices, processes, and procedures that have been developed and refined over decades to keep us safe and secure while we go about working and playing in our day to day lives. The world seems stable, so our situational awareness grows dull, and we lose our respect for things that can bite. We trust that the world will stay tame – as it always has for us up to this point. This is a shaky alliance at best, but one we grow increasingly reliant upon as we gradually lose our edge. When it goes bad, it goes bad quickly, ends badly and usually leaves a humbling epitaph.

For those of us who work and play in lower risk environments, the problem is even worse. We become so far removed from the mental possibility of having to perform at our best – we can’t comprehend that danger lurks nearby. We text as we drive, ignore dark corners of the parking lots, and allow our skills and awareness to atrophy as if tomorrow is guaranteed.

It is not.

Over the past few weeks, I have reviewed a few tragic endings where good men were overwhelmed by conditions they should have been able to handle. Out of respect for their memories, I will not go into further detail here. It is sufficient to say, that they had the training and technology to handle the situations they were put in, but when the world turned on them, they did not respond with their best - or what should have been their best based on their training and experience - and they died ingloriously. They also took others with them.

To put a somewhat finer grained analysis to this line of thinking, I believe many of us have lost the distinction between accuracy (good enough to get by) and precision (as good as I can be). Or perhaps better said, we have lost sight that precision is important in life - or worth the effort. Or maybe, in a world where competition is devalued and every kid in Little League gets a trophy - we never understood the importance or value of staying at the top of our game the first place.

In truth, striving for precision is seldom critical to either safety or success. Good enough is usually good enough. But not always, and the time of reckoning is not of our choosing. The world is not bound by any law to stay stable or safe for us or those we protect. Rogue waves – once thought to be a myth of drunken sailors – exist everywhere in our world. There are times when the alliance will be broken and we will be given one chance to respond with our best judgment and our most refined skills.

On the back side of this challenge – we will be judged.

The Janus of Close Calls: A Tale of Two Mishaps

tkern@convergentperformance.com (Jefe, Global War On Error) — Fri, 06 Feb 2009 22:41:00 +0000

By now everyone in the world has heard about the heroic actions of the Captain and crew of US Airways Flight 1549 – now simply referred to as the “Miracle on the Hudson.”

But I doubt that most readers are aware that an eerily similar accident occurred in the spring 1999 in Eastern Europe, when TransGlobal Airlines Flight 1144 experienced dual engine failure shortly after takeoff out of Chelyabinsk International Airport after flying through a flock of migrating birds. The IL–113 aircraft – a clone of the Airbus 320/319 series – was forced to ditch in Lake Ostrovo four miles off the end of the Runway 33. The aircraft was successfully brought to rest in the lake and initially stayed afloat for about twenty minutes, but the pilot’s failure to activate the pre-ditching switch on the overhead panel resulted in the aircraft’s outflow valves remaining open, eventually sinking the aircraft before help could arrive and resulting in the drowning and exposure deaths of 78 passengers and all five members of the flight crew. Forty three passengers survived in emergency and make shift life rafts until they were rescued by fishing boats only moments after the aircraft sank.

In the subsequent investigation by the Eastern European Aviation Investigation Board (EEAIB), multiple factors were identified as contributing causal factors including (1) poorly designed procedures that required the pilots to go deep into a confusing automated checklist to find the emergency procedure that required the pre-ditching switch activation, and (2) the failure of TransGlobal Airlines to adequately train emergency ditching procedures in the simulator. While these factors were contributory, the proximate causal factor was pilot error. In a statement issued from the EEAIB lead investigator, the Captain was singled out as “being put in a very difficult situation, but one that was survivable for all on board, if the procedures had been followed.” The local prosecutor stated that he would have seriously considered charging the Captain with manslaughter had he survived, and was now looking at the potential culpability of the airline and aircraft manufacturer. "With a tragedy of this magnitude, someone has to be held accountable," the prosecutor said.

In both of these cases (if the NTSB early reports on Flight 1549 are accurate), the pilots failed to activate the "ditching switch" prior to a water landing. The major difference between these two accidents was not the skill or expertise of the Captain or crew, but rather the circumstantial factors that surrounded them. In one case, rescuers were on the scene in a matter of minutes, in the other, they could not reach the aircraft until it went under.

Another major difference is that one mishap actually occurred and the other is purely the work of my imagination. There is no TransGlobal Airlines, IL-113, EEAIB, Lake Ostrovo or Runway 33 at Chelyabinsk. This was written merely to prove a very important point about performance and lessons learned. Outcomes should not be used to evaluate our need to improve or make changes. Please understand that this is not intended to take anything away from the stellar crew of Flight 1514. It is intended to cut through the media fueled hype to take advantage of some free lessons.

In Roman mythology, Janus is the god of gates, doors, beginnings and endings. He is typically seen as having two faces looking in opposite directions, representing moments of choice. The lessons of Flight 1549 will take time to sort themselves out but had it ended differently, the drum for “someone to be held accountable” would be beating loudly and the FAA would be holding hearings on pending rulemaking. Let’s not be blinded by success or failure in our search for opportunities to improve. If checklist modifications and/or training improvement opportunities come out of this recent success – we have two great stories to tell.

So let me summarize this flight of fancy with three main points. First, life itself a mission simulator. Second, free lessons are there for the taking every day and everywhere if we will just look for them and not be blinded by outcome bias, and finally, not all mandates for improvement need to be written in blood.

By the way, nice job Captain Sullenberger and crew.

Freedom of a Locked Room

tkern@convergentperformance.com (Jefe, Global War On Error) — Fri, 19 Dec 2008 22:13:00 +0000

I picked this short article up yesterday and will use it to leverage a short discussion on compliance, judgment, and the difference between the terms capable and qualified. Here it is:

Pilot Tells Passengers 'I'm Not Qualified to Land Plane'
Thursday, December 18, 2008

A pilot with more than 30 years experience was forced to turn his plane around — because he was not qualified to land in fog, an airline confirmed Thursday. Passengers on the 8:45 AM Flybe flight to Paris were just minutes away from landing at their destination when they were told they would have to go all the way back to Cardiff, England.

One passenger from Bristol missed a job interview in France because of the incident. Cassandra Grant explained: "Twenty minutes outside Paris, the captain said, 'Unfortunately I'm not qualified to land the plane in Paris. They are asking for a level two qualification and I only have a level five. We'll have to fly back.'"

A spokeswoman for the airline said Flybe, a low-cost airline, backed the pilot's decision "100 percent." He had recently switched from flying a Bombardier Q300 to a Bombardier Q400 and has not completed the "requisite low-visibility training," she said. The dense fog covering Charles de Gaulle airport had not been there when the flight took off, she added. The plane was already three hours late due to bad weather in Wales. The pilot's situation is "quite unusual but probably not unheard of," according to the Civil Aviation Authority.

The obvious slant of this article – and the initial reaction from many readers – is “What kind of pilot with 30 years of experience can’t land in low visibility conditions?” The key to answering this question lies in defining the difference between what an individual is capable of doing, and what he is formally qualified to do.

Capabilities > Qualifications = Discipline and Compliance

There are many times when your capabilities will exceed your qualifications. I suspect this was likely the case with the airline Captain in this article. Although frustrating, this was a non-decision for the pilot. The decision was made for him by policy. Unfortunately, not everyone has the level of maturity or understanding to see the world though the simple but powerful lens of compliance.

Individuals who have this type of uncompromising personal and professional discipline operate with purpose and clarity – what I often call the “freedom of a locked room.” Absent an emergency situation, the rules make the decision for you, as well as protecting you from the second guessing of armchair quarterbacks operating at groundspeed zero. Compliance is the link between good policy and safe mission accomplishment. There is no need to ponder unauthorized options based on what your physical skill set might or might not be on any given day. In an ironic twist to the angle of this article – a less professional airman might have flown the approach into Paris and made the landing.

Qualifications > Capabilities = Courage and Judgment

But there are also times when our qualifications exceed our capabilities – and this is a much more difficult test of professionalism. Let’s assume for the moment that this Captain was qualified to fly to the lower visibility minimums, but was having difficulty flying a stabilized approach on this particular day due to any one of a hundred factors. Would he try to will the aircraft to the ground by continuing an unstabilized approach because his qualifications said he should be able to fly it – or execute a missed approach and proceed to an alternate based on his subjective evaluation of his limited abilities on this day?

Qualification levels are fixed sums – coldly objective, they not affected by mission or peer pressures or the urgency of the moment. Or at least they shouldn't be. Capabilities on the other hand, are subjective, and by definition can be altered by different states of personal readiness (physiological or psychological) or internal or external pressures to perform. Accurately ascertaining our capability level in real time is true connoisseurship, and the decision to admit when personal proficiency is the limiting factor is one of the most distinguishing marks of a true pro.

What kind of pilot tells his passengers he “can’t land the plane?” Whether the decision is based on professional discipline, compliance or personal self-awareness, the answer is the same - a professional one. Well done, Captain.

The Gift of Borrowed Time

tkern@convergentperformance.com (Jefe, Global War On Error) — Wed, 10 Dec 2008 21:34:00 +0000

I let yesterday pass without comment, just like the 9,131 days that preceded it since 9 Dec 1983. On that memorable date 25 years ago yesterday, I was at the controls of a KC-135A air refueling tanker and was involved in a human error induced mid-air collision with an E-3 AWACs with a call sign of Sentry 99. Without going into grisly detail - miscommunication, poor risk management, oversized egos and an inexperienced 2nd Lieutenant with less than 500 hours flying time (that would be me) combined into a sequence of events that put two very large, fast moving aircraft at the same exact coordinates of time and space. It was a severe collision that ripped large pieces off of both aircraft. It is no exaggeration to state that it was an event no one should have survived. Yet we all did. For some unknown – and perhaps unknowable – reason, I was spared from an event that should have taken my life.

From my perspective, I have lived on borrowed time since that moment.

Only from this side of the last 25 years can I gauge the magnitude of this gift. Sons that would never have been born, achievements that would have never been realized, love and life that would have never been experienced – all turned on that 11 seconds of metal on metal over the skies of the Persian Gulf.

In 1898, The English Dialect Dictionary defined the phrase borrowed time this way. "A man who lives on borrowed time lives on trespass-ground." To me this means that those of us whose time on earth has been extended through no fault of our own, need to earn our keep.

I have had one or two other near death experiences since then, but none quite so spectacular. My quest since that fateful day has been to discover and fulfill the reason for this gift and to “pay my way forward.” I’m not sure what this experience might mean to others, but I do see a difference between those who see their time on earth as a right of birth vs. a gift. I have no such burden of expectation that life owes me anything. For me, it will always be the other way around and for that clarity and every future moment, I am grateful.

Compliance – Seldom simple and never easy

tkern@convergentperformance.com (Jefe, Global War On Error) — Fri, 14 Nov 2008 22:34:00 +0000

You would have to be marooned on Mars not to realize that the United States Air Force has gone through some tough times lately (see previous posts “Crime and Punishment” and “Early Onset Alzheimer’s: The Air Force at 60”), but last month the new USAF leadership gave us a hint on where the effort to turn the tide would begin, and to use an airman’s metaphor, it was a precision guided bomb delivered on target.

The weapon – compliance.

The target – front line operators and maintainers.

In a speech to US Air Force personnel at Joint Air Base Balad (Iraq) in late October, General Norton Schwartz, the new Chief of Staff said "There is one way to do the nuclear mission, and that is the Air Force way. There is one way to do aircraft and missile maintenance, and that is the Air Force way. We collectively need to back a little bit toward something called compliance. We must, as an Air Force ... do the right thing and do the right thing right. That's as simple as it gets."

Simple – maybe, put probably not.

Easy – not a chance.

Compliance has many enemies. Any attempt to oversimplify this cornerstone of performance is doomed to frustration and eventual failure. There is an old military axiom that says “Beginners chat about tactics while professionals ponder logistics.” Translation: It takes a sustained – and sustainable - effort to win a war, and it will take more than a call to arms from the new USAF Chief to make it happen. So what firepower does the Air Force need to bring to bear on this target to make the General Schwartz’s vision a reality? And what can the rest of us learn from their challenge?

Here are two ways to look deeper at the challenge of creating and sustaining a Culture of Compliance in any organization, big or small.

Compliance Prerequisite #1

Leaders and supervisors should comprehend that there are different types of non-compliance, each with a different cause, and therefore a different remedy.

It is vitally important for supervisors and commanders to comprehend the various types of non-compliance, some of which can actually be beneficial to an organization, if they take the time to learn from them. Currently, in our professional discipline courseware, we teach four distinct types of non compliance:

• Routine – frequent and unofficially condoned violations of procedures – everybody’s doin’ it, nobody cares
• Optimizing – people who have discovered truly “better ways” of getting the job done outside the lines
• Situational – “Just this once” type violations based on a unique set of circumstances
• Rogue – People who violate policies and procedures for self-gratification and to feed their egos

Routine violations lead to a dangerous condition known as the Normalization of Deviance. Rogue violations are festering wounds and decay an organization from within. But Optimizing and Situational violations can be used to create new and better processes and procedures. The bottom line is that treating all non-compliance the same points to a lack of understanding of human behavior by leadership, lost trust, and a poor command climate.

Compliance Prerequisite #2 – Compliance in “3D”

While researching my book Flight Discipline, I discovered that cultures of compliance leverage three key areas: (1) Personal and professional discipline (not to be confused with punishment), (2) diligence, and (3) attention to detail.
Greatly simplified, this 3D approach is outlined as follows:

Personal Discipline – Doing the right thing. When General Schwartz directs his airmen to “do the right thing,” this is really an issue of professional ethics – a prerequisite for voluntary compliance. Therefore, we must begin any quest to change the status quo with the understanding that voluntary compliance is not automatic for many in our society, who were brought up to believe that breaking rules is cool, and that everyone does it. Before someone can be expected to do the right thing – they must value “rightness” for its own sake.

Beyond the ethical issues, the next logistical underpinning for compliance is Attention to Detail – thoroughly accomplishing all tasks with concern for all the areas involved, no matter how small, repetitive or routine. The chilling words of Cameron Diaz to Tom Cruise in the final scene of the movie Vanilla Sky make this point clearly. Cruise, lamenting how his near perfect life was destroyed by a single momentary lapse in judgment, asks how “one little thing” could have such enormous consequences. Diaz’s reply, “Don’t you know, there is nothing bigger than the little things,” has a distinct ring of truth for all corners of our lives, personal and professional. (In order to get the full impact of this line, you really need to see the movie!) An obsession with details is a clear indicator of a high reliability organization with a commitment to compliance.

The final “D” in the 3D approach is a deceptively simple word – Diligence – which is the detail work done with concentration and care all the way until the last checklist step is done, the last part stops moving, and the handoff, debrief and paperwork is completed. In the words of Atul Gawande, M.D. in his outstanding book Better: A Surgeon’s Notes on Performance, “Diligence seems an easy and minor virtue . . . it is neither. It is both central to performance and fiendishly hard.”

Empowering discipline, detail and diligence at the level of each individual are just starting points for any organization serious about motivating and enabling their people for world class compliance. Next steps should include a scrub of policies and procedures for clarity and relevance, and a hard look at how they are trained and evaluated, as well as developing close-looped quality assurance and supervision.

There is no question that the first shot of this battle for a return to rigorous compliance was on target, and if General Schwartz was serious about this call to arms, his organization will follow up with a warfighter’s relentless pursuit of the objective on all fronts.

Small Doses of Perfection

tkern@convergentperformance.com (Jefe, Global War On Error) — Wed, 29 Oct 2008 20:45:00 +0000

I’ve been talking with a lot people lately about a hot button word - perfection.

Toyota’s vaunted quality system claims to seek it, some religions claim it is unattainable, and most of us don’t think about it much. In a time stressed world faced with declining resources, “good enough” seems to be a common – if seldom stated - mantra. Who’s got time to think about perfection?

Fortunately, thinking about improvement is my job, or I probably wouldn’t have time either. As one who spends considerable time and money researching and applying new human performance concepts, I know that there is no such thing as the status quo. You are either getting better at something – or you are getting worse. And since I don’t like to begin anything with a presumption of ineptitude (especially when thinking about my own performance) – I start most days with the attitude that I am good, need to be better, want to be great and should strive for perfection. But how?

As I began to seriously engage with the subject, it became clear that the two biggest obstacles to seeking perfection are 1) the inability to picture what it looks like, and 2) the commonly held fallacy that perfection is unattainable. It turns out that neither of these obstacles are insurmountable.

I’ve started a bit of a strange exercise lately to work on these challenges. To test the idea that "thinking perfect" might improve my performance, I took one of the most mundane activities I do every day - the ten minute drive to and from work - and began a quest to do it perfectly. Not just flawlessly - which means error free, but perfectly - which means . . . what?

So here was the first challenge - what would a perfect drive to work look like? This seemingly simple question proved not to be so simple.

On Day 1, my view of the perfect drive was pretty straight forward - don’t hit the curb when backing out of the driveway, stop at all the stop signs, follow the speed limit, stay in my lane, arrive on time.

By Day 3, I had added a few items: conserve fuel, avoid following too close, time the two traffic lights to minimize delays.

By Day 5, some rather interesting new opportunities began to present themselves. In addition to driving more safely and efficiently, I began to look for opportunities to practice proactive courtesy, spread good will, wave, smile, help someone else start their day a little better. I was beginning to view perfection from a systems angle.

By Day 7 (the day of this posting) I was looking at parking strategies to minimize the chance of a dinged door and to allow others to get in and out of our parking lot more easily. I have started scouting alternative routes for traffic congestion and bad weather days.

You can see where this is going. My insights on perfection have grown from the little world of my F-250 cab to a part of the larger system, where my random acts of driving and parking courtesy might have some type of ripple effect beyond my previously misperceived sphere of impact or influence. I'm better, and just maybe, the micro-world around me is too.

From my initial starting point on Day 1, I could not see the same performance landscape as I did on Day 3. Likewise on Days 5 and 7, a new horizon of performance revealed itself. The insight was that - in least in my little test - perfection revealed itself in small bits. As one piece of improved performance was achieved, the next beckons. My emerging vision of perfection - much like our physical vision – improves the closer you get to the object of your efforts. What was started a silly test of a concept, has become effortless efficiency.

There have been other ancillary benefits to this little experiment. Upon arrival at my destination – be that work or home - I am thinking about how to do things better and this mindset carries across the home-work threshold. In previous days, I would reflect or project on the worries of the day and often arrive distracted or occasionally even morose. No longer. An odd but nice side effect.

If this whole exercise sounds weird - it is because it is weird. But the point here is that in a resource strapped world, I have found a way to grow without spending a dollar or adding a minute to my schedule. And along the way I have gained an insight or two through a self discovered truth - the only kind that really works for a skeptic like me.

I've taken to task the twin demons of complacency and perceived competence - and beaten them back a bit, at least in this small corner of my life arena. It appears that perfection is certainly approachable and perhaps even attainable in small pieces -- two minutes today, three tomorrow. More to follow.

Small Business Rage – One CEO’s Perspective

tkern@convergentperformance.com (Jefe, Global War On Error) — Fri, 10 Oct 2008 18:14:00 +0000

I don’t get mad very often. It clouds my personal and professional judgment. But I’m mad right now. I’m the CEO and a founding partner of Convergent Performance, LLC – a veteran-owned small business providing training to those who protect the rest of America – U. S. Marines, Coast Guard search and rescue operators, wildland firefighters, doctors, nurses and even long haul truck drivers who pull hazardous materials over our highways. Our products and services make their jobs safer and their people more productive. Every one of our 20 plus employees clearly understands both our business and humanitarian mission. We work hard and take our jobs seriously, and none of us have a golden parachute should our efforts fail.

Five years ago, my partners and I left secure government and corporate jobs, borrowed a million dollars, and armed with little more than some good ideas and a Spartan work ethic, started our own business. Three years later, we had paid off our loan, added a couple of dozen good paying positions to our payroll and have since plowed every available penny into growing our product line, infrastructure, quality, employee benefits and services.

We do not outsource any of our work, because we believe in American small business. Even though we could save 20% on printing costs if we shipped it overseas, we contract our work to a small businessman who runs his print shop out of a cinderblock building in Bend, Oregon. Even though we could save over 25% on software development if we outsourced it to India or Bangladesh, we contract this work to another veteran-owned small business in Woodbridge, Virginia. I know and trust these owners. They have our interests at heart as I do theirs. The point is that American small business is tightly intertwined and moves forward with symbiotic relationships like these. Economic downtimes hit small business hard – and even before the meltdown, many of my competitors were laying off good people. Now the future is dark indeed – and even a well planned and well run business like ours must make some very difficult decisions based on an entirely new playing field.

But in spite of all this, I wouldn’t take a government “bailout” (handout, hand up, work out, or whatever other bogus cliché gets invented) if Secretary Paulson hand-delivered gold bullion to my 300 square foot office that I vacuum myself. If we can’t make a go of this, we are not about to ask the rest of America to pay for our lack of foresight or mistakes. It violates the ethos of entrepreneurship – you make it on your own merits. Small businessmen are a proud, hardscrabble lot. If we fail, we will find other ways to make our mortgage payments and get our kids through college.

It is clear that the double whammy of a severe recession and the coming massive tax burden creates a treacherous future for American companies like ours. But how we will react to this challenge is the difference between people like us and the financier class that run the mega-corporations. In the midst of this storm, when our company could be pulling in our sails, laying off employees or asking for a part of the government handout – we took a new bold risk. After long deliberations on how the economy might drive our future, we hired a world class expert last week to create a new business line called “Reinventing Ethics and Leadership in American Business and Government.” It will become a training, assessment, reporting and accountability system built around the premise that personal accountability and sound character still count. The lessons from this recent disaster need to encompass more than a few public hangings of corporate execs and a couple dozen new business books.

Leaders of character were once the hallmark of what made American business and government the envy of the world, at least before the train jumped the tracks over the past few decades. The corner on the quality movement moved to Japan, our production jobs moved to where ever the lowest priced workforce could be found and American big business types lawyered up and demanded golden parachutes before even accepting a position. The time for mandatory accountability and a new code of business conduct has come. We must start with a new model for the next generation of business leaders. At Convergent, we are putting our money (not the taxpayers') where our mouth is and weighing in to be a part of the solution to a problem we were not a part of creating. But if we build it – will they come?

Every supervisor, manager and executive in each company that receives a dime of taxpayer money in this bailout – as well as every regulator that oversees how they spend it – should be required to take this ethics and leadership training and pass the end of course exam – since they failed the recent real world test so badly. But it is unlikely that government regulators and big business types will find the few dollars that it would take to achieve the cultural change that is so badly needed. After all, they have multi-million dollar executive retreats, lobbyists and legal fees to think about. But build it we will, and market it, and service it and all of the other things good businesses do - and hope to turn a profit.

Small businessmen in America are walking the wire without a net, but we’re used to it. What we are not used to is watching the dollars that would find their way into our customers' supply chain given to rich dudes who couldn’t manage their own businesses. Even worse, we object to being personally and business taxed out of existence to prop them up to make more mistakes. But at the final turn of this road, we will remain fluid and look for opportunities to turn lemons into lemonade – at least until the corporate bank account hits zero - it’s what we do.

Tony Kern, Ed. D.
CEO, Convergent Performance, LLC

Another Technology Tailchase Against Human Error

tkern@convergentperformance.com (Jefe, Global War On Error) — Thu, 25 Sep 2008 21:53:00 +0000

Another Technology Tail Chase

In an article by the Associated Press today (GAO: Risk of runway collision still high” by Joan Lowy), “the GAO reported that the rate of close calls on airport runways is up over last year and the risk of a collision is high, according to Gerald Dillingham, the General Accountability Office's top expert on aviation safety.”

In testimony to a House panel, Mr. Dillingham said that even though the Federal Aviation Administration "has given a higher priority to runway safety" the rate of serious incidents — measured by number of incidents per 1 million takeoffs and landings — has increased about 10%, Dillingham told the House transportation committee's aviation subcommittee. Both the number and rate of all types of runway incursions are also are up, Dillingham said.

The FAA, responsible for oversight of the airline safety programs has proposed three technology solutions to this human error problem:

• Installation of electronic mapping equipment in the cockpits of 80 airliners, belonging to four airlines, that will provide the position of the aircraft while on the ground
• Installation of runway status lights over the next three years at 21 airports to signal pilots when a runway is safe to enter or cross, and in the long term,
• Plans for a satellite-based map system on all commercial airliners that will show pilots the location of their aircraft in the air and on the ground, as well as the positions of other planes.

Yikes - another plan to spend tens of millions of taxpayer dollars in an attempt to find technological solutions for people problems. Don’t get me wrong, I’m for safety widgets and gadgets where they make sense, but they must always be complemented to the maximum extent with the human side of the error chain.

Everyone seems to agree, but we still burn incense at the alter of the techno gods instead of confronting the challenge head on (pun intended).

Later in the same article referenced above, “GAO expert Dillingham and FAA Chief Operating Officer Hank Krakowski agreed that mistakes by pilots and controllers rather than technology problems were key factors in many incursions.”

Really? If so, why are we not getting serious – really serious – about error control training and personal responsibility? The problem here lies in the mistaken belief that the major airline training programs are already doing all they can to educate and train pilots against human error.

There is much more that can and should be done. Outdated programs such as Crew Resource Management (CRM) and Threat and Error Management (TEM) are required for airline pilots on a recurring basis, but these classroom group hug sessions have changed very little since the late 1980s when they were first offered, and pale in comparison to the rigorous error control training currently required in some sectors of the US military. Compared to what the Marines have done with their Global War on Error initiative, traditional airline human factors programs have become polished antiques.

It used to be that the military turned to the airlines to find industry best practices. Perhaps now it is time for the regulator (FAA) and oversight agencies (GAO and NTSB) to politely suggest (or demand?) that the Part 121 air cariers look at the highly sophisticated error control programs currently available to confront this serious problem.

NTSB Chairman Mark Rosenker told The Associated Press he applauds the steps the FAA has taken to reduce runway accidents but worries they may not be enough to head off a disaster. He goes on to say ‘we have been very close in recent years to seeing a terrible collision . . . very fortunate that the airmanship and the seconds in which pilots have had to react have averted potentially catastrophic results.”

So if human error is the problem – and fast thinking pilots are the best solution, why are we – once again - putting all our eggs in the technology basket when the answer is much simpler, far less expensive and far more effective?

Hurricane Survivors and Train Wrecks

tkern@convergentperformance.com (Jefe, Global War On Error) — Mon, 15 Sep 2008 21:59:00 +0000

This past week has seen tragedy strike Americans on two coasts; one the result of a natural disaster, Hurricane Ike; and the other man made, the head on collision between a Los Angeles Metrolink commuter train and a freight train near Simi Valley, California. Interestingly, the grim reaper’s toll is nearly the same for both. As we sort through the rubble in a search for lessons, a few items stand out. In one particularly interesting story, one brave but foolish soul found his 15 minutes of fame by being the only person in Surfside Beach, Texas who defied authorities and refused to evacuate before the oncoming hurricane. Sixty-seven year old Ray Wilkinson, a former Marine and retired carpenter refused the mandatory evacuation order from police and drank the night away as the winds and rain howled. Authorities found him Saturday morning after the storm – safe and stone drunk. When interviewed after the event, he stated “I consider myself to be stupid.” No argument there.

Further west, there was little or no warning for the victims of the worst train crash in the US since 1993. Early words from the investigation hint definitively at human error as the primary cause, with two possible threads emerging in the early investigation. The first is that recorded audio tapes from the Metrolink train seem to indicate that the required crew coordination calls between the engineer and conductor did not take place on the two signals prior to the crash. If this is indeed what occurred, it is a simple case of non-compliance with regulations and procedures. Another lead said that two teenagers reported receiving a text message from the engineer just moments before the crash, possibly indicating the engineer was not paying full attention to the task at hand. Both are errors of personal origin and both can be trained (no pun intended) out of existence. But it is unlikely that we will do so. I fully expect we will once again hide behind the oft heard refrain that "to err is human." In this case - as in many similar cases where the outcome of an avoidable mistake results in an immeasurable toll on innocent victims - to err is inhuman.

Already there are cries for technology to save the day and prevent this type of error from ever occurring again. If the past is prologue, whomever markets the “Positive Train Control” system, which supposedly stops a train if a signal is disobeyed by the humans, is about to get a new contract. But technology is never the complete answer, and I seriously doubt it will be here. Don’t get me wrong, I am all for gadgets that makes things safer, but my experience tells me that if you make something foolproof today – tomorrow someone will give birth to a more sophisticated fool. And while this is a good way to keep the wheels of the "safety-industrial complex" turning, there is a simpler and far more effective measure we can and should be taking. More on that in a moment.

So my point in bringing these two tragedies together on the same page is simply this; I’m not sure that Mr Wilkinson, currently Surfside Beach’s most famous resident, isn’t the key to understanding the human dynamic in both of these events. While I don’t advocate his Jack Daniels approach to problem solving, he at least recognizes his own human limitations and has found a way to deal with them. As the NTSB and government officials work out the details of the Metrolink disaster, perhaps someone will realize our current collective limitations in understanding the nature of error and advocate getting serious about training to control these events.

The science is available and the means are here for such error control programs to become a part of every high risk employees’ training. But that is not the typical American response to large scale disasters. Why make people learn when we can build a machine so we don’t have to think? If the past is a guide, the response to this tragedy will be to (1) blame the dead engineer, (2) sue the hell out of Metrolink, and (3) put some new technology in place to prevent this specific event from occurring again at this specific location, and (4) claim the problem is fixed . . . until the next time.

But we can do better. Error control will never be engineered out of existence with technology. Human error is a force of nature, and just like the hurricane it can be studied, its movements tracked and predicted. To be certain, there are places where technology can help, but at the end of the day error is an individual phenomena that can be measured, understood and predicted. Predictable is preventable.

The forgotten key to error control is personal responsibility and accountability. As simple as it sounds, we can teach people to make less errors. This cannot be done in the traditional sense of training against someone’s last mistake, but rather through a systemic approach to comprehending how and why we get unintended consequences from our well intended decisions and actions. It is no longer enough to train people to do things right – they must learn why they do things wrong, and these are two very different skill sets. If you want to know more about how this is being successfully accomplished today, please contact me at tony@convergentperformance.com.

In Praise of Plan C

tkern@convergentperformance.com (Jefe, Global War On Error) — Fri, 12 Sep 2008 17:21:00 +0000

Last week, NASA Administrator Michael Griffin was embarrassed by a leaked email about his frustration with the United States plan to retire the Space Shuttle fleet without a good backup plan for manning the International Space Station. If the current plans remain intact, the US will not have its own launch vehicle during the period of time between the current Shuttle fleet’s retirement in 2010 and the new Orion Crew Exploration Vehicle fleet launch – estimated in 2015. It seems during the great thaw in post-Cold War US-Russo relations, we put all our space eggs in a matryoshka (Russian nesting doll). Our Plan B was to purchase space on Russian Soyuz launches to keep up our end of the bargain for manning the International Space Station. When Russian tanks rolled into Georgia last month and President Dmitry Medvedev made statements about not fearing the return of the Cold War, that plan hit a small snag. Administrator Griffin’s email pointed to the now obvious fact that there was no Plan C, where he went on to say, "In a rational world, we would have been allowed to pick a Shuttle retirement date to be consistent with Ares/Orion availability, we would have been asked to deploy Ares/Orion as early as possible and we would have been provided the necessary budget to make it so.”

Would have, could have, should have - 20/20 hindsight is of little practical value, assuming no nearby portal through the time/space continuum. But a Plan C – that is something we can use in the here and now.

A more personal example:

Back when my skin was green and baggy and my mind, body and soul were owned by the U.S. Air Force, we used to have a fancy name for Plan C – “tertiary.” The North American Encarta Dictionary defines tertiary as “third in degree, order, place, or importance” – Plan C. I am embarrassed to say that the one time in my life I really needed to know the meaning of this adjective, I was running behind on my way to a Saturday morning B-1B bomber training launch, doomed to playing catch up by a teenage cashier at the Seven Eleven who broke open his roll of nickels and scattered them on the floor while attempting to make change for $1.39 of rot gut coffee. As I rushed through Squadron Operations on my way to the jet that fall morning, I was perplexed by a strange note, neatly handwritten on the bottom of our mission flight schedule that read cryptically “usafa flyby tertiary.” Quickly turning to the daily operations officer – I inquired “What the hell does this mean?” “Nothing really,” he replied, “there is an Air Force football game we are supporting with a flyby in Colorado Springs, but both the primary and secondary aircraft have launched and are in the green – forget about it, the chances of you guys getting a call are next to nil.” Good enough for me, "let’s roll," I said to my intrepid crew mates. You can guess the rest . . . or at least part of it.

Half way through our low level route in western Kansas we got a call from a Flight Service Station on Guard frequency that asked we abort the route and contact our Command Post. The little voice in my head started his evil and foreboding “I told you so” chuckle. In short order, we were told that we were to proceed with greatest haste to make an 1158 Mountain Time flyover in accordance with the “wing flyover plan” – a document we had never heard of and did not possess. (We were later to learn that there were only two copies of said document.) These were minor hurdles for high steppers like us. With real time precision communications and precise execution, we swept the wings back and got clearance for a supersonic run to central Colorado, where if we could keep our speed up, we would arrive 40 seconds early – plenty of time to visually ID the stadium. To make a long story readable, we flew over the stadium in the wrong direction at the wrong altitude (not too high) and wrong airspeed (not too slow), and most importantly, wrong decibel level (not too quiet). Upon return to base, there was another note at the Ops desk that said simply “Major Kern, Call Wing Commander,” which led to a memorable and unpleasant conversation. To this day, I occasionally hear Falcon Fans remark of the day that “B-1 bomber did an insane flyby.” I never let on that I know the culprit. To hear the story told from ground level, cadets cheered, civilians screamed in fear, babies cried, and if I got the story correct from a third hand source, a few windows broke and a horse may have died off base. This was not cool – it was unprofessional – and it was directly the result of not comprehending the need for an actionable Plan C.

In a world ruled increasingly by dynamic change – Plan B is highly likely to become Plan A without much advance warning – and the word “tertiary” has real significance. Plan accordingly.

Crime and Punishment

tkern@convergentperformance.com (Jefe, Global War On Error) — Mon, 09 Jun 2008 21:28:00 +0000

The big news last week was the unanticipated firing of the top leadership of the U.S. Air Force. Chief of Staff Gen. Mike Moseley and Secretary Michael Wynne were forced to resign following a report on the Air Force’s problems handling nuclear weapons. Now, I would bet my next month’s Air Force retirement check that neither Mr. Moseley nor Mr. Wynne has ever actually “handled” nuclear weapons, especially not the ones in question. (Actual fondling of nuclear weapons is a metaphysical event. For example, did you know that the nosecone of a nuclear short range attack missile is squishy, like the stuff that they used to make Stretch Armstrong out of? But I digress . . .) So why fire these guys? Of course we’ve heard the answers about leadership accountability, and where the buck stops, etc., but in reality – these guys were fired to send a message. There will likely be lots of reminiscing during their post-Air Force consulting careers about “being in the wrong place at the wrong time.” Yet this latest round of "accountability firings" does beg the question, “is it fair to fire a leader for the unknown actions of his or her subordinates?" Perhaps the better question is "Does it work to improve the organization?"

Leadership decisions about “accountability” always fascinate me, and as a retired Air Force officer who still bleeds blue, this one enticed me more than most. In fact, it got me to thinking about things like crime and punishment and something called a “just culture.” It’s not that firing people doesn’t work to change behavior. You can bet your bottom dollar that the Air Force is being pretty damn careful with their nukes right now (just like we used to ALL the time – see “The Air Force at 60” post). The real problem with the blame game is that it only works for a while.

On Organizational Culture, Climate and Weather

This situation reminds me of a small blackboard we used to have on the wall in a B-1 squadron I once served in that said “Don’t be the next one caught doing ________.” From time to time something new would appear in the blank space. It might be anything from sloppy paperwork to letting your night landing currency expire. The point was, it was a bellwether of where our diminutive volcanic squadron commander was likely to erupt next. If organizational culture is defined as the enduring values of an organization, and organizational climate is a shorter term phenomenon, than what we were forecasting was the organizational weather – which could change quite rapidly and with little warning. The point here is that firing leadership only really changes the organizational weather – not the climate or culture. Right now, the Air Force has a metaphorical blackboard that says “Don’t be the next one caught mishandling nukes – or tolerating those who do.” But before long, that blackboard will change to the next hot topic. You see, no one really believes that firing leaders works for long. But executives come under tremendous pressure to hold someone accountable after a bad outcome. While no one advocates outcomes based punishment, nearly everyone practices it when the pressure gets intense to “do something.”

Out with the blame game – in with ?

One reaction to this problem has been the creation of something referred to as a “just culture” approach. A just culture advocates defining “clearly acceptable versus unacceptable behavior” and even provides some means for making these difficult determinations. But when we get to the point where life and death, and even more importantly – executive careers – are on the line, this system buckles under the white hot light of public scrutiny and the demands for “someone to pay for their mistakes.” Further down the spectrum are those for whom personal accountability is simply unacceptable. For example, inside the current patient safety debate there is serious discussion of whether individual human error even exists.

The real problem with all of this polarization on accountability is that it has caused the world to go brain dead on the topic of personal responsibility. We have allowed this discussion to become an either-or debate between outcome based punishment and the new enlightenment that shifts blame to the “system.” There are significant problems with both approaches when you try to actually apply them in the real world.

The problem with the crime and punishment approach is that it is a usually fool’s errand if the goal is to provide long term solutions to real problems. The problem with the systems safety approach is that is typically requires significant change to fix the systemic issues, if the culprit really is systemic at all – and to paraphrase the words of Bobby Kennedy, everyone is for progress, but progress requires change, and change has many enemies.

Both of these approaches are the metaphorical equivalent of kicking a door down when you have the keys to the lock. There is a third option of personal accountability through self awareness and individual error control. I continue to practice, believe and advocate that most human error can be predicted and prevented by the individuals who make them – if they are appropriately prepared to recognize their personal error patterns and respond to available cues. Before we throw good leaders under the train, or give up on the idea of personal accountability and professional reliability all together – let’s give self control a serious look.

The Evolution of Convergent and the Global War on Error

tkern@convergentperformance.com (Jefe, Global War On Error) — Fri, 30 May 2008 14:28:00 +0000

Dear Valued Customers, Neighbors and Friends,

I am thrilled to announce a major milestone in our company’s evolution. Effective Monday, June 2nd 2008 – Convergent Knowledge Solutions, LLC will become Convergent Performance, LLC. The purpose of this letter is to help you understand that this event marks far more than a name change and new website (www.convergentperformance.com), but also a dramatic enhancement in our ability to serve our current and future customers.

As we enter our 6th year in business, we are ready to respond to new requests from our stakeholders – customers who asked us to (1) increase the scope and breadth of our product and service line into new markets and (2) enhance the current product line through multiple modes of delivery such as web-based learning, videos, podcasts, live workshops and train-the-trainer programs. We listened.

Make no mistake – Convergent remains clearly focused on our “one big thing” – empowerment of individuals to take control of their performance. More than ever before, this core competency runs through every product and service we offer. We have taken this proven concept from our flagship Global War on Error® and Automation Airmanship® programs and built enhanced program offerings at the individual, team, organizational and systems levels. Key new offerings include:

· Expansion of the Global War on Error® into the Maintenance, Manufacturing, Energy, Transportation, Natural Resource Management, and First Responder industries

· Retooling of our Patient Safety products and services, focusing on culturally appropriate solutions and support for complex issues

· 500Experts™ – an exciting cultural change tool that uses appreciative inquiry techniques to capture and leverage the power of positive deviance and best practices within an organization

· Blue Threat Error Control Certification programs for Program and Project Managers, Continuous Improvement, Six Sigma, LEAN, Baldridge, Quality Control and Safety Management professionals

· Character and Ethics and Leadership seminars and workshops

· Faculty development programs for educators – teachers and administrators at the K-12 and higher education levels

Another exciting opportunity can be found on our “Partnership Opportunities” webpage, where we are seeking research and development partners to test and expand these vital new concepts into new and unconventional arenas. Download one page briefing papers or submit your own ideas to our team for consideration.

For our current customers, these changes will be transparent and require little or no action, except for a few minor details such as noting our new website and email addresses (firstname@convergentperformance.com). Our old addresses will continue to work for the time being or simply redirect you to our new sites or inbox.

Delivering a great product, superb value, exceptional service and an uplifting customer experience have made us what we are today and will continue to be cornerstones of our company. Since we do little to no advertising (one means to keep our prices low and our value high), we rely on you – our customers, neighbors and friends – to share with others who we are and what we have to offer. What you think matters greatly to us, and I look forward to hearing your thoughts on our new look, offerings and services.

Very respectfully

Tony Kern, Ed. D.
CEO, Convergent Performance, LLC
tony@convergentperformance.com 703.441.9213 (office) 540.497.1363 (cell)

Early Onset Alzheimer’s? - The Air Force at 60

tkern@convergentperformance.com (Jefe, Global War On Error) — Wed, 19 Sep 2007 15:52:00 +0000

By Tony Kern, Ed.D, Lt Col, USAF (Retired)

It seemed a bit awkward this week to see the USAF celebrating its 60th birthday while simultaneously trying to shake off one of its most embarrassing moments – the uncontrolled movement of nuclear weapons across the continent. Viewed through the long lens of military history, 60 years does not even register in the bottom of the hourglass, yet it appears to be long enough for the Air Force to have forgotten who they once were.

The Air Force was born with professional discipline in its DNA – forged with the iron fisted, take no prisoners approach of the Strategic Air Command (SAC), where uncompromising discipline was a condition of continued employment. The minimum passing grade on a doctrine test was 100% and the penalty for failing was mission decertification, several weeks of humiliating remedial study, followed by a recertification in front of the Wing Commander. SAC is no longer with us – reorganized out of existence in 1992. But somewhere between then and now professional discipline fell from favor. I’m not talking about the lite beer version of flight discipline that continues to show up in safety posters and general’s speeches, but rather the hard core professionalism where one aviator looks the other in the eye and demands peer to peer accountability.

A quick journey through the USAF’s recent history reads like a Rogues’ Gallery of high profile errors resulting in not only service-wide humiliation, but national embarrassment, including

C-5 self-induced mishap at Dover AFB
B-1B gear up landing in the Indian Ocean
F-16 friendly fire in Afghanistan, resulting in 4 dead and 18 wounded Canadian infantry
A-10 friendly fire in Iraq which killed a British soldier of the Blues and Royals Regiment
The uncontrolled transfer of nuclear weapons across the continent
Officers and aviators lawyering up and taking the UCMJ (Uniform Code of Military Justice) version of the 5th amendment

What the hell?

Perhaps, in its quest for the technological high ground, the Air Force may have lost track of one of its professional touchstones – uncompromising attention to detail and professional flight discipline. General Fogelman, the Air Force Chief of Staff sensed this in the late 1990s and began to tackle the challenge in a “Little Blue Book” of Air Force Core Values (1997 Version), where he stated:

We're entrusted with the security of our nation. The tools of our trade are lethal, and we engage in operations that involve risk to human life and untold national treasures. Because of what we do our standards must be higher . . .

But we need to go back even further to find the genetic material that the Air Force must regenerate to reclaim both its proud heritage of professional reliability – and its reputation.

Whether we venture into realms of Space in our latest vehicles, or whether we are concerned principally with overhauling our engines and loading our ordnance here on the ground, we will still be part of a vast proud mechanism which must function cleanly if it is to function at all.

The author - General Curtis Lemay.

The path forward must begin by finding this lost discipline, as well as the courage to challenge on a peer to peer level. This is more than a leadership challenge for commanders – it is a gauntlet thrown down to every living member and of this proud service, past, present and future.

General Lemay finished his quote above with five simple words – “Crank her up. Let's go.”

N=1

tkern@convergentperformance.com (Jefe, Global War On Error) — Mon, 30 Apr 2007 13:36:00 +0000

In case you missed it so far, the Global War on Error is a new way of looking at a very old problem – the disease of human error and its Grim Reaper’s toll.

For the past four decades, the cure for the disease of human error has been approached indirectly (if at all) in most of the industrialized world through a variety of efforts that can broadly lumped into the following five categories:

Blame and punish the individual
Emphasize leadership (then blame and punish the leader for failures that occur under his or her command)
Teamwork strategies to capture or contain errors through better communication
Systemic approaches that put multiple layers of protection in place to avoid or respond to errors, and most recently
Cultural approaches that focus on social factors such as trust and fairness to create a so called “just culture.”

To some extent all approaches have been effective in the short run, many are still useful, but even in a combination have only been marginally effective in addressing the challenge of human error. Experts cite the randomness and wide variability of human error present even in relatively small groups, as the reason for these meager results. These are compelling arguments made by bright and well meaning people. Every year, millions of dollars are expended to provide education and training on these subjects – and every year we look at the statistics and continue to see less than desireable results. Some small successes are reported, but on the whole, human error remains culpable for nearly 80% of failures in high risk, high reward industries.

Human performance experts continue to struggle to find a broad spectrum antibiotic to cure the human error disease. If we extend this metaphor another step, we can shed some light on why it is not working. Human error is not an infection that can be fought with a broad spectrum antibiotic – it is more like a virus that the immune system must handle from within. Although the antibiotics can help, when you’re fighting a mutating virus, every battle is an inside job, won or lost at the individual level. As we continue to search for a more effective remedy against human error – the sample size – or “N” – must eventually equal 1.

Uncommon Sense

tkern@convergentperformance.com (Jefe, Global War On Error) — Mon, 30 Apr 2007 13:08:00 +0000

Over the past few months, I have reviewed a series of military and industrial failures from a variety of settings where highly experienced and well trained teams made the most fundamental of errors with often tragic – and always embarrassing - results. These events were things like aircrews shutting down the wrong engines or inadvertently landing gear up; ships running into each other or aground in broad daylight and known waters, and project teams forgetting the most fundamental communications factors resulting in snatching corporate defeat from the jaws of victory.

In each case, the reason these highly skilled and highly trained professionals did not realize what was going on with their situation, team or equipment is because they first lost awareness of what was going on with themselves. Interestingly, and not surprisingly, the organizational response in each case was to create more procedures and training to deal with the tactical operational scenario. While this is an appropriate step in error proofing that specific sequence of events, it does little to address greater danger of lost self awareness – a far more common occurrence than we like to admit, and nearly always a precursor to lost situational awareness (SA).

Self awareness encompasses many complex variables, ranging from an accurate assessment of one’s skill and knowledge to the physiological readiness to perceive, interpret, evaluate, plan and act in a tightly coupled, real time environment. Self awareness is not “common sense” as many would have us believe. It is complex stuff – but it is also learnable stuff. To truly cut to the heart of human error, we must pull back the veil with regards to our current and dynamic state of readiness, and engage with the situation to accurately assess ourselves in a real time manner. Developing this “uncommon sense” is the reason the Global War on Error was launched. The strategic battle continues to heighten awareness of these key issues across industrial settings and around the globe. But the tactical battle is waged within each of us. How goes the fight with you?

Mystery Solved - Problem Created

tkern@convergentperformance.com (Jefe, Global War On Error) — Thu, 01 Mar 2007 14:37:00 +0000

Human Error: Problem or Mystery?

While re-reading my dog-eared copy of Steven Pinker’s How the Mind Works, I ran across an interesting insight that applies to our current war on human error. Norman Chomsky maintains that human ignorance can be roughly subdivided into two simple categories – problems and mysteries. Problems may not yet have a solution, but are generally frame-able and discussable as something that may be solved at some future point. In Pinker’s words, we may not have a full grasp of it, but we have insights.

Mysteries, on the other hand, are more magical. Mysteries continue to be beyond our grasp to shape a meaningful discussion about what any solution or explanation might look like. In truth, it is likely that given the right set of data and time to work through it; we could turn all mysteries into solvable problems. The difficulty with doing so is always managing the moment when a previously supernatural, unknowable, magical thing comes into the realm of the real and manageable.

Human error is at just such a “cusp” moment for individuals and organizations who are tired of the Reaper's toll.

One reason is that the scientists are doing their jobs, and new insights on human motivation, performance and error are being rolled out at an ever increasing rate. Just last week, I read a complete set of fully referenced articles on the scientific explanation for romantic love - yet I must confess it remains a mystery to me, but perhaps only because I could not understand the chemistry or technical jargon - a likely product of my mispent youth.

A second, and perhaps more important reason for this amazing opportunity to confront human error head on, is that human beings who have now been born and raised in the information age, are far more comfortable perceiving, acting and reacting within the torrents of data that flow by us nearly every moment of every day than members of my Baby Boomer generation.

This combination of new knowledge and better adapted human vessels sets the stage for a dramatic change in how we manage human performance. It will require the courage to dive deep into the nature and causes of general, specific and individual human error patterns and tendencies – as well as the ability to stay adaptable and flexible in the heat of battle. But the solution to human error is closer than it has ever been in the history of the human race.

In short, human error is no longer a mystery – but is still one hell of a problem. Relatively speaking, that’s a very good thing.

Breakthrough Point

tkern@convergentperformance.com (Jefe, Global War On Error) — Thu, 18 Jan 2007 16:59:00 +0000

Study hard your policies
Follow all the rules

Master your machines, my friend
Sharpen all your tools

Polish up your teamwork skills
Then turn the light within

Take the final step to excellence
When the fight for you begins

Tony Kern, Copyright 2007

Thief and Murderer: Nothing Less

tkern@convergentperformance.com (Jefe, Global War On Error) — Tue, 09 Jan 2007 20:53:00 +0000

“The will to conquer is the first condition of victory.” - Ferdinand Foch

Human error is the thief of human happiness and the slayer of dreams, careers, potential, and all too frequently – life itself. Viewing it as anything less hostile is to willfully expose your throat to the knife.

The global cost of human error is almost incomprehensible, and very few will look at the numbers without agreeing that “someone” needs to do more to prevent it. But when viewed from a personal perspective, the danger appears remote. Like many thieves and murderers, error producing conditions live among us hidden, almost invisible. We ignore the threat because most error is of the petty thief type, annoying, occasionally resulting in minor loss of productivity, but certainly not life threatening. This perception holds until the very same conditions that we have cohabitated with safely for years, suddenly manifests itself in some major way, changing our lives and those around us in tragic ways forever.

Error is a persistent thief, who will continue to steal from you until you make a conscious decision to put an end to it. Additionally, errors that result in trivial outcomes of little consequence on one occasion can suddenly and without warning result in a life or career ending result on another. People are lulled into a false sense of security because the tragic outcome has not yet occurred. Let’s put human error Lesson #1 on the table right now:

Things that have never happened before happen all the time.[i]

In the blink of an eye, the same petty thief you have grown accustomed to as a minor annoyance on the street corner becomes your worst nightmare. In hindsight, it becomes all too clear – you could have and should have seen it coming. The signs were there, the hazard was present, but you could not and would not believe it could happen to you. Those that have been though this sing a common refrain – “I had no idea this simple problem could turn so ugly so fast. This had been going on for years without serious consequence.” These individuals have fallen victim to a phenomenon known as the Normalization of Deviance, a dangerous dumbing down of our risk perception, and a subject we will discuss in depth in a later posting.
The first purpose of this weblog is to raise the alarm, to point out how prevalent and destabilizing human error is in our daily lives, as well as how quickly small errors can lead to tragedy. Human error Lesson #2:

Anything less than a conscious commitment to understanding and reducing personal error is an unconscious commitment to accepting their continuing presence and all future consequences.

Please reread the previous paragraph. Unnecessary and avoidable human error is likely the most dangerous threat to your health, family, professional development and life that you face in your day to day life – at home, in your car, at work or at play. It manifests itself without warning, and changes lives forever.

[i] Attributed to Dr. Kathleen Sutcliffe, University of Michigan Ross School of Business, 2006

A Short History Lesson: 216 BC

tkern@convergentperformance.com (Jefe, Global War On Error) — Fri, 29 Dec 2006 17:04:00 +0000

On the 2nd of August, 216 BC, the two largest armies in the civilized world stood face to face on an open plain near the mouth of what is now the Ofanto River on Italy’s east coast – and the fate of the civilized world hung in the balance.
The Romans held the better ground and had nearly double the troop strength of their adversary. Nearly 80,000 armed men – over 55,000 in the heavily-armed and legendary Roman Legions were arrayed in three bristling lines of attack. Opposing the Roman juggernaut was a far weaker adversary in an inferior tactical position. With the river on one side and the ocean to the rear, an estimated 49,000 Carthaginian forces – mostly mercenaries who did not even speak a common language - prepared for what appeared to be a certain crushing defeat from the Roman sledgehammer.
Less than four hours later - in spite of superior troop strength and advantage of favorable terrain - nearly 60,000 Roman soldiers lay dead or dying on the ground near the village of Cannae – victims of poor decisions born of the common human errors of ego and anger. Perhaps even more important than the errors committed – was the fact that the Carthaginian commander – Hannibal Barca – predicted, induced and leveraged these errors to defeat a far superior force on unfavorable terrain. Therein lies the lessons for us today.
In 216 BC, Hannibal was one of the few commanders in the world that understood the intricacies of human error and how to leverage them to his advantage. Today, that information is available to all who desire it. Over the past two decades, human error research has expanded exponentially. Error causes and effects have been studied and codified to the point of being actionable for behavioral change for all of us – both as individuals and as organizational team players and leaders. Human error is no longer the shadowy, ill-defined foe it once was, yet few have utilized the new discoveries to attack error as a system – an oversight we intend to change.
In the next few months and years, we will undertake a fundamental and aggressive approach to combating the life-taking and resource-draining enemy we lump into the category of “human error.” Like Hannibal in his day, the enemy we face is formidable and the terrain not advantageous, but we also understand our enemy, have a sound strategy and a solid plan of attack. No matter what role you play in your organization, or even if you are not a part of any organization - you are a foot soldier in this war. Error stalks us all.

Jefe

What is the Global War on Error?

tkern@convergentperformance.com (Jefe, Global War On Error) — Tue, 26 Dec 2006 01:57:00 +0000

The Global War on Error (G-WOE) is a program designed to dramatically reduce human error in high risk endeavors. Based upon a strategic military science approach, the initiative has two distinct components – one strategic and one tactical in nature. The first is an over arching system of systems approach, designed to take existing resources and realign them against key centers of gravity for greater synergy and impact. The second half of the G-WOE program is an education and training curriculum designed to create comprehension and personal mastery of error reduction principles at an individual level.
The G-WOE approach describes the fight against error as a war, utilizing the proven concepts of military science to simultaneously attack multiple centers of gravity. Fortunately most of the tools for accomplishing these objectives already exist. But what is painfully clear is that safety and error prevention tools have never been effectively coordinated to the level that they could be for maximum impact. In fact, in most cases, differing approaches to safety compete with -- rather than complement -- each other for attention, credibility and resources. To date, most organizations have searched in vain for a magic bullet for error reduction, shopping a variety of approaches with varied results. Things don’t work, or they only work for a while and then initial gains begin to fade as new error patterns manifest themselves. A gap analysis of the current safety efforts also reveals a startling omission in the efforts to reduce human error – the lack of a strategy for personal error awareness and prevention. To remedy this omission, the G-WOE is also a curriculum designed to assist professionals in understanding why they – as unique individuals -- make errors and how to prevent them.