In many organizations, like those discussed in this chapter, countless small problems routinely occur, presenting early warning signs that the company's strategy may be falling short and needs to be revisited. Yet these signals are often squandered. Preventing avoidable failure thus starts with encouraging people throughout a company to push back, share data, and actively report on what is really happening in the lab or in the market so as to create a continuous loop of learning and agile execution.

The responsibility for finding and fixing problems should be assigned to every employee, from the most senior manager to the lowliest person on the production line. If anyone at any level spotted a problem in the manufacturing process, Deming believed, they should be encouraged (and expected) to stop the assembly line. Japanese companies that implemented Deming’s ideas made it easy for workers to do so: They installed a cord that anyone could pull in order to bring production to a halt. Before long, Japanese companies were enjoying unheard-of levels of quality, productivity, and market share.

The stories we tell ourselves from a few scant pieces of evidence are often flat-out wrong, especially when we’re in the Pit. Nine times out of ten, the other person is not out to get you. Your coworkers don’t think you’re an idiot. And, yes, you deserve this job.

When a negative story takes hold of you, step back and question whether your interpretation is correct. Are there alternative views you’re not considering? What can you do to seek out the truth?

The problem with Perrow’s idea that organizations could not safely function with interactive complexity and tight coupling was that so many such organizations did in fact function without mishap for years, even decades. Nuclear power plants operated without incident nearly all the time. So did air traffic control systems, nuclear aircraft carriers, and a host of other inherently risky operations. A small group of researchers led by Karlene Roberts at the University of California, Berkeley, set out to study how they did it. What they discovered was more behavioral than technical. The term high reliability organization, or HRO, captures the essence of the theory. HROs are reliably safe because of how they make everyone in them feel accountable to one another for practices that consistently catch and correct

deviations to prevent major harm. Vigilance is one word for it. But it’s more than that. To me the most interesting part of HRO research is the observation that rather than downplaying failure, people in HROs are obsessed with failure. My colleagues Karl Weick, Kathie Sutcliffe, and David Obstfeld wrote a seminal paper highlighting the culture of HROs as preoccupied with failure, reluctant to simplify, acutely sensitive to ongoing operations (quick to detect subtle unexpected changes), committed to resilience (catching and correcting error,

rather than expecting error-free operations), and valuing expertise over rank. In other words, HROs are weird places. Rather than holding back to see what the boss is thinking, people there don’t hesitate to speak up immediately. A frontline associate, to avert a crisis, can tell the CEO what to do. Failure is clearly seen as an ever-present risk that can nonetheless be consistently averted.

To help overcome this ubiquitous tendency, best practices for RRTs included a list of early warning signals nurses could consult to legitimize their calls. This list helped nurses build on their vague hunch—because they’d simply be following the protocol. When the RRT showed up, it brought more trained eyes to the bedside to assess whether the patient was failing.

This is more than vigilance. When people are given permission to amplify and assess weak signals (such as with an Andon Cord or a rapid response team), they are invited to engage wholeheartedly in the work—to embrace its inherently uncertain nature, to believe that their own eyes and ears and brains matter.