What Were You Thinking?

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Things happen for a reason – Cause & Effect is a physical reality

“Stuff Happens” isn’t quite accurate. It happens alright, but it’s always due to some reason or cause. Eliminate that cause and “Stuff Stops.” Whether we realize it or not, every judgment or decision that we make is based upon some underlying premise or belief. That premise or belief could be based on fact or an assumption. If our premise is sound then our judgment and actions will likely succeed. When the belief is flawed then every subsequent action will be flawed, simply because there is no valid basis to support that action in the first place and the action is misdirected.

The Error Carried Forward

You probably went to work or ran an errand today by driving your car, which you started either by twisting the key or pushing a start/stop button. What did you think would happen when you did so? Why did you believe that? You may have answered that 1) it would start, and 2) because it always has.

That belief would only be true if the vehicle had been properly maintained in good mechanical condition, with adequate oil pressure, coolant, sound electrical system, and a good battery. My teenage children often neglected to consider these issues, which usually meant I got the late night call asking me “Can you come get me”?

This same scenario plays out in other ways as well. Almost without exception, investigation of industrial accidents and events always reveals instances where individuals or parts of the organization misconstrued or miscommunicated information that became the invalid basis for their subsequent actions leading up to a serious occurrence.

As an example, in one case that I investigated, a technician was nearly killed (but fortunately survived) when they placed a handheld screwdriver across a high voltage electrical source. That technician believed that the equipment had been de-energized and was safe to work on. The organization knew that they were performing an activity that was different than but similar to what they had done before.

In this case, no one in the organization, over a four month time frame, and with literally dozens of opportunities to catch it, recognized that they were individually and collectively basing all of their judgments and decisions on the old way they had done this in the past without changing anything to protect against the difference this time. Their underlying premise and belief system was pinned on facts that were no longer true.

So when did the error occur that almost killed the technician; when they placed the screwdriver in the equipment or four months prior to that when the activities were set in motion, based on bad judgments? When all of the details are known, most people would agree that the most serious error was committed at the origin four months earlier and the failures to recognize the fault could be described as the “Error Carried Forward”.

Another way to look at this is to say that the failure to maintain your vehicle properly is the Error Carried Forward that results in you walking.

We don’t need no stinking plan!

Perhaps, you have heard the phrase “Plan the work and then work the plan”. What this means quite simply is to a) understand the task at hand, b) organize and plan the activities to accomplish the objective, c) follow through with the plan you put in place and d) check and adjust the plan along the way.

This is the short description of Project Management, and at least in hindsight it is surprising how many of us forget to apply these simple principles to our daily activities. When things don’t go “according to plan”, we may have a tendency to find the guilty party, or other variations of “the blame game”. Mostly because that’s easier than doing a critical review of “our plan” to determine where it was either inadequate, incorrect, or simply wasn’t followed.

I used to find it surprising when groups did not question their actions in spite of having no details for what they were trying to accomplish (sometimes referred to as “winging it”). But more surprising is when a group does have a well thought out plan that makes sense to everyone involved, and then they somehow decide to deviate from the plan. They always seem surprised that the results are not what they expected because their rationalized deviation had an irrational basis. If you decided to start your automobile one morning by avoiding the key or the start/stop button, why would you expect it to be the same as every other morning?

Trust BUT Verify

At first glance the phrase “Trust but Verify” seems to indicate that the level of trust is not that strong, but that is not the case. The intent is to positively employ a Questioning Attitude to guard against the unexpected. The emphasis here is on risk assessment to ensure that the plan is correct, its basis is sound, and that activities are proceeding according to plan.

The technician mentioned above would not have been shocked if their organization had questioned conditions more thoroughly. Instead, no one challenged their own thinking or beliefs to verify that conditions were as thought. When this happens it often does not end well.

High performance organizations will routinely employ methods to verify these conditions periodically to ensure that everything will turn out as expected with no surprises. No plan is perfect and emergent issues that were previously unexpected can and do come up. It should be anticipated that these emergent issues will need to be addressed.

Part of the verification process is to constantly be on the lookout for these issues and evaluate their effect on the plan and it’s foundational basis; has the basis changed, can the plan proceed unaffected, must changes be made to address the emergent issue, do we understand the basis for those changes, and can unintended consequences be avoided, etc? This practice actually builds trust and teamwork as the organization avoids problems.


Remember, you can’t avoid cause & effect. If you don’t have the right basis, your objective won’t be reached. If you don’t take the time to think through everything that is needed to accomplish your objective, it won’t be reached. And if you don’t follow the plan or don’t make rational adjustments, not only won’t your objective be reached, but you may also suffer unintended consequences.
The best defense is to employ a Questioning Attitude as a great offense.


About The Author

Joseph M. Latham is the President of TDS PowerGen O&M.

A graduate of the Naval Nuclear Power Program and a Nuclear Senior Reactor Operations Instructor, Mr. Latham has served in numerous management positions in the power industry. Mr. Latham has forty years military and commercial power experience, providing services, products and consulting to a wide array of industrial clients.

Areas of expertise include operations/technical training, simulation, configuration management, programmatic root cause analysis, corrective actions, facility assessment/due diligence, process re-engineering, business management, product development, marketing/sales, and international export & payment mechanisms.

Mr. Latham has successfully managed and directed service and product deliveries to multiple industries both domestically and internationally. In addition to many of the nation’s largest utility clients served today, Mr. Latham has previously supported clients such as Boeing Aircraft, Eastman Chemical, Miller Brewing, Kellogg’s, Westinghouse, the Federal Government, and the University of Cairo (Egypt) among others.

Recent activities have included Operational Assessments, Corrective Actions, Regulatory Margin Recovery, Business Planning, Due Diligence, Power Plant Acquisition, Material Condition Assessments, Severe Storm Damage Assessment/Claims and Operational Performance Improvement.

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