D. Scott Vaughn

Decades dedicated to global safety and security. Passionate about safety & crisis management. Embracing fine wines as an art. Family always at the heart.

[D. Scott Vaughn @DSV1968166126]

I have spent a considerable amount of time lately thinking and writing about leadership, work, failure and why people do what they do.

Not as an academic exercise. I keep returning to things I have seen over more than three decades in complex operations around the world.

Good people making decisions that looked inexplicable in hindsight but made sense to them at the time. Leaders unintentionally creating pressures they never meant to create. Procedures gradually drifting away from the work. Near misses being wasted because nobody was injured. Frontline knowledge sitting in plain sight while organizations searched elsewhere for answers.

I think about investigations that found a person but never found the problem. I think about rules added after incidents that made work more complicated without making it safer. I think about experienced people who quietly adapted broken systems every day and were only noticed when one of those adaptations failed.

And I keep returning to the same uncomfortable thought.

Organizations spend an enormous amount of time asking people to behave differently. We train them, remind them, measure them, observe them and, when necessary, discipline them.

Perhaps leaders should spend just as much time examining the conditions that make certain behaviors predictable.

That idea has been occupying a great deal of my thinking lately.

More than I expected, actually.

There is more to come.

[D. Scott Vaughn @DSV1968166126]

Most of us have told someone to “be careful” at some point in our careers. I certainly have. It is usually well intended, particularly when we know someone is about to perform difficult or hazardous work.

The older I get, the less useful I find those words.

Be careful of what? The stored energy that has not been fully isolated? The suspended load? The line of fire? Poor access? Changing weather? Fatigue after twelve hours? A weak handoff between crews? The schedule pressure nobody particularly wants to acknowledge?

“Be careful” asks the individual to compensate for whatever conditions we have left in place.

There are times when that is unavoidable. Work carries risk, people must remain alert, and personal responsibility does not disappear simply because conditions are imperfect. But I worry when attention and caution become our answer to hazards that could have been better controlled through design, planning, equipment, staffing, supervision, or leadership decisions.

These days, I prefer a different conversation. What could seriously hurt you here? What makes this job difficult? What are we relying on to keep this from going badly?

Those questions tend to reveal far more than “be careful” ever did.

#SafetyLeadership #Leadership #OperationalRisk

[D. Scott Vaughn @DSV1968166126]

I do not believe in a blame-free workplace.

That statement occasionally surprises people who know my views on human performance, but I mean it.

There are standards. There are expectations. There are choices. People remain responsible for their actions, and there are times when accountability is entirely appropriate. Pretending otherwise does a disservice to good leadership and to the overwhelming majority of people who make difficult decisions responsibly every day.

What I reject is the idea that accountability and understanding are somehow opposites.

Before deciding what should happen to a person, I want to understand what happened around the person. Was the expectation clear? Was the individual capable and properly prepared? Were the right tools available? Had the behavior occurred before? Had supervisors seen it? Had the organization benefited from the same behavior when the outcome was good? Would another competent person placed in the same conditions have been likely to make a similar choice?

Those questions do not eliminate personal responsibility. They help us determine where responsibility actually belongs.

Sometimes it belongs with the individual. Sometimes it belongs elsewhere. Often, if we are willing to examine the situation without protecting ourselves or our systems, responsibility is shared.

Blame is attractive because it gives us somewhere to stop looking.

Leadership requires us to keep looking.

#Leadership #Accountability #HumanPerformance

[D. Scott Vaughn @DSV1968166126]

Over the years, I have watched organizations respond to failure in remarkably predictable ways. Something goes wrong and we retrain the person, issue a reminder, revise the procedure, hold a stand-down, or add another layer of control.

Sometimes those actions are necessary. Sometimes they are simply evidence that we do not know what else to do.

After more than three decades working around complex operations, I find myself increasingly interested in a different set of questions. What was happening around the person when the decision was made? What were they trying to accomplish? What information did they have at the time? What pressures existed? What had gradually become normal? What were leaders rewarding, tolerating, or simply failing to see?

I have rarely found that people come to work intending to fail. More often, they adapt to the world we put them in. They solve problems, make tradeoffs, compensate for weak systems, and find ways to keep the operation moving. Most of the time those adaptations help the organization succeed, which is precisely why they can remain invisible until something goes wrong.

Accountability still matters. Standards still matter. Personal responsibility still matters. But if we genuinely want different outcomes, we should be willing to look beyond the last person who touched the work and examine the conditions in which the work was done.

That is often where the more difficult answers are found.

#Leadership #OperationalExcellence #HumanPerformance

[D. Scott Vaughn @DSV1968166126]

Some of the best operational conversations I have had over the years began with a simple request:

Show me what makes this job difficult.

I am not asking for the procedure, the KPI, the audit score, or the presentation prepared for the visit. I want to understand where the work becomes harder than it needs to be.

That question has taken me to places formal reviews often miss. People will show you the valve they cannot easily reach, the tool that does not quite fit, the handoff that regularly breaks down, or the step everyone skips because it adds little value to the actual work.

They may show you the target that creates unintended pressure, the workaround everyone knows about, the temporary repair that survived three budget cycles, or the piece of equipment that technically works but nobody trusts. They may show you a process that requires experienced people to succeed despite the system rather than because of it.

I have learned a great deal from dashboards, audits and performance reviews. They all have value. But I have learned just as much by standing beside someone who does the work and asking them to show me where we make their job harder than it needs to be.

The important part comes next.

Do not explain.

Do not defend.

Listen long enough to hear what they were not sure they should tell you.

#Leadership #OperationalExcellence #FrontlineLeadership

[D. Scott Vaughn @DSV1968166126]

A procedure can be technically correct, professionally written, properly reviewed, fully approved and completely wrong for the work being performed.

I have seen it more than once.

On paper, everything made sense. Then you stood beside the person actually doing the job and discovered that the equipment had changed, the access was different, the sequence was impractical, or the procedure depended on conditions that had not existed for years.

So people adapted.

That word deserves more attention than it gets. Adaptation is often how work continues when reality and design no longer meet. Experienced people find a way through the problem. Production continues, the customer is satisfied, the schedule recovers, and because the adaptation works, it becomes easier to use the next time.

Eventually, the workaround becomes the work.

Then something goes wrong and the organization discovers a violation.

Sometimes the violation is the problem. There are requirements that are non-negotiable, and accountability remains real. But sometimes the violation is evidence of a deeper disconnect between how work was imagined and how work actually had to be done.

The difference is rarely visible from a conference room.

You have to go see the work.

#OperationalExcellence #Leadership #HumanPerformance

[D. Scott Vaughn @DSV1968166126]

Production pressure rarely arrives as an instruction to take a shortcut. If it did, it would be relatively easy to identify and address.

In my experience, it is usually much quieter than that.

People notice which numbers dominate the morning meeting. They see what happens when a job runs late, a customer becomes unhappy, a shipment misses its window, or production falls behind plan. They know who gets praised for delivering, and they also know who gets questioned for stopping.

No leader has to say, “Take the shortcut.” People are remarkably good at reading an organization.

Over time, they learn what really matters by watching where leadership attention goes, what creates discomfort, what gets rewarded, and what gets explained away. They learn the difference between the values displayed on the wall and the values revealed when the operation is under pressure.

I have worked with many leaders who genuinely cared about people and would never knowingly ask someone to accept an unreasonable risk. I have also seen sincere leaders unintentionally create conditions where the message received at the point of work was very different from the message they believed they were sending.

That is one of the harder realities of leadership. We do not get to judge our influence solely by what we intended.

People experience the organization we create, not the organization we imagine we are leading.

#Leadership #Culture #OperationalExcellence

[D. Scott Vaughn @DSV1968166126]

I have always viewed near misses as freebies.

I realize that is an unusual word for an event that could have seriously injured or killed someone, but I use it deliberately.

Something happened. A weakness was exposed. A control failed, an assumption proved wrong, or the margin between success and disaster turned out to be much thinner than anyone realized.

And somehow, nobody paid the full price.

That is a gift.

Too many near misses disappear because there was no injury, no significant damage and no operational loss. We got lucky, everyone exhales, and the work continues. Maybe a report gets filed. Maybe a few people discuss it. Then the organization moves on to whatever is urgent next.

I think we should do the opposite.

When the potential outcome was serious, I want to understand why it was not. What failed? What worked? What interrupted the sequence? Did a person recover the situation? Did a control actually function? Was it simply luck? And if the same event happens tomorrow, can we reasonably expect the same outcome?

The operation just showed us where it is vulnerable without sending someone to the hospital or worse.

Near misses are our freebies.

We should stop wasting them.

#learning #SafetyLeadership #OperationalRisk

[D. Scott Vaughn @DSV1968166126]

“He knew better.”

I have heard those words after more incidents than I can count. In many cases, they were technically true. The person had been trained. The procedure existed. The rule was clear. The expectation had been communicated.

But “he knew better” has never been a particularly satisfying answer for me.

If someone knew better and still made the decision, I want to understand why. Was the right equipment actually available? Did the procedure reflect the work as it was really being done? Had the same shortcut worked successfully fifty times before? Had supervisors seen it? Had experienced people accepted it? Was the job behind schedule? Was a customer waiting? Was there pressure, spoken or unspoken, to get the operation moving again?

None of those questions excuse a poor decision. That distinction matters. Understanding behavior is not the same as absolving people of responsibility.

But if our investigation ends when we identify the person who made the final mistake, we may feel that we have solved the problem when all we have really done is locate the last person in a much longer story.

And the next person may already be standing in the same conditions.

[D. Scott Vaughn @DSV1968166126]

I have walked a lot of operations over the course of my career. Offshore rigs, land operations, marine terminals, manufacturing plants, warehouses, distribution centers, workshops, yards and facilities across very different parts of the world.

Different languages. Different cultures. Different equipment. Different risks.

One thing has been remarkably consistent.

The people closest to the work usually know where many of the problems are.

They know which procedure no longer matches reality. They know which piece of equipment is unreliable and which repair never quite fixed the problem. They know where people are improvising, which task is harder than it looks from the conference room, and which temporary fix quietly became permanent three years ago.

They also know what everyone has learned to live with.

That last category interests me most.

Every operation has things that gradually stop looking unusual because people see them every day. The awkward lift. The difficult access. The unreliable alarm. The workaround. The repeated leak. The congested area. The step in the procedure that nobody actually follows.

The challenge is not always that leaders lack information. Sometimes the information is standing ten feet away wearing work boots.

The question is whether we have created an environment where people believe telling us the truth is worth the effort.

[D. Scott Vaughn @DSV1968166126]

Unconscious Error in Safety, The Complacency Projection https://t.co/08aoF1UhAh So much of the discourse in safety is about judgement of intent. We see this demonstrated in the language...
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[D. Scott Vaughn @DSV1968166126]

Safety Beliefs by Semiotic Evidence https://t.co/XBbQ9AiDhd If you want to know what safety believes, look no further than its semiotics, curriculum and language/discourse. If one...
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[D. Scott Vaughn @DSV1968166126]

What is Justice in Safety – Video Part Two https://t.co/4yZZknXWmn In our previous video we tackled the challenging question: What is Justice in safety? (https://t.co/Aa6ozY11MS) In this conversation...

[D. Scott Vaughn @DSV1968166126]

Can You Influence Safety Beliefs? https://t.co/2hbZc9dkrw The short answer is yes. The longer answer is, it depends. The extended answer is, how much time have...
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[D. Scott Vaughn @DSV1968166126]

Believing is Embodied, The Foundation for New Beliefs in Safety https://t.co/W8SO1IM3n1 So much of the semiotic of safety is about brains, supporting the metaphor and myth that the brain directs...
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[D. Scott Vaughn @DSV1968166126]

Free Workshops – Understanding Safety Beliefs https://t.co/chPrdSN5PQ This is your last opportunity to register for the workshop series on Safety beliefs. The workshops will be held...
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[D. Scott Vaughn @DSV1968166126]

The Weick Collection https://t.co/x0dKVfVdwk In SPoR, we have been teaching a module on the work of Prof. Karl. E. Weick since 2014. We...
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[D. Scott Vaughn @DSV1968166126]

The Radical Pioneer in Organising and Risk, Prof. Karl. E. Weick https://t.co/8SMW32uVVZ In Making Sense of the Organisation, The Impermanent Organisation (2009) (book 5) Weick explores six styles of organisational theory...
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[D. Scott Vaughn @DSV1968166126]

Two Small Washers and Human Error https://t.co/yyUEheQPWd There are certain jobs about the home we don’t do, we call a tradesperson. This is the case often...
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[D. Scott Vaughn @DSV1968166126]

Weick’s Six Properties of Thrownness https://t.co/ywVH7hO0MP In Weick’s second book Sensemaking in Organisations he introduces the reader to ‘thrownness’ (p.44) which comes from Heidegger (dasein)....
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