Las Vegas 2018

Discovering Your Way to Greatness: How Finding & Fixing Faults is the Path to Perfection

Steven J. Spear is the author of the award-winning and critically acclaimed book, The High Velocity Edge. He is a senior lecturer at MIT Sloan School of Management and is a Senior Fellow at the Institute for Healthcare Improvement. He is also a founder of a consulting firm built on the tenets of his book, and of See to Solve Corp., a business process software company.


Expert on the ways that "high-velocity organizations" generate and sustain advantage, even in the most hyper-competitive markets, Spear has worked with clients spanning technology and heavy industry, software and healthcare, and new production design and manufacturing.


Spear's 1999 Harvard Business Review article, "Decoding the DNA of the Toyota Production System," is part of today's lean manufacturing canon. "Fixing Healthcare from the Inside, Today" was an HBR McKinsey Award winner in 2005 and one of his four articles to win a Shingo Research Prize.


Spear helped develop and deploy the Alcoa Business System, which recorded hundreds of millions of dollars in annual operating savings, and he was integral in developing the "Perfecting Patient Care" system for the Pittsburgh Regional Healthcare Initiative. He has published in the New York Times, the Boston Globe, the Annals of Internal Medicine, and Academic Medicine, and he has spoken to audiences ranging from the Association for Manufacturing Excellence to the Institute of Medicine.


Spear has a doctorate from Harvard Business School, a master's in engineering and in management from MIT, and a bachelor's degree in economics from Princeton.

DS

Dr. Steve Spear

Principal, HVE LLC

Transcript

00:00:02

One of the most impactful learning moments for me was taking a workshop at MIT in 2014, which ended up tremendously influencing my thinking. Uh, I took the class because it was taught by Dr. Steven Spear, who I mentioned earlier today in my opening remarks. He's famous for many things, but he's probably most famous for writing one of the most downloaded Harvard Business Review papers of all time. In 1999, he wrote a paper called Decoding the DNA of the Toyota Production System. This was based in part on his PhD dissertation that he did at the Harvard Business School. And in support of that, he worked on the manufacturing plant floor of a tier one Toyota supplier for six months. Since then, he's extended his work beyond just high repetition, uh, and manufacturing work to engine design at Pratt and Whitney, uh, to building a safety culture at Alcoa, uh, helping make safe healthcare systems. He was also part of a US Navy initiative to create high velocity learning across all aspects of the enterprise. Uh, he spoke at the conference in 2015. He was a part of the panel with Dr. Richard Cook, uh, and Dr. Cindy Decker from the safety community. And I shared with you my belief that what will replace the current modes of management thinking is dynamic learning organizations. And that belief really comes from Dr. Steven Spear's work. So with no further ado, I'm hoping you'll believe the same thing. Thank you. Alright,

00:01:11

How y'all doing? Good. Alright, so, uh, gene, thank you for the nice introduction. Be, be behind. He said, Steve, you gotta keep it to 30 minutes 'cause uh, people have to finish up and get drinks before the next piece. I said gene, the, uh, the socks and the dodgers in the middle of the first with Mookie bets on second. I may, if I'm the last 10 minutes, I'm happy. So drinks may be early a anyway, so lemme let me cut to the chase here. Um, I, I'm gonna make a case for, uh, three key points. Um, first, uh, learning is good. Uh, not surprising a guy coming from MIT wearing a bow tie and glasses. But what I mean, uh, more particularly what I mean more particularly is that, um, knowing how to get smarter, better, faster matters a lot. And I'll give some examples of just the profound differences between those who learn very, very well and those who learn in a more normal fashion.

00:02:06

Second point is, uh, learning's fairly easy. All it requires is that you aggressively seek out fault. Um, I grew up in New York, the same neighborhood that Trump family is from. You can see it's a natural thing where we come from. You know, no matter what you're doing today, that that sucks. That's awful. That's terrible. Um, but it turns out that finding fault is a necessary trigger and the first and former that you don't understand and that you need to do something differently. So we'll build on that in some examples. And then of course, that leads to the third critical point that, um, easy to say and hard to do in terms of this whole finding fault in your thinking, finding fault in you're doing and correcting on it. So anyway, lemme, lemme take it that first point, uh, Jean mentioned that my Ruths are trying to understand why Toyota had such a, a hugely dominant presence.

00:03:00

Still it does actually in its sector. So just to sort of, uh, qualify, quantify what that difference looks like. So Toyota came to the US market in the late 1950s and they showed up with a car called the Toyota Pet. Now, just I, you are the guys, I can see anyone ever hear, hear of a toil pet and one or two of you, right? What does that tell you about a toil pet? Because you've heard of a model t you've heard of a Lamborghini, uh, Chevy Corvette. So if one in a few hundred heard of a toil pet, it suggests you said it, it sucked. It sucked, right? He said it. Nami I'm just quoting right? <laugh>. Yeah, yeah. It's, it's his vulgarity. I'm just, you know, reporting accurately. Um, so he, he, here's let, let's add some dimensionality to the word suck. So the, uh, the toil pet when it came to the United States, if you had to drive up a hill, um, the odds, again, no guarantee you'd get to the top of the hill, but if you wanted to increase the odds, it was better if you were in reverse

00:04:04

<laugh>

00:04:06

First market for the to pet was California. So, uh, I, I'm willing to bet that there's some hills either, uh, east of Los Angeles or by San Francisco. If you go by and you see like a, a rotten pile of metal all covered in rust, that well me be a Toyo pet. All right. So, uh, well let, let's take this through. So, um, Toyota starts off with this abysmal product called the Toyo Pet. Turns out they were abysmal at making an abysmal product. Toyota's productivity in 19 57, 58 was about one eighth the world standard, which I guess is good. 'cause if they was as good as everybody else, they would've made a lot more toil pets. Um, but here, here's the thing. From 1957, you can imagine they left the US market then until 1962. Toyo, uh, Toyota went from one eighth the world standard in terms of productivity to e to equal the world standard.

00:05:02

By the late 1960s, their productivity was double the world standard. Now, Toyota comes back to the US market in 1973 with small fuel efficient cars, compacts, MicroComp, subcompacts, uh, sort of invited in by the rising price of gasoline. And uh, again, to sort of give you a qualification on this, at first the car was appealing because it needed far less fuel than what was on the market. But people came to a quick realization. It was incredibly reliable. And to give you a visualization on this, up to 1973 in the morning, you knew where your neighbor parked his or her car the night before by all the fluids that had stayed in the driveway, they were leaking out. If someone owned a a a a Toyota Celica, you had no idea where they had parked because it was all clean. And so here's what happened. 1973 Toyota Reestablishes the competitive bar in that sector because showing up with a car that they can make, um, with twice the productivity, it's wickedly affordable with a car that doesn't leak all you over your driveway, it's also wicked easy to maintain in service and it proves to be a much more affordable, reliable car than what's on the market.

00:06:21

Now, that value proposition of affordable reliability Toyota added to because they started, uh, showing up with not only small cars, but mid-size cars. Now, again, the world's standard to do a major model upgrade on a car, it's a big deal actually. 'cause you have to, um, redesign the car. So that's thousands of engineering, um, years worth of work. Uh, retrain the workforce, re-equip the workforce, redesign your supply network. It's a big deal. It's a, you know, so the world's standard for such a thing was, uh, four years. And Toyota proved that at half the cost, you can do it in half the time, their world standard was two years. Now that has a devastating impact on everybody else. 'cause now Toyota is not only selling a car, which is more affordable, more reliable, but it's fresher too. And you start thinking about the products you buy and the difference in perception of something which is recy, you know, cycling through and updating on a two year cycle versus four.

00:07:20

I mean, four is like for my kids, like four. What was that like, what Abraham Lincoln used? You know, so, so, um, anyway, there was, there was that changing the game. And then the other piece was in the late eighties nineties when Toyota decided that they needed to be a US manufacturer of cars for the US market versus an exporter from Japan, they proved that you could, um, introduce new plants and train up workforces at a pace, at a pace no one else can match. Now it sort of begs the question, how does Toyota go from the Toyota pet in 1957, which they were really pathetic at making to this dominance on terms of affordability, reliability, time to market, et cetera, by the mid eighties, early 1990s. And the starting point for the Toyota folks was something like this, which is, why the hell are we selling a toilet pet in the first place?

00:08:15

And some other guy says, 'cause we don't know how to make a better car, right? If we knew how to make a better car, we would sell it. Is that this is the best we can do. And similarly, when someone asks the question, well, why does it take us eight guys to do the labor of one elsewhere in the world? They said, 'cause we don't know any better. If we knew better, maybe we'd have seven or six or five. We certainly wouldn't invest the pro the, the input of eight where one must be enough. So Toyota gets into this mindset that whatever they're doing, they very, very aggressively have to seek out problems in what they're doing. And, and wild aggressiveness, I mean me on a box of donuts after a fast, I mean that, that kind of aggressiveness <laugh>.

00:09:06

And then they say, when you're on a problem, rather than recognize it and cope, be heroic, firefight, et cetera, do as much as you can to understand the problem, at least its causes and do something to try and solve the problem. And then in this kind of interesting point, right, 'cause the conventional view of people turning wrenches in factories, that they were there to turn wrenches and that you measured that person by how many wrenches they could turn, how many nuts they could drive, how big were their guns to do all that wrench turning. But in a Toyota case, they're saying, wait a second. If we're starting ignorant about what we're doing and someone is arrived to see that we have a problem, which we didn't really understand or well articulate, and they have insight into this, all of a sudden they're the world expert on this situation, right?

00:10:02

And, and you start thinking about that, it sounds like highfalutin to say, but the reality is, if you had that situation which no one else had been able to resolve, and someone comes over to that situation, comes to an understanding, meaningful enough that they can make some kind of positive impression on it, they're the expert and the rest of us aren't. So say, well then we, what we have to do is build in as committed time and to people's activity, not only seeing problems and solving problems, but sharing what they've learned. And so, anyway, taking this one step further, 'cause as I preface, knowing how to get smarter, better, faster matters a lot. It depends on finding fault, but it's a little bit hard to do that 'cause we're psychologically, socially not well equipped to say, oh, hey, look at how badly I suck. Right?

00:10:48

<laugh>, um, there's a, there's a whole element here that if you're gonna build your competitive presence on your dynamic of seeing and solving problems and sprinting what's learned, then what you really have to make sure is that this whole thing is buttressed by leadership. We're just constantly modeling, coaching, enabling this finding of fault. So anyway, what's the result of that kind of behavior? So, uh, as we said, our starting point was the Toyota Pet in an absolutely abysmal car, made in absolutely abysmal fashion. Um, by the time Toyota gets to the mid 1990s, they have products, not just one. They have products in every significant category in the domestic automotive market. Ranked one or two. Now, just, just to give you some sense of things, when we think of auto automobiles automation, that's where you, you think back to Ford. Now, if I read correctly, Ford a few months ago decided that they can't make money with cars.

00:11:49

They're gonna concentrate on trucks and SUVs and minivans and that kind of thing. And they're like, ah, well the cars will leave for somebody else. So anyway, that's one example. I wanna give you one more example of how knowing how to get better, smarter, faster, knowing how to get to the right answer quicker. And again, that's not in one of these like, oh, Harvard Business Review. Oh, well, what you have to do is be first to market. No, no, you had to be first to market with the right answer. Being right first to market with the wrong answer. I mean, that's just like stupid, right? <laugh>. So, um, so, and an example. So, uh, the world auto market, that's you and me send the same signal to the world automakers, which we wanted double the fuel efficiency. And, um, everyone, there's a sort of a nice side story, but Gene said, I don't have that much time.

00:12:38

So we'll park that for later. But there's a side story on how everyone tried the same approach to tinkering around the edges with existing architectures, uh, more aerodynamic, plastic and aluminum to reduce the weight, electric, electrical, electronic controls on the engines to get better combustion. And all, while all of that helped incrementally, it didn't solve for twice the fuel efficiency. So everyone went back to the drawing board for round two, um, having gotten the answer wrong the first time, and they came up with the idea of a hybrid. And again, you know, we, we can have separately over beer like the, the <laugh> the nerd excitement over how cool a hybrid is, but it is a cool product. And so the idea of taking electric motor, which is wicked good for acceleration, couple it with an internal combustion engine, which is wicked good at steady state.

00:13:30

Put those dude together, throw a whole mess of software on top to coordinate them. You can get double the fuel efficiency. So Chevy's expression of that is the vault. Toyota's expression of that was the Prius. But again, this gets back to knowing how to get to the right answer faster. Toyota showed up with the Prius with a 10 year headstart on the Chevy Volts. And with a 10 year headstart, not only did have they put that technology through six and seven and maybe eight cycles now of modification and improvement, they've diversified its application. So it first came out on the Prius with a value proposition of a very, I don't know, statement making green product. But then they moved it onto the Camry with a value proposition to taxi fleets. Look, fill up your tank once a day instead of twice. Basically pay in in fuel savings.

00:14:23

You pay for the car in the first year. Alright? Then they started putting it on the Lexus where it wasn't so much the savings and gas cost, it was the performance. So anyway, Toyota's taken their hybrid drive 'cause they had a 10 year head start, put it on 24 different platforms. And in the years since the Chevy Vault and the Prius came to market, the Chevy Vault has had about a hundred thousand units sold. And Toyota with its hybrid system has had 9 million units sold. Again, folks, it was the same flipping problem. And the difference in results is 90 to one. I mean, if some, some of my students came in like that, I'd either say, damn, we'll just give you the Nobel now or you're cheating <laugh>. It is one or the other. All right? So this is not just an auto phenomenon. And again, there's, there's countless others. Just to illustrate with one other. Pharmaceuticals is another crazy industry where you invest billion, a billion, billions of dollars over a decade to try to get to market with a product. Um, they have this crazy system that, um, when they have a, like the puff of an idea, what you all might call vaporware, they file a patent. And that's great. You can tell em, mom, Hey gay mom, guess what? I filed a patent, right? And your mother's like, oh, I knew you were gonna be a great biologist, but

00:15:40

<laugh>

00:15:42

It would've been nice if you'd gone to medical school, become a doctor. But I'm okay with the biologist, right? But you file a patent then. But the problem is the clock starts ticking. And, and when the clock stops ticking, um, your revenues go to zero. 'cause it's, you know, someone's gonna make it the generic version. And we did a calculation that if you could get to market with a pharmaceutical, um, every day earlier, it's $3 million. It's crazy, right? Right. Answer faster. And the other thing I I just want to point out is, in their market, if you're in the market with a therapeutic, first you get about 50% of the revenue that therapeutic will ever yield. If you're second, you're about 25% of your third year, about 15%, and your fourth, fifth or sixth, it was a waste of time and a huge burn of money.

00:16:31

All right? So anyway, all of this to the point of getting to the right answer fastest matters a lot. One last example, and this ties into the leadership. So, uh, this is a picture of Hyman Rickover known as the father of the nuclear Navy. And if you really have to dig into how he managed the creation of atomic power, the plate all, now you have to think about when he started this in the late 1940s, no one really had control of atomic power. They had explosive atomic power, but not a controlled atomic power that required the invention of new science, the invention of new materials, the invention of new processes, et cetera, et cetera, et cetera. There was a lot of invention going on. You have, and and this was spread across not only the navy uniformed and civilian, but a contractor workforce, which ran easily into the tens of thousands.

00:17:20

And he asked, how did Rick over accomplish this? Well, he ran an organization which was raised based on the same learning dynamic, um, design, whatever you're doing. So you can see what's stupid about what you're doing. That that's Rick over's language. It's kind of a crass guy. Find out what you're doing wrong when you see you're doing something wrong. Find out immediately as best as you can, why you're having that problem. And whatever you've learned from that experience, it could just be that the problem exists. It could be how to resolve the problem. Make sure you tell somebody else. That's the multiplier effect. And there's a, there's a whole, oh, the product placement, right? So <laugh> in the bottom left hand of my slides is a Bitly link. So if you wanna read the Rickover case in more detail, you can download it there, right? Anyway, back to our programming, Rick, over <laugh>. No, seriously, I'm blowing through a guy a 60 year career. I'm doing in three minutes. It's not fair, <laugh>.

00:18:21

All right. So anyway, there's a lot of detail about how you lead in that environment, which has a lot of status and hierarchy in it so that you get people to act actively aggressively. Uh, there was a mention of safety before safely, um, seek and call out problem, solve them and share what's learned. Now here, here's the result of running an organization that way the US put to see the first nuclear powered, uh, submarine in 1955. Since then, across all the different generations of attack submarines and ballistic missile submarines, all the different crews which have, uh, uh, sailed on them, all the different shipyards which have built and maintained them. The US Navy's record on safety related to submarines and, and reactors is perfect since 1955. There's been no injury due to reactor failure on a US submarine or aircraft carrier that for that matter, uh, no injury and no environmental damage. Now, alright, now let, I'm just a step back here for a second, right? This is Rick overs dynamic of, hey, if you've got a problem, call it out loudly. If you've, if it's called out, it, it's a, we're obliged to try and solve it. And, uh, if we solve it, we gotta tease somebody. Now, who's the competitor for Rick over in the Navy in the 1950s?

00:19:39

Yes, the Soviet Union and, and l le let's just say we can assume their dynamic was not this <laugh>. Yo comrade Stalin, I got an issue to raise with you, <laugh>.

00:19:52

All right, so what's the result of trying to define de uh, develop nuclear power in an environment where you can't even raise your hand? It's this <laugh>, this is the curse. And the thing is, I could have filled up this slide with failed submarines from the Soviet Navy. Now, yes, well, what was the difference? It's the same basic science, right? The, you know, the universe has laws and they were trying to harness the same laws. They're trying to develop the same materials, the same processes, et cetera. So what was the difference? Was this, I got a problem one side, this was okay, the other side, well, nah, everything's fine, comrade <laugh>.

00:20:32

So, um, anyway, huge difference in performance if you can get this learning dynamic. Now, um, I'll, uh, blow through this example real quick. Um, when I, as, as Gene mentioned, uh, I was inspired around some of these ideas by doing this Karate Kid immersion at Toyota, trying to stand up a first tier supplier factory. And what really got impressed upon me was the absolute profound commitment, aggressive energetic commitment to making sure that no matter what you were doing in an operating setting, you could see things going wrong. And, um, that's like the entire third chapter through my book and elsewhere, is about failures in operation that get ignored. They, they, they may be seen, but they're not swarmed and solved, snowballing to catastrophic effects. So there's one example of a nurse who gets confused in a fairly normal fashion between a vial of heparin and a vial of insulin.

00:21:34

Same touch, same feel, same size, small type, but it's just the right set of circumstances because these confusions hadn't been identified and resolved that those same confusions, uh, cause someone to confuse one for the other and cause patient harm. And a similar thing, uh, NASA's experience both with the challenger in the Columbia, when you do a kind of root causes to, um, why they suffered those catastrophes. The answer in both cases is that there were known problems, but the known problems were frequent enough, small enough to be kind of waved away, normalized and dismissed until the moment that they congealed in a, in, in a fairly fatal way. Anyway, won't spend any more time on this part, worried about it for 15 years. It's in the book, knock Yourself Out. But here, here's another example. Um, so, uh, June 4th, 1942, the Japanese Navy show up at the island of Midway in the Pacific.

00:22:36

They show up with twice the aircraft carrier with which the, um, United States Navy shows up. They show up with, uh, twice the pilots, twice the planes, twice the et cetera, double everything. Now, given that, who should have won the battle of midway Japanese? The Japanese, right? They show up with twice of everything. All right, well, of course it didn't end that way. They ended it, it ended that the United States won the battle of Midway. It was a catastrophic defeat for the Japanese Navy. And, uh, because that catastrophic defeat, it really impacted their ability to wage war in the Pacific for the remainder of the Second World War. So anyway, the reason I put this, uh, book cover on the left, the, the folks who wrote that book had access to Japanese archives. So they didn't write the battle from the US perspective, they wrote it from the Japanese perspective.

00:23:29

The book runs like 600 pages. I mean, it's so big that to read it, you know, I wanted to carry it on trips and stuff. I I cut it down the middle because I, it was too heavy <laugh> and I, and, and you know how when you put your bags through a screen, it wouldn't go through the hole. I mean, <laugh>. So I cut it. I mean, it's a big book. So I cut the book in half and I'm reading through this whole thing, and, and the authors are magnificent. They give you almost like minute by minute, man by man account of what's going on. You know, like, you know, um, this particular pilot as he turned his plane into a bank, you know, this is what it would've said on his instrumentation. It's at that level of detail. So you make it all the way through the end of the book.

00:24:09

And then there's this last chapter, and it starts with kind of like my words, but clearly their intent. The authors say, dear reader, you've just read our 600 page book, congratulations, <laugh>. Now, after reading this gigantic book, when do you suppose the Japanese lost the battle of Midway? So I'm thinking, that's a trick question, right? Because I've seen the movies from Hollywood, and in Hollywood it's three o'clock in the afternoon because at three o'clock, maybe four o'clock in the afternoon, there's some very handsome American aviator. He is got that, you know, square jaw and a scarf and whatnot. And, and, and at three o'clock in the afternoon, he turns his plane and comes diving and he releases his ammunition, right? Exactly. A place to cause a huge explosion and the Americans win. But I'm saying, well, you know, this is 600 page book, not a movie.

00:25:00

So I started flipping through knowing the answer can't be three o'clock in the afternoon. So I'm going back and I'm thinking to myself, well, maybe it's in the morning. Maybe something happened 10 o'clock in the morning, but I, I'm not nearly the front of the book yet. So I keep going and going, and I find a spot late May, the Japanese Navy has some of its ships late to deploy out of the harbors around Tokyo. And so that's it. These guys didn't get to where they needed to be on time. So I'm thinking, all right, you know, I got you, you know, late May, that's when the Japanese Navy lost the battle of Midway Flip the page and the author say, dear reader, you're probably thinking late May <laugh> <laugh>.

00:25:42

The answer is, the Japanese Navy lost the battle of Midway no later than 1929. I'm like, 1929, I'm flip as says, I'm at the table of contents. There's no 1929 in here. I said, you with me? Right? So then I keep reading and I say, well, here's the deal. By 1929, the Japanese admiralty had, um, locked in their assumptions on how war would be fought at sea. They had drawn a whole bunch of lessons off of the 1905 encounter with the Russians, and based on those assumptions that the entire fleet of one nation would meet the entire fleet of another nation, they meet head on one inflicting devastating impact on the other. And the one that got devastatingly impacted its nation would lose the will to fight in 1929. They locked in as that was their doctrine, and everything else was built off of that one assumption about how navies would collide on the high seas.

00:26:40

And so how they designed their aircraft carriers, how they designed their aircraft, how they designed, fueling, arming, launching, recovery, training tactic, et cetera, all came off of that. Now, here's the thing. Once they locked in on that assumption, by 1929, they left it unchallenged. And the book concludes with a description that for midway, not surprisingly, the Japanese admirals had a battle plan. And so going into the Battle of Midway, they said, you know, what we need to do is run a war game to rehearse, stick on that word for, to rehearse our battle plan. So here's what they do. They set up a giant table, like big, huge ping pong table or boardroom table, probably boardroom table, and they're over here and all their Admiral finery. And way down here they got some junior officer Schmo. And over there, their job is to fight the Japanese side.

00:27:36

And over here, his job is to fight the US side. So they take a stick and they shove a little piece of, um, a little wooden ship forward, and he takes his turn, they, they da da da da, back and forth, back and forth. And after a few moves, the referee, you know, throws a flag, blows the whistle. Now, ostensibly, ostensibly, it's 'cause the junior officer is not fighting according to the battle plan. What's the real reason he's kicking butt <laugh>. So what do they do? Well, what should they do? At that point, they should stop, right? Because if that smoke, right? But what they do instead, what do they do instead? They said, well, he's a moron. He doesn't understand the battle plan. Let's get another guy <laugh>. So they got another yo schmo junior officer. Well, he does the same thing. He looks down the table, he looks at the book, down the table, look at the book.

00:28:32

He says, you gotta be outta your flipping mind to fight this way. They got twice everything. So he moves this way and that way, not that way. There's another whistle. And, and, and the way the book ends, you get the sense that they've gone through junior offices, they've gone through petty officers, they've gone through their sailor recruits, and they're just getting noodle vendors off the street to stand over here, but they keep losing. Now, now, from my perspective, I think that's a very good thing. Um, but what, what, what's the, what's the real cause of loss is that they got it in their head that they weren't going to seek out problems. And, and I, I went through the word quickly. They were using the war game to rehearse the battle plan when they could have been using the war game to stress test the battle plan.

00:29:22

But they didn't, they didn't stress test it. They did, they just ignored it, I guess, right? They didn't use the war game to stress test, to use it to rehearse. And because they didn't at that moment find the bugs in their plan, the fault in their thinking, they didn't correct the fault in their thinking. And those fault, that fault in their thinking became fault in their doing. And the good guys win. All right? So, um, what they did is the exact opposite of what Toyota did. They did the exact opposite of what Admiral Rickover did. They didn't seek problems, they didn't solve problems, they didn't spread learning. And why was that? Pathological leaders. So anyway, um, I got about a minute left. Here's the other thing I just wanna offer to you. I, I'll give the example. If, if I run over a minute, gene can sue me. Um, <laugh>.

00:30:12

So, uh, quick example. So, uh, well, so let's go with the positive one. Email me for the negative one. All right? I'll send, I'll send you the paper. This is in, all right, the, the positive ones. So, uh, 61, president Kennedy says, uh, you know, we're gonna send a man to the moon by the end of the decade, return him safe to the earth. And they do that, right? There's a lot of drama. If you haven't seen it, check out the movie First Man, because when Neil Armstrong and his crew mate are getting ready to land on the moon, they discover that NASA has picked sort of a cruddy landing spot. And the way the story goes, something like with, um, 30 seconds of fuel left, they turn off the autopilot, manually fly the lunar, uh, excursion module to a safer place. And when they land, they land with about eight seconds of margin of error left.

00:31:02

And you go like, damn heroes. How'd they improvise? Literally, figuratively on the fly like that to figure out what to do with 30 seconds left to go? The answer is they didn't improvise at all. And so the picture in the bottom right, that spotty spidery leg contraption was the earth version of this lunar excursion module in which a flight simulator in which the astronauts practiced all sorts of screw up scenarios. Now, the reason I bring that up, our natural inclination is to prepare to practice, to rehearse for the situation. We expect what we consider normal, what we don't do is gain, typically what we don't do is gain competency in the outliers. And if we don't gain competency in the outliers, again, ask me for the article, we get results like this rather than heroic results like this. So anyway, just to finish up here, um, my slides will be up on the website, but there's a set of actions you all can take. For example, during planning, when you have a plan or a code, whatever it is, do you show it to your colleagues and advocate for it and say, oh, well, let me tell you here, here's my plan, here's my code, here's my design. Lemme tell you all the good things about it. Or do you stand up and say, here's the best I could do. Now tell me what's wrong.

00:32:28

All right, now that's uncomfortable, but that's necessary. Similarly, if you supervise other people when they put something up, do you say, oh, that was nice, da da da, da. Or do you help them discover the faults? That's the planning side. And then anyway, one, so here's what you can do in terms of your just basic habits of the day. Um, when you go up to somebody, you say, Hey, how's it going? What are you doing? Their inclination will be, ah, hey, everything's going fine. And your question has to be, what's not working? Not 'cause what's you're not doing wrong, but what's wrong with the situation we've created for you that's not working? And then ask the question next. Well, why isn't it working? What do, what, what's your understanding? You're the person who's got the most tactile sense of it not working. And why? What can we learn from that?

00:33:25

What can we change and, um, what can we teach? Alright, anyway, that, that's my slides. Gene asked me, he said, Steve, you know, last in the day, you can do a little, uh, what you're up to now, what's new? And also it's sort of, all right, so we'll get through these guys in a paper. Send me an email. Um, in terms of what's new is that, uh, we've, um, over 15, 20 years now have been wildly, aggressively advocating for this dynamic of seeking problems so that they can be solved. And in the seeking, the, the identification, the investigation, the solving something can be learned both individually and collectively. What we've discovered, what we've discovered is that this is wicked hard to do in large organizations with a workforce that's dispersed and a workforce, which is mobile. Nurses in hospitals think, think about mechanics and technicians at an airfield, so on and so forth.

00:34:20

So anyway, we've created a little piece of technology. See, I wanna fit in with y'all guys 'cause the bow tie's not doing it. So I wanna have a tech angle. So we created a, a piece of software to solve for the problem that the person with the problem, uh, can't tell anybody in an effective, efficient fashion. So they kind of sweep the problem under the rug until it explodes on them or someone else. And so the format of this is that we've put on mobile devices a quick, it's sort of a portable land on court for the lien people in the room, portable land cord, you know, 3, 5, 10 seconds. Boom, I've got a problem. That becomes a ticket to someone who owns that type of problem to come and help. And here, right, <laugh>. And, um, so Steven, what is the help you're looking for?

00:35:04

All right, so anyways, so here's the help. I'm looking for 10 more seconds. <laugh> eight, seven. All right, so here's what we're looking for. We're looking for the fourth guy. We got three guys. Now, you know this, A lot of this grows outta my own work and interaction with folks. We've got a guy who's really good at, uh, getting, uh, users set up. We got another guy. Let's just say he has a perfect personality for the technical side of things. What we need is the fourth person who can, uh, when we have a lead, develop that into a real possibility. And if there's anyone in the room who might want to be a user, let us know too. Thank you, <laugh>.