PAPod 499 - Navigating Confusion: A Lesson in System Design

So you guys have probably seen those slides before because they used to show them all the time. It's funny. I haven't seen it for a while, but I'll tell you why this matters because it all came up. But you know those slides that say is 99% good enough, and then they bullet point out a bunch of stuff that would happen if reliability was only at 99%. Like 12 newborns would be given to the wrong parents daily in the United States. 105,000 income tax returns would be processed incorrectly.

Two planes would land unsuccessfully at O'Hare International Airport in Chicago. Almost 20,000 pieces of mail would be misplaced. 880,000 credit cards would be billed the wrong number. I mean, you've seen those before, haven't you? Because they used to show that all the time. Music.

Hey everybody, Todd Conklin, Pre-Accident Investigation Podcast. How are you? Yes, I ask because I care. That's why I ask is because I care. And because, you know, it's finally here, the time of year when I have no weather to complain about. And so I'm kind of, I don't have anything to talk about because I truly have become an old man. That is when you talk only about the weather, then either a, you've run out of stuff to talk about or B, you become really super old.

And I don't know if that's true completely, but now I just, you know, just got off a big bike ride. That was amazing. In case you're wondering, same bike, no thefts yet. I have gone more than, I shouldn't even, why am I even talking about this? I'm probably jinxing it right now, but I've gone more than six months on the same bicycle. It's a miracle.

It is a miracle. So today's, it's a good day to chat with you because I've just come off seeing a whole bunch of people and man, has it been fun hanging out with you guys. So that is kind of a cool thing. You know, if we're someplace. I'll always, come talk to me. Don't be scared. Just because I look like I'm sitting there bored, which by the way. May very well be true. Doesn't mean you can't interrupt me in the midst of my boredom. I promise you, I can make it.

I can totally handle it. And it happens a lot. I mean, you know where I see people a bunch or people see me, but I also see them is like in airports and stuff. I'll run into people. And that's kind of fun because we're all going someplace. You know, everybody's going to some site someplace there and some site someplace here and things are happening. And so that's exciting and very cool and kind of a fun thing to do.

So that's been cool. And in fact, that's a little thematically tied to what we're going to talk about today. So it's really an interesting time because I was just talking about the conference that we're going to have in Santa Fe in September. And I've heard it is more than halfway filled and we haven't even really promoted it yet. So we might have to think about another one, which is also freaks me out, but we can do it. I mean, I'm really excited about it because it's, we'll have a good time.

And, and, and in case you're wondering, there will be bike rides then too. So, because it seems to to be my favorite thing. I forget. So I haven't been able to ride because I've been out a lot. And, and so I forget how much fun it is. It's just, it's just nice to be outside. And I think it kind of clears my brain. Not that there's a lot in there anyway, but the stuff that is in there gets kind of cleared away and that is very refreshing and super nice and makes a huge difference.

So that's definitely the fun we're having. So let's see, what am I supposed to talk about? the conference I talked about. If you're interested in that, you can do officetoddconklin, all one word, gmail.com. That'll get you on the way. If you want to go, if you can't go, but you want to, you know, hang out with us anyway, you can do that too. And I probably haven't said this before, but it goes without saying all the

slides and stuff you can have. I mean, you don't even have to go to the conference, but that's true of all my stuff. If you want stuff, just take it. There's no reason to not share. And it's just, they're just slides. I mean, it's not like it's a part of my being or anything. It's not like it's my bicycle that got stolen a million times. You can have them. So, but anything you need, it's there for you. So whatever you need, you can totally vibe on it and that will be perfectly good.

Let's see what else. Gosh, there's probably more stuff, but I kind of want to get into this pod discussion because I think the pod discussion, this one's interesting to me. And you'll see why. I kind of teased it at the beginning and a little more sense as we progress through. Music.

So anytime you start with that 90% good enough or 99% good enough, you know you're going to have a discussion about high reliability. And we probably don't talk enough about high reliability. We should because Carl and Kathleen are dear friends and incredibly thoughtful people. Carlene Roberts, I've known for many years. And her and Todd Laporte, they sort of started the whole idea of highly reliable organizations. In fact, I think they've changed it to highly reliable organizing.

Making it a verb, which is probably kind of a cool idea. And all that is super interesting and very cool. And the thing about highly reliable organizations is that they provide really interesting snapshots. That's probably a good idea of kind of how the world exists when the thought of failure is simply unaccessible. It's not permittable, maybe is a good way to say that. And if you remember, Carlene and the gang came up, and I think Carl actually originally, Carl Weick originally coined these.

It gets really fuzzy to me because they were all super intertwined and working with each other. But they came up with five key characteristics found in a highly reliable organization. And if you remember these, if you don't know them, it's definitely worth looking. And we can talk about them more if you want to. Just tell me. But let me see if I can do this from memory. I bet I can, actually.

There are five key characteristics. characteristics the first one is that highly reliable organizations are preoccupied with failure so they think about failure a lot now i would phrase that now as we've been on this little trail a while with the idea of keeping the conversation about risk alive but it really is it's a preoccupation with failure it's recognizing that failure is a potential and that it exists and And systems are stable until they're not.

The second characteristic is a reluctance to simplify. And that's really profound because, well, two things. One is we probably should declutter our systems, but we probably can't simplify complex operations. And the reason is, is because complexity is not made better through simplification. So complexity really is only made better through transparency. So you don't simplify a complex problem. You make the couplings, you make the problem more known.

The third characteristic is a sensitivity to operations, which makes 100% sense, that you're really looking at how operations function. And this kind of reminds me of Eric Holnagle's comment, what's happening when nothing bad is happening, which is actually a really great snapshot into sensitivity to operations. The fourth characteristic is this commitment to resilience, that you know the system will fail. You don't know when, you don't know how, but you know it will fail.

And because you know the system will fail, so you have to recognize that the system is pretty fragile. And because you know it'll fail, you're committed to having recoverability, that resilience suite. So you have a robust system that is also resilient. The relationship between robustness and resilience comes up there. And then the last characteristic, which is probably the most controversial, if I can have controversy in this, is a deference to expertise.

And what I would tell you deference to expertise really illustrates, if I may, is that experts live at every level of your organization. So experts don't just live in the expert office, although you probably have experts that live in an expert office somewhere in your organization. But experts also live on the dock, on the production floor, on the rig platform, in the wheelhouse, in the pumping room. I mean, there are experts that live everywhere throughout your organization.

And you know that's true. I mean, it's absolutely true. What's cool about that is that you really want to recognize that those people are an incredible resource. They're available pretty much 24-7.

They're incredibly sensitized to what's happening. They know your systems that are good. They also know your systems that are brittle. And that deference to expertise becomes a really important way to sort of point to the workers not being the problem, but the workers, in fact, being the solution. Now, that's kind of a quick overview of high reliability. And you may ask, why are we talking about high reliability?

Well, that is a really stinking good question. And it has to do with coming back from my brother, Chris's daughter. Her name's Lauren, Lauren's high school graduation. So one of the places I went this week was to Lauren's high school graduation, which I was honored to be a part of. I loved going to, she had a great party afterwards. It was super fun. And I was really proud of her and she did great. She was amazing.

But what's interesting is that I had to leave. I didn't want to leave because it would have been fun to hang out there. But I had to leave because I had a bunch of other stuff I had to do. And people were waiting on me. And you know the drill. I had obligations. So they drug me to Des Moines, Iowa to the airport. Now, those of you that are fancy may call it Des Monez. But I believe the locals pronounce it Des Moines. And I got to the airport. And the Des Moines airport is a cute little airport.

I mean, it's it's it's fine. It's it's great. It's it's the perfect airport. Not too big, not too complicated, not too stinky. I mean, it had it all going on. I didn't get a chance to look around at the potential food offerings, but I'm sure there were great things offered there. I didn't because probably I was in a hurry because that is the story of the airport. But anyway, long story short, I jump out of the car, grab my bag and run into the airport. Every one of us has done this.

Many of you a million times. So you know exactly what I'm doing. Dragging my little bag and the security, the TSA guys are on the second floor and there There are two matching escalators, both going up, and one has a big giant sign over the top of it that says TSA PreCheck. And then the one next to it says Passenger Security. So I think, well, I have TSA PreCheck. Not bragging. I don't want to sound braggy because I do think security is a little classist.

I don't think it. I know security is a little classist. And then when you add that clear thing to it, it gets really snotty. But nonetheless, I have pre-checked. So I go up the escalator that says TSA pre-check. And this kid, you know, I bet he's like 17. Nice kid, seems really charming, seemed a little nervous, so probably not a highly experienced flyer, but he's going to make it.

I mean, he's confident and he's right next to me and he goes up the normal escalator, the passenger security escalator. And we get to the top of these two escalators, and they dump out exactly into this hallway, and there is no difference at all at the top of the elevators between TSA PreCheck and security. Zero difference. And in fact, there's the stanchions, you know, those little poles with ropes that make you zigzag, right? They're set up, and there's a big, fat line.

Pretty big line. I mean, like bigger than I think Des Moines would have in security. And so I'm pretty sure I rolled my eyes, although I couldn't see myself. And the kid just got right into that line. And because I was behind the kid, I went right behind the kid. And sure enough, some people came right behind me. And the guy that came behind me, he was probably, I don't know, I would say 45, pretty cocky, kind of dressed up like a tech bro, if you know what I mean by tech bro.

So he had on like a Patagonia vest and some chinos and those blonde leather shoes with white soles. You know this look. And he's got his hair. He didn't really have any hair, but I'm not hair judgy. But I mean, he looked good. He was definitely in work attire. He gets in behind me and we're standing in line. And pretty soon it becomes really clear, kind of maybe 10 minutes into this line. It's a pretty long line, right? It becomes really clear that this is, in fact, the TSA pre-check line.

Because you can see now that you're in this one line, that the stanchions next to that line are for the regular passenger security and you to get there you'd have to go to the top of that escalator and take a pretty hard right and go to the far end and then get back in it that way but it wasn't marked i mean there weren't signs or anything so don't get me wrong it was and that's going to be a part of this story so the kid all of a sudden looks a bit freaked out and he looks He looks

in front and he looks in the back and a man says, this is the TSA pre-check line. Have your IDs out. You know, you know how all this goes. And the kid clearly recognizes at that moment in time, exactly snapshot, bam, that he's in the wrong line. So he turns and he's got to get past us all because, you know, he's in the single line and there are ropes that are keeping us from escaping. And he turns to me and he says, I'm in the wrong line. I'm supposed to be in the other line.

And I say to him, no big deal. We'll let you out. I said, it seems a little confusing. And then I turned to the guy behind me as I was letting the guy pass, the young kid pass me and said so that the young kid could hear, they could probably have made that more confusing. But in order to do that, I think they would have had to shut the lights off because I thought that was, well, two things. I think that's kind of funny. So I'm going with that.

And two is it sort of cuts the tension for the kid because he's kind of, this is uncomfortable for him that he's got to cut by all these people. My guess is because he has to go backwards in the line, which is going to be uncomfortable. And two, I bet he's feeling a tiny bit embarrassed. I know he is, because you can just kind of tell just by looking at him.

And this tech bro behind me, this 45-year-old guy in his Patagonia vest with his company logo on it, which was some insurance company, but it's Des Moines, so it's a pretty good bet it's going to be an insurance company. He says to me, that sign was perfectly well marked. If people would just read it, they wouldn't get in the wrong line. And I just stopped. Now, the young kid, he's escaping, so he's not going to hear the rest of this conversation, thank goodness.

And I turned to him and I said, what are you talking about? And he said, those signs make perfect sense. It's incredibly clearly marked. marked, people just need to pay attention. And I said, well, I don't think you get to blame the people when the problem is the system. And I said, and quite honestly, I found it really confusing when you came up to the top of the escalators, where to go. And he said, well, you're in the right line. You must not have been that confused.

And I said, well, I'm in the right line because it was a coin flip. I mean, I actually just kind of followed the crowd. And he looked at me and he said, that's ridiculous. You simply just need to read. If people were smarter, we wouldn't have this problem. And I said, yeah, I'm not going to let you have this. And he looks at me and I said, because I actually think that's incredibly offensive. Those signs are bad. And then I

made a mistake. I mean, it didn't curse or anything, but I made a mistake. I used some tech talk. I shouldn't have. I don't know where it came from. It just shot out of my mouth. I said, the signal strength on the TSA direction signs was about as weak as I can imagine. I can't imagine it any weaker. And he looked at me and he said, well, 90% of the people get it right. And that's enough. And I thought, wow, really? That's the sword you're going to die on, 90% of the people.

So I turned to him and I said, you think 90% – because we're trapped in this line. He's not going to go anywhere, and it's not anger. I mean, he might have been mad at me, but I don't think he – it didn't feel like an argument. But I said, if you think 90% is enough, I said, quite honestly, I certainly wouldn't want to fly on a plane that's only 90% effective. And I absolutely don't want to eat at a restaurant that's only 90% safe.

And at that point, he turned and stood backwards so he wouldn't have to talk to me. Which between us, you guys, don't judge me, okay? Please don't judge me, but I kind of felt like I won. I mean, I'm not sure what I was winning, and I'm really not sure other than defeating boredom and having something to do while standing in the line what I wanted to accomplish, but it kind of felt like him turning his back on me was the payoff.

And then I went through security and walked down to the gate, completely convinced, by by the way, that when I sat on the plane, the person next to me would be this guy, because that is the way my world works. But in fact, it wasn't that guy. So I kind of lucked out. I made it. But I started thinking about that a lot. And I actually think there's lots to this. It's the entire reason I came and recorded a podcast as fast as I could, is because that is a really interesting example from real life.

I mean, from real life of two, well, probably more than two things, but two things that I think are worth observing. And one, the primary starting place for this discussion has to be on the fact that if the system is confusing, the system is not good. Right? Now, you know, because we've talked about it before, but good design tells you what to do. And really good design is almost invisible.

You just know what to do. So when Don Norman, who wrote The Design of Everyday Things, and if you've not read that book, it's time to crack that baby out and read it again. When he talks about a door that you approach and you can't determine whether you push or you pull, that that's not a user problem, that's a design problem. Well, the very same thing is true, is if you go up these very well-marked separate escalators, and they were really well-marked.

I mean, there clearly, in my mind, was going to be a discernible difference when you got to the top between TSA pre-check, and it was probably going to be covered in furs and have massage therapists and free champagne and stuff and regular security, which would be filled with cows and chickens and smell like manure, right? I mean, there was clearly going to be a huge difference between those two. At least that's what the signs told me at the bottom of the escalator.

But when I got to the top of the escalator, it dumped us out into the very same place and there were no real signs at all. It sort of created an environment that sort of guaranteed that that 18-year-old kid would get in the wrong line. Almost certainly, if you didn't know that airport, you would not know where to go. And that's not the fault of the person trying to get through airport security. Oh, no. En contraire, mon frere.

That's the fault of the people who designed whatever crowd control design they designed to get people through the check stations and the magnetometers and the x-ray machines for your carry-on bags. Now, my guess is the tech bro is from Des Moines. I mean, I pretty much can guarantee he's from Des Moines because he had an insurance tech bro, Patagonia vest on. And he was very, you know, matter of fact, and kind of defensive about his airport.

He was definitely saying, you know, it's perfectly well marked. If he just read the signs, he'd be fine. So he's kind of, you know, he's holding up the local, he's a hometown hero. But my guess is, is that because he goes to that system all the time, it makes perfect sense to him. The problem is, is not everybody that goes through that system goes through that system.

And that I think is a really interesting place to begin a discussion. And you can look really around your organization and you can ask this question, where is it not apparent what I'm supposed to do next? And when you find those places, what you're going to find is a place where your system has a weak link. Your system isn't sending the right signals. And so therefore, and this is pretty worthwhile, we're not doing the right thing. Part two of this is blaming the person for being stupid.

So I'm not going to let you have that ever. I mean, I'm just, you could be the meanest tech bro in the world, and I'm not going to let you have that because blaming the people right and blaming the people in front of the people as they're walking backwards like a salmon swimming upstream out the line embarrassed probably benefits no one the important thing is that because he thought the people were not obedient or stupid which i kind of interpreted it as a stupid

he thought the system was fine and the people were with a weak link. But as a non-familiar user of this new system, I will tell you that I think the people were just trying to get through it. And that what hurt them was that the system at best was confusing. That, my friends, is the story I wanted to tell. It's an interesting little story. I mean, it's worth talking. That's for sure. Music. So here's hoping the kid made it to wherever he was going because he wasn't

on my flight either. I looked for him as well. I'm sure he made it. I mean, I'm sure he got in the other security line and whipped right through it and everything was fine. I got through. The guy didn't smack me or hit me or spit on me. So all was well. I'm not sure I created the perfect teachable moment. And that's probably best evidenced by the fact that he turned his back to me. But I did get a pretty good story to tell you. And it's really fresh. I mean, that baby, that story is so fresh,

the paint is still wet. That's how fresh it is. But it's one that really made me think. And I guess what I'd ask you guys, because it's a reasonable question, is how many of those happen to you? Because my guess is stuff like this happens all the time. And what's cool is if you're kind of in the right headspace, it's a pretty teachable moment. And that's kind of worthwhile. So learn something new every single day. Have as much fun as you possibly can. Be good to each other, for sure.

Be kind to each other. Even if you're a Patagonia vest wearing tech bro with an insurance company logo on it, I should be kind to you. And for goodness sakes, you guys, be safe. Music.