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particular combination of psychological safety and accountability.
I ERR, THEREFORE I LEARN
Years ago, an engineer turned management professor named Amy
Edmondson became interested in preventing medical errors. She went into a
hospital and surveyed its staff about the degree of psychological safety they
experienced in their teams—could they take risks without the fear of being
punished? Then she collected data on the number of medical errors each
team made, tracking serious outcomes like potentially fatal doses of the
wrong medication. She was surprised to find that the more psychological
safety a team felt, the higher its error rates.
It appeared that psychological safety could breed complacency. When
trust runs deep in a team, people might not feel the need to question their
colleagues or double-check their own work.
But Edmondson soon recognized a major limitation of the data: the
errors were all self-reported. To get an unbiased measure of mistakes, she
sent a covert observer into the units. When she analyzed those data, the
results flipped: psychologically safe teams reported more errors, but they
actually made fewer errors. By freely admitting their mistakes, they were
then able to learn what had caused them and eliminate them moving
forward. In psychologically unsafe teams, people hid their mishaps to avoid
penalties, which made it difficult for anyone to diagnose the root causes and
prevent future problems. They kept repeating the same mistakes.
Since then, research on psychological safety has flourished. When I
was involved in a study at Google to identify the factors that distinguish
teams with high performance and well-being, the most important
differentiator wasn’t who was on the team or even how meaningful their
work was. What mattered most was psychological safety.
Over the past few years, psychological safety has become a buzzword
in many workplaces. Although leaders might understand its significance,
they often misunderstand exactly what it is and how to create it.
Edmondson is quick to point out that psychological safety is not a matter of
relaxing standards, making people comfortable, being nice and agreeable,
or giving unconditional praise. It’s fostering a climate of respect, trust, and
openness in which people can raise concerns and suggestions without fear
of reprisal. It’s the foundation of a learning culture.
In performance cultures, the emphasis on results often undermines
psychological safety. When we see people get punished for failures and
mistakes, we become worried about proving our competence and protecting
our careers. We learn to engage in self-limiting behavior, biting our tongues
rather than voicing questions and concerns. Sometimes that’s due to power
distance: we’re afraid of challenging the big boss at the top. The pressure to
conform to authority is real, and those who dare to deviate run the risk of
backlash. In performance cultures, we also censor ourselves in the presence
of experts who seem to know all the answers—especially if we lack
confidence in our own expertise.
A lack of psychological safety was a persistent problem at NASA.
Before the Challenger launch, some engineers did raise red flags but were
silenced by managers; others were ignored and ended up silencing
themselves. After the Columbia launch, an engineer asked for clearer
photographs to inspect the damage to the wing, but managers didn’t supply
them. In a critical meeting to evaluate the condition of the shuttle after
takeoff, the engineer didn’t speak up.
About a month before that Columbia launch, Ellen Ochoa became the
deputy director of flight crew operations. In 1993, Ellen had made history
by becoming the first Latina in space. Now, the first flight she supported in
a management role had ended in tragedy. After breaking the news to the
space station crew and consoling the family members of the fallen
astronauts, she was determined to figure out how she could personally help
to prevent this kind of disaster from ever happening again.
Ellen recognized that at NASA, the performance culture was eroding
psychological safety. “People pride themselves on their engineering
expertise and excellence,” she told me. “They fear their expertise will be
questioned in a way that’s embarrassing to them. It’s that basic fear of
looking like a fool, asking questions that people just dismiss, or being told
you don’t know what you’re talking about.” To combat that problem and
nudge the culture toward learning, she started carrying a 3 × 5 note card in
her pocket with questions to ask about every launch and important
operational decision. Her list included:
What leads you to that assumption? Why do you think it is correct?
What might happen if it’s wrong?
What are the uncertainties in your analysis?
I understand the advantages of your recommendation. What are the
disadvantages?
A decade later, though, the same lessons about rethinking would have
to be relearned in the context of spacewalk suits. As flight controllers first
became aware of the droplets of water in Luca Parmitano’s helmet, they
made two faulty assumptions: the cause was the drink bag, and the effect
was inconsequential. It wasn’t until the second spacewalk, when Luca was
in actual danger, that they started to question whether those assumptions
were wrong.
When engineer Chris Hansen took over as the manager of the
extravehicular activity office, he inaugurated a norm of posing questions
like Ellen’s: “All anybody would’ve had to ask is, ‘How do you know the
drink bag leaked?’ The answer would’ve been, ‘Because somebody told
us.’ That response would’ve set off red flags. It would’ve taken ten minutes
to check, but nobody asked. It was the same for Columbia. Boeing came in
and said, ‘This foam, we think we know what it did.’ If somebody had
asked how they knew, nobody could’ve answered that question.”
How do you know? It’s a question we need to ask more often, both of
ourselves and of others. The power lies in its frankness. It’s nonjudgmental
—a straightforward expression of doubt and curiosity that doesn’t put
people on the defensive. Ellen Ochoa wasn’t afraid to ask that question, but
she was an astronaut with a doctorate in engineering, serving in a senior
leadership role. For too many people in too many workplaces, the question
feels like a bridge too far. Creating psychological safety is easier said than
done, so I set out to learn about how leaders can establish it.
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