Zero Defects

Welcome to the psychological safety newsletter and thanks for subscribing. You are amazing. This week discusses the way in which aiming for zero defects can actually result in more defects, not fewer.

Zero Defects.

I’m currently reading “Boyd, the fighter pilot who changed the art of war” and it’s excellent. John Boyd was a fascinating guy, flawed in his own ways, but a genius in others. He devised Energy-Manoeuvrability Theory (EM), as well as the strategic practice of OODA loops. We’ll cover OODA in a newsletter soon, but right now I want to dive in to brief story in the book from Boyd’s time at Eglin Air Force Base.

In the mid 1960’s, the base commanders began a campaign of “Zero Defects“. This was a popular philosophy in American industry at the time, and meant everyone at the base had to sign a pledge stating that they would make no mistakes in the following year. Boyd thought it was a stupid idea, and knew that it was impossible to make no mistakes, so he refused to sign it, despite threats of court-martial. A group of lieutenants working for Boyd even raised a flag stating they were “100% Against Zero Defects“. Zero Defects means the goal would be considered ‘failed’ if there were even a single defect, so even if the intention behind the goal was good, it puts great pressure on people to find other ways to achieve this impossible objective.

It was in fact a Zero Defects type of culture that first fired my interest in psychological safety and safety culture over 15 years ago. I was crucially aware that the business leadership’s zero tolerance for mistakes was resulting in very slow project delivery, over-planning and minimal innovation and risk taking. It was ultimately damaging the business. 

Reading the story of Boyd at Eglin reminded me of the “Zero Accidents” movement in health and safety, which always struck me as, well, a bit risky! Indeed, it’s often remarked that “it is important that Zero Accident Culture is not a quantitative target” – which rather begs the question of why the word “zero” is in the title. The aims of Zero Defects and Zero Accidents programmes are laudable, well-intentioned, and may well have some positive outcomes, but I have to wonder what is happening under the surface of the organisation. Just as in the photo below showing 548 days since the last accident, nobody wants to be the one who resets the counter, so there’s a clear risk that people hide accidents until one occurs that is impossible to hide.

Boyd was a great systems thinker, but he was also belligerent, outspoken, and had a great status in the Air Force, which meant that he felt able to speak up against the potentially damaging target of Zero Defects at Eglin Air Base. He knew it would lead to people gaming the system in order to reach the target, potentially resulting in more defects than before the target was in place.

There are a few “cheat” strategies we can apply in order to reach a Zero Defects target:

1. Do less work. By doing less, we will incur fewer defects.
2. Redefining defects so that things that were defects no longer are.
3. Hiding defects and under-reporting.
4. Excessive planning. This can reduce defects but is often a CYA (Cover Your Ass) exercise, plus the opportunity cost of excessive planning means you’re also applying strategy 1 as a side effect.

All these strategies may provide results that look like we’re closer to our Zero Defects goal, but the actual outcomes are worse. If we insist on Zero Defects, we may even increase the number of defects produced – but not seen.

Deming himself, in no. 10 of his 14 points, states: “Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.“

Like so many aspects of safety culture and psychological safety, the implications of a Zero Defects philosophy are counter-intuitive. We may think that we’re setting an aspirational bar, but in practice, we risk lowering the bar to the lowest acceptable outcome. Under a Zero Defects philosophy, we may plan as much as possible until further planning provides no more return on investment. We may only do as much as we need to in order to keep our heads below the parapet, lest something we work on results in a defect. We may err on the side of hiding or under-reporting defects, in particular those defects that are just on the margins of being defective. Or we may simply redefine what a defect is.

All this not only risks greater defects, but robs us of any opportunity to openly work on the system in order to improve the defect rate. In order to have open and honest conversations about addressing failure, we must be open to the possibility that failure can occur.

This newsletter is sponsored by Conflux

Conflux is the leading business consultancy worldwide helping organizations to navigate fast flow in software. We help organizations to adopt and sustain proven, modern practices for delivering software rapidly and safely.

‘The Fearless Organization’ by Amy Edmondson is considered by many to be essential reading on the topic of psychological safety. In this article, Sophie Weston, Principal at Conflux, has put together some key takeaways from the book.

Psychological Safety in the Workplace

Here’s a fab podcast episode of Agile In Action with Bill Raymond, featuring our very own psych safety community member Richard McLean. Some great points in here, particularly about the complexities and dangers of measuring psychological safety, and, just as the discussion above, a great point about the dangers of trying to reduce the number of near-misses recorded.

Thanks to Roy White for sending this in – Creating the conditions for psychological safety and its impact on quality coach-athlete relationships, by Sophia Jowett, Jose Roberto Andrade Do Nascimento-Júnior, Chen Zhaoa, and Jyoti Gosai. There remains quite some debate in elite sports coaching circles about whether psychological safety improves performance (though evidence suggests it does), but this article nicely addresses the practices and cultures that help to foster psychologically safe coaching environments.

Here’s a rather worrying piece about Berkshire NHS Trust, who have been accused of destroying email evidence related to a legal case concerning geriatric patient safety. If this is true, alongside the threats to claw back liability costs from the claimants, it sends a disturbingly clear message that whistleblowing or speaking up with concerns will have dire negative consequences for those doing so.

In a lot of my workshops, Elizabeth Holmes and the Theranos case often comes up as an example of a lack of psychological safety in the board room, resulting in awful consequences including people being told incorrectly that they were HIV-positive, suffering from cancer, or would miscarry their unborn child. Elizabeth Holmes has already been sentenced to 11 years in prison for her part, and Theranos exec Sunny Balwani was this week sentenced to 13 years in prison for defrauding patients and investors.

Here’s an interesting piece from BBC Work Life about younger generations speaking up at work: “Gen Z feel a moral obligation to speak up, and that can catch some people off-guard if they’re not used to politics making the workplace awkward.” I’m a little uncomfortable with the tone of this article potentially pitching generations against each other, but I’m pleased that psychological safety is receiving mainstream attention!

I came across this David Bowie quote this week, and just had to share it:
“I thrive on mistakes. If I haven’t made three good mistakes in a week, then I’m not worth anything. You only learn from mistakes.”

Things to do and try:

From the book “Rituals for Work“, this is a team exercise called “Crash The Desk“. 

When someone is away from their desk in the office, everyone else takes the opportunity to leave something personal to them on their desk. When they return and find their desk full of interesting things, they must try to work out who each item belongs to. It’s a great way of getting to know each other in a low-pressure environment. One adaptation could be to write interesting facts on post-its, and they must work out who the fact is about. 

Be careful to not put too much pressure on the person trying to work out who the items or facts belong to though, and choose an appropriate time to do it – 1 hour before an important meeting with the CEO maybe isn’t the best time! 

Photo by Ferenc Horvath on Unsplash

This week’s poem:

The Darkling Thrush by Thomas Hardy

I leant upon a coppice gate
            When Frost was spectre-gray,
And Winter’s dregs made desolate
             The weakening eye of day.
The tangled bine-stems scored the sky
             Like strings of broken lyres,
And all mankind that haunted nigh
             Had sought their household fires.

Mission statement

The mission of this newsletter is to make the world of work a better, safer, more inclusive and equitable place. We work towards this by sharing, as widely as possible, new research and opinion, case studies, news, practices and methods related to psychological safety. 

This includes topics such as inclusion, human factors, facilitation, safety critical environments, systems thinking, leadership and management, diversity and equity, mental health, organisational dynamics, culture, ethics, and more. 

A core goal is to amplify the voices of minoritised groups and those who are less represented in this field. This includes (but is not limited to) voices of people of colour, neurodiverse people, LGBTQ+ people, women in leadership and tech, and more.

Another goal is to share insights and best practices across different domains: for example, so that those of us in tech may learn from healthcare, and those of us in education can learn from aviation.

I believe knowledge is worthless unless it’s accessible. A key principle of this newsletter is to only share content that everyone can access. This excludes content behind paywalls, research papers that are not open-access, and proprietary tools that don’t open source their algorithms (preventing us from observing how systems make decisions about us). There may be some exceptions to this principle in practice, for example, where authors are able to share original texts of papers.

Whilst this statement will evolve this over time, the core principles of equity, amplification, and progressive & humanistic leadership shouldn’t change.