The world of organizational performance is being revolutionized by new concepts. High Reliability Organizing and the New View of Human Performance are complementary disciplines which have emerged from the leaps in organizational performance achieved by the civilian nuclear industry and commercial aviation respectively. The principles and practices of these disciplines have enabled the commercial airline industry to achieve the highest level of safety performance of any industry on the planet, and have helped organizations across the globe dramatically improve safety, productivity and profitability.
High Reliability Organizing and the New View of Human Performance
In the late 1970s, the civilian nuclear industry and commercial aviation industry were in crisis. In each of them, a small error could mean a catastrophe. The Three Mile Island nuclear incident alerted the industry that it needed to do something to prevent another near nuclear meltdown. In commercial aviation, major airline crashes were a regular occurrence; Hollywood was sensationalizing the problem; people became afraid to fly. Something had to change. What the commercial airline industry did was revolutionary and almost unthinkable. In 1983 the airlines stopped blaming crashes on pilot error. What they had discovered was that in every crash, if they looked hard enough, they would always find a pilot error. And during the best flights, conducted by the best pilots, there were dozens of pilot errors there too. By focusing on the imperfect performance of humans as the cause of crashes, airlines had inadvertently created a system that depended on human perfection to be successful. They discovered along the way that any system that relies on human perfection for success is ruled by luck. And luck is a very unforgiving business plan.
The commercial airline industry discovered that an airline crash was not caused by human error; the error was a sign of trouble deeper inside the complex system in which the air crews operated. Learning about the system and improving it was the key to better performance. In the three years following the decision to stop blaming pilots for crashes, safety performance in commercial aviation skyrocketed. In the ensuing years, commercial aviation became the safest system in the world. From 2004 to 2008, for four years, there was not a single fatality on an aircraft in the United States. That had never happened before. The error rate for commercial aviation in the U.S. is now 1:26,000,000. The manufacturing industry ideal of Six Sigma is but 1:10,000.
The commercial airline industry discovered the secret to organizational learning and improvement: You can blame and punish, or you can learn and improve. You cannot do both. What is paramount is how an organization responds when something bad happens. If the organization works to understand the system the worker was operating in and to explain what the worker was doing inside that system and how the system allowed the incident to happen, the organization can improve performance dramatically. These concepts are not self evident truths. They require elaboration and explanation. I do not take on those tasks with this article, but I hope readers may enjoy reading the sources I have noted. Several of them are dedicated to fleshing out these concepts.
So What’s the Problem?
When I speak to people about these concepts, about High Reliability Organizing and The New View of Human Performance (generally, the New View), the most difficult hurdle is the first one. To most people, a suggestion that people not be blamed and punished for making a mistake is heretically preposterous. They react reflexively, saying people who make mistakes deserve to be punished. The organization cannot survive with flawed people in it. If flawed workers remain, accountability, performance and excellence, they will argue, must go out the window. Often this ends the discussion. Even the lure of an approach to organizational learning that yields results such as the airlines’ 26,000-fold increase in performance beyond the Six-Sigma ideal is still insufficient to overcome the resistance to this central tenet of the New View, to look beyond blame to examine trouble deeper inside the system. It’s still a hard sell. Why? Why is this idea so objectionable, so laughable, that this New View has to be nuts? The answer lies in our brains and how they work.
The brain is the last frontier. We conquered the globe centuries ago; we came to understand our place in the universe; we unlocked the secrets of biology, physics, chemistry and engineering; we split the atom and harnessed its awesome power. In the fields of health and medicine, we have unlocked the genome, cured horrible diseases, even cardiovascular disease. The protests of Star Trek fans notwithstanding, we know more about outer space and the universe and have explored more of it than we have the brain. But over the past 20 years, the fields of neuroscience and cognitive psychology have begun to unravel the mysteries of what goes on within those skulls of ours. What they have learned already is, well, mind blowing.
The human brain is an amazing organ. It weighs three pounds and is made up entirely of neurons and glia. The neurons are vastly interconnected and complex, forming tens of thousands of axonal connections to other neurons, so much so that in one cubic centimeter of our brain there are more axonal connections than there are stars in the Milky Way Galaxy. The human brain is the greatest information processor ever created. It lets us walk upright, talk, make new discoveries, explore the galaxy and even discover itself. As amazing as it is, it does not perform with the consistency of a computer, and it does not enable us to act with perfection.
Among the most dramatic of the recent discoveries is just how our conscious minds operate, how we make decisions, and how it all relates to unconscious processes going on within. Although we think our conscious minds are our masters, our decision-makers, the beings that do the hard work of thinking, this is not the case. What neuroscientists and cognitive psychologists have discovered is that the unconscious processes of the brain do the vast majority of the work. Much like an iceberg, the conscious mind is but the tip. What is submerged, what is unconscious, what lies under the surface of our knowing, is where we make our decisions, make plans and react to problems.
Rather than doing all the brain’s work, our conscious brain works like the CEO of a Fortune 500 company. The CEO doesn’t need to know everything that goes on in the company. She just needs to know a high-level view of it. After all, what if the CEO tried to be involved in the decision about what brand of paper towels would be used in the break room? She would be gridlocked, unable to manage. Our conscious brains work the same way, leaving the details to others, guiding the work but not intimately involved in the minutiae.
When we gain conscious access to the inner-workings of the unconscious brain, the results are automatic and intuitive. We perceive anger in a face and do not have to think about it. Anger is simply what registers. It works quickly. But when our conscious brain overcomes the urge to meet anger with anger and instead allows us to speak calmly to the angry person, it is a higher level of cognition at work. It works more slowly and with effort. Cognitive psychologists often call these two modes of thinking System 1 and System 2. Generally throughout this article I will refer to these two modes as the unconscious brain and the conscious brain.
Our minds conserve effort in practically every higher-order task they do, from reasoning to decision-making to perceiving speech. As part of that effort to conserve, our brains work to overcome the inherent limitations of the unconscious and the conscious. The built-in limits on our capacity to focus attention is what is bedeviling the poor CEO in her quest to choose the right paper towel. She can maintain the focus of her attention consciously, but it has capacity limitations. The unconscious brain frees up the conscious to focus on the important things.
When we make decisions, we believe our conscious brains are the ones doing the work. We congratulate ourselves about how our conscious brains analyzed all the intricacies of the decision. But in reality, that is not at all what happens. Our brains have a vast machinery of unconscious decision-making processes that grind through the decision with intuition, while we sleep, while we work and while we play, and we are only barely conscious of it.
Sometimes our conscious brains have flashes of insight of what is going on under the surface. When we say “I am of two minds about this,” it is our conscious brain being aware that two rival decision pathways are working out the problem. When we say “I’m going to sleep on it,” it is our conscious brain recognizing that the unconscious machinery needs time to process it. Ultimately our conscious brain operates as the emcee of an award show. Our unconscious brain hands over an envelope, and the conscious brain reads it and announces the decision. The conscious brain has a relatively small ceremonial role in the work. Only if the unconscious brain is struggling with the decision is the conscious brain called in at all.
Some of this new information on how the brain works is very unsettling. How is it that so much of our mental lives are not accessible to our conscious brains? Our conscious brains fulfilling the role of emcee at an awards show? Humbling at best. It seems the more we understand about ourselves, the less significant we become. This news about our brains is but another example. We are dethroned – our belief that we are our own conscious masters undermined by neuroscience and cognitive psychology.
We shouldn’t feel too bad about this. The decline of the belief that man is the center of the universe has been going on for centuries. In 1615, Galileo Galilei questioned the geocentric model of Aristotle and Ptolemy, stating instead that he had proof that the earth rotated the sun. “Galileo’s critics decried his new theory as the dethronement of man.” For his efforts, Galileo was hauled before the Inquisition and forced to recant, spending the rest of his days in a prison cell. “Evidently, not everyone appreciates a radical shift of worldview.” He was right in the end, but that was little solace in his lifetime.
It happened again when Charles Darwin published his work, The Origin of Species, in 1859. No longer were we placed on the earth a man and a woman in a few days; rather we emerged as products of an evolutionary process of adaptation and natural selection, over billions of years. Darwin’s work is now the foundation of the natural sciences, but it was another dethronement, deeply disturbing to many even today.
With what we have learned about the inner space of the brain, we have been knocked from our thrones once again. What, after all, can human freedom mean, if the courses of our lives are determined by unconscious processes? If we are willing to learn, however, we can see, coming into focus, an even more “splendid universe” than the one that has the conscious human self at its center.
As I write this, I am watching the weekend tennis players in Flamingo Park across from my home. Their unconscious brains are hard at work: judging the speed and direction of the ball, moving the players’ bodies around the court, coordinating their movements, allowing them to fire off a devastating serve to their opponent. Want to bring all that athletic skill to a halt? Just get the conscious brain to interfere. When your opponent delivers a serve you can’t return, ask them, “hey great serve, how do you serve so well?” Their conscious brains will trip them up and they will serve up duds. Although their conscious minds have a role in the game, what allows them to play the game well is almost entirely automatic and unconscious. Their most skilled work has almost nothing to do with their conscious minds. Every athlete knows this. They call it “muscle memory.” And it comes from relentless practice and dedication. Sometimes we understand our unconscious brains and embrace them. But introduce consciousness to these automatic processes, and we grind the works to a halt.
The Lizard Brain
Part of the unconscious machinery that we possess is ancient, preexisting the mammalian class. It is the amygdala, a small structure of two nuclei the size of almonds, located deep within the temporal lobes. The amygdala is responsible for elements of memory, decision making and emotional reactions. It is part of the limbic system. It is common to complex vertebrates including reptiles. It is popularly called the “lizard brain.”
Calling the amygdala our “lizard brain” creates a powerful image – after all, who wants to be a lizard, using a lizard brain? Even if the particular lizard stands upright, contemplates auto insurance and has a London accent? Fear ignites it. “The lizard brain is a holdover from our prehistoric ancestors. It has two responses: fight or flight.”
The amygdala helps us survive. It springs into action by reflex when danger appears. When we flee from a wild animal it is our amygdala that makes us take flight. Our conscious brain does not have to mull it over. The amygdala saves our lives, with split second timing, the difference between life and death. But it comes at a price. Think of it like this:
The amygdala is the most primitive part of our brain. it doesn’t have higher-level decision-making skills. It responds only to perceived threats. Unfortunately the lizard brain isn’t very smart. And since it can’t distinguish between a threat to your life and a threat to your ego, it responds to both in the same way.
You don’t make good decisions when you’re afraid. You tend to focus on the short term, and you don’t come from a place of confidence.
Logic and reason, the best elements of our conscious brains, are hijacked by our lizard brain and the lizard brain takes to the controls.
Lizard Brains in the Executive Suite
When something bad happens in our organizations, an explosion, a derailment, a crash, a deal falling apart, a construction-site fall, a trial loss, we fall prey to the lizard brain hijack – our lizard brains take control throughout the organization. The incident ignites our fight or flight instinct and we feel fear. First things first: we have to get the hell away! From the earliest moments after an incident, you can see the lizard brains at work in our organization: personnel scramble to make sure they are not the ones to blame.
The phenomenon of fleeing from blame has been recognized for a long time. John F. Kennedy summed it up well: “Victory has a thousand fathers, but defeat is an orphan.”
Finding the person who IS to blame is the only thing that will make us and our egos feel safe. We have to escape the peril. When we blame, it is our lizard brain telling us to flee. Our company’s executives will issue public statements that the accident will be investigated and those responsible will be punished. When we punish it is our lizard brain telling us to fight. Our conscious, rational brains simply play a ceremonial role in the prehistoric pageant being played out by our lizard brains. Try as we might, we have been hijacked by the lizard. Our lives are not at risk but our egos are.
We see it in other business contexts, too. Seth Rogan, author of Purple Cow, puts it this way:
Want to know why so many companies can’t keep up with Apple? It’s because they compromise, have meetings, work to fit in, fear the critics and generally work to appease the lizard. Meetings are just one symptom of an organization run by the lizard brain. Late launches, middle of the road products and the rationalization that goes with them are others.
The anxiety we feel in facing the novel and taking risks to innovate paralyzes us and makes us mediocre. It is not simply the fear we feel after something bad that happens in our organizations that make us resistant to embracing the practical innovations of High Reliability Organizing and The New View of Human Performance.
Tennis Players and Lizard Line Judges
Back to our tennis players in Flamingo Park. Think of them like you do your best workers. They are playing the game, their unconscious brains doing a vast amount of the work automatically, guided at a very high level by their conscious brains. How much of what your workers do is choice? How much is unconscious, automatic reaction resulting from years of practice, experience and training? Do tennis players play perfect games? Do they never lose a point? Do we let our lizard line judges fire them if they do? Do we expect them to be perfect? If not, why do we expect anything different from the people who work for us? By demanding that they be perfect, aren’t we setting them up for failure? Why would we blame them and discipline them for “losing a point” when so much of what they are doing is unconscious reaction to the situations they encounter on the job? Maybe, instead of trying to fix our people, we should try to change the systems they operate in so that we set them up, like expert tennis players, ready for success rather than failure.
Lizard Brains in History
We humans have been answering the call of our lizard brains and struggling with them through our law codes for thousands of years. The Code of Hammurabi from 1754 BC Mesopotamia is one of the most famous early examples. “An eye for an eye and a tooth for a tooth.” “A son who strikes his father shall have his hands hewn off.” Death, the price for many infractions. Today we view the predominant focus on punishment as barbaric, but the code was considered just in its time. Likewise, 15th Century Europe was gripped by the Inquisition. 17th Century Salem, Massachusetts had the witch trials. Our conscious brains were grappling with the crippling effects of our lizard brains, trying to make sense of them and looking for justice.
Our law codes and our responses when something bad happens have increased in sophistication since then. The presumption of innocence and the differentiation of criminal and civil penalties for different kinds of wrongs are examples of the change. The debate over whether criminal sentencing should focus more on punishment or rehabilitation shows that the change continues. But certainly the primordial call still exists in the way we administer civil justice and conduct accident investigations today. The lizard brain still rules: it is flight and fight. So it would seem we are hard wired to act upon these impulses to blame and to punish when something goes wrong. Biology is destiny. It cannot be escaped, right? Or can it?
Silencing the Lizard
Science and history have shown us examples where our conscious thinking brains have overcome our lizard brains and kept the fear at bay. Humans were not meant to move fast, but we overcame our fear of speed to ride on trains and drive cars. We overcame our fear of loud noises to master the bagpipe, and eventually the rifle, and the canon and the ear-splitting sound of a jet plane or a Who concert. We have overcome our fear of heights to stand atop hundred-story buildings and to sit in a narrow tube at 240 mph, 50,000 ft. above the ground. We drive through the Holland Tunnel, under the East River, without a paralyzing fear of suffocating or drowning.
In each instance, we controlled our lizard brains and overcame our engrained fears because it was beneficial to do so. Experience, observation, and science proved we would survive.
Someday soon we will conquer our lizard brains and learn to put aside blame and punishment to help our organizations learn and improve. We will do it because it is beneficial to do so. Experience, observation and science are showing the way. After all, the chance to reach an error rate of 1:26,000,000 in our own organization is pretty good reason to put the lizard brains away.
 Dekker, Sydney, The Field Guide to Understanding Human Error, 2006. One of the most important works by perhaps the most important writer and thinker in the entire field of the New View, this work serves as the underpinning of much of this article. Standing on the shoulders of giants.
 Conklin, Todd, Pre-Accident Investigations, 2012. This great work by my friend and colleague Todd Conklin serves as a great introduction to the field of the New View. His focus on the importance of investigation and management response to bad things make this an important read.
 Eagleman, David., Incognito: The Secret Lives of the Brain, 2011. I have borrowed liberally from this work. Eagleman focuses on neurophysiology. Incredibly well written and lively, it is one of the most exciting works of nonfiction I have read in a long time. It is a must read about the brain, and it really will blow your mind.
 Kahneman, Daniel, Thinking, Fast and Slow, 2011. Kahneman won the Nobel Prize for Economics in 2002 for his work on many subjects, primarily Prospect Theory. This book discusses much of the cognitive psychology research on the brain in an easy-to-read way. Like Eagleman, his work goes far beyond the reach of this article to discuss how our brains work.
 Kahneman, Daniel, Attention and Effort, 1973. This was Kahneman’s earliest important work.
 Id. The concept of “dethronement” is an interesting philosophical point and one that scientists who bring forth new ideas are often ill-equipped to deal with.
 Id. I appreciate Eagleman’s sense of humor, as displayed in his “radical shift of worldview” comment. It is part of what makes Incognito such a great read.
 Id. Eagleman shows that, although the new discoveries of how the brain works cause a sense of dethronement, these discoveries open a whole new world that our conscious and unconscious minds can explore together.
 Goleman, Daniel, Emotional Intelligence, 1995. This book is important in its own right, addressing the issue of why some extraordinarily smart people don’t do as well as people who aren’t quite as smart. The difference is their emotional intelligence and how well they are able to overcome emotional impulses to deal with people more effectively. He popularized the term “lizard brain” with his book and includes an excellent description of the amygdala, the limitations it causes and how those limitations can be overcome in our lives.
 McLeod, Lisa E., Selling With Noble Purpose, 2012. Following the work of Goleman, this book discusses emotional intelligence in the context of sales. She has a writer’s flare and is very quotable.
 Id. I enjoyed reading McLeod. This book contains the most succinct description of the “lizard brain” that I have found, so I quoted it.
 Goleman, Daniel, Emotional Intelligence, 1995. Goleman coined the term “lizard brain hijack” to describe the phenomenon of the conscious brain being overpowered by the fearful impulses brought by the amygdala.
 This quote is from John F. Kennedy, 1961, paraphrasing Count Caleazzo Ciano (1903-1944), 1942. “La victoria trova cento padri, e nessuno vuole riconoscere l’insuccesso.” And quoting Leo G. Carroll as Field Marshal Gerd von Rundstedt in the film The Desert Fox (1951), according to William Saphire, Saphire’s New Political Dictionary (1993).
 A full discussion of justice and punishment is beyond the scope of this article. I risk oversimplification. Punishment has its place in the criminal context. When a worker makes an error and something bad happens in an organization, my starting point is that the worker did not show up for work that day to do a bad job – they did not come to work with the intention of doing something wrong and causing harm. When that does happen (luckily it is a rarity), it is something different entirely – it is a crime. That is not what I am addressing here.