Precursors of Consequence
“Leadership”
A persistent, unresolved topic in the infancy of the urgent focus on the drilling industry is well
containment and the emerging discipline of process safety during the drilling and completion of
oil and gas wells. There is interest in knowing if there are leading indicators of the safety of our
operations and yet few proclamations of any valid examples. Part of the reason of why this is
so is both the lacking in our industry of sufficient interest and focus on this subject and the
complexity of subject matters that must be mastered in order to develop such indicators. The
driving cause behind this lack of interest and focus is the subject of this chapter in my
installments of thoughts on engineering management of the most complex and dangerous well
construction projects and true leadership and the precursors of consequence in this endeavor.
First of all let’s examine the driving force behind our industry and the unintended consequences
in lack of leadership in the most complex and dangerous operational teams that explore and
develop the fields of our future. Our industry’s developments have been lead by nations with
cultural traits that innovate and take risks in the face of uncertainty and unknown “worst cases”,
in exploring and developing the most accessible and cheapest to develop fields of the past
using a “do, hope and mitigate” mindset and yet do not lend themselves to key mindsets needed
in order to explore and develop in the most complex and dangerous situations we will be facing
more and more as these easier and cheaper to develop fields are depleted luxuries of the past.
Examples of the “do, hope and mitigate” mindset can be seen from the Spindletop Field, to the
deepwater arena, where at Spindletop the wells were allowed to essentially “blow out” and then
oil was contained within “berms” built around the derrick and the oil pool was collected and
hauled away to sales. This of course would not meet any of the most lacking standards of today
and yet it is still the model by which our industry has been “following” lagging standards of
operation and the “do, hope and mitigate” mindset. We also see most recently that our
operations have been “do, hope and mitigate” mindset following the recent discovery that even
though industry experts had announce in industry technical articles that the dangers of drilling in
deepwater were the unmitigatable prolonged blowout. How easily these warnings are ignored
are a tribute to the explorer instinct and focus on the “do, hope and mitigate” mindset that acts
where other more “uncertainty adverse” mindsets do not, and this mindset should be applauded
as a first step to commit to act facing uncertainty and is clearly an advantage to cultures that are
adverse to explore because of the uncertainty. Yet we move above and beyond this mindset, to
include the explorer spirit and subjugate it to the leadership spirit and mindset that uses the
wisest leadership principles and looks to measure and manage leading indicators and apply this
to themselves and their organizations that is the essence of the focus on the Precursors of
Consequence. Even more so today we are looking at and developing lagging indicators and
mitigations and this is the way of strong appetites for uncertainty that have defined the corporate
cultures that have brought us here, and must be applauded, and yet will not get us there, to the
future full of the most difficult, complex and dangerous projects. In the past we, as an industry,
have for the most part skipped over projects involving the deepest of water locations and the
sourest of oil and gas reserves with preference for the easier and cheaper alternatives and yet
today we are faced with the need to explore and develop in these areas and the good news is
we have the technology and the leaderships wisdom right before us and we merely need the
discipline of process safety leadership to include them. In order to develop the healthiest of
safety culture in the projects with the highest levels of interactive complexity and tightest
coupling we must develop that highest levels of leadership, knowledge, understanding and
wisdom and relegate our mitigation based safety programs to a lower tier in the safety pyramid.
Leading indicators of consequence; "precursors of consequence" are simply the operational
envelope as referred to in other industries. In the above Mach 1 flight operational industry this
is referred to as the “flight envelope”. Our industry esteemed Dr. Andrew Hopkins cited in his
recent article “Why Safety Cultures Don’t Work”, to an air traffic control term known as
“maintaining separation". Its not “too simple” to conclude that “leading” means using leading
indicators and following means focusing too much on lagging indicators and yet it is strongly
asserted that they are exactly appropriately named and safety leadership must lead by
prevention and leading indicators and move away from mitigation based safety programs. It’s a
delicate balance that’s most important and yet prevention is a focus on the operational envelope
that must balance a margin safely between loads and our resistance to them. It’s focusing on
things right before us and akin to personal safety issues of how our fingers and toes are
interacting with loads, and obstacles while we perform routine operations and yet first and
foremost, in the realm of planning interactively complex and tightly coupled operations, and
building and managing the teams that are executing them safely in real time. So many lagging
indicators are being pursued, very well in fact (WCD designs, capping stacks maintained and
ready for use, etc.), that they have become distractions in their simplicity and tendency to focus
blame for the incidents on frontline company men and “bungling” in general by the “culprits” that
the frontline worker become in the hearts and minds of the “in group” away from the frontline, in
management. And mitigating their "failure to follow" (lagging errors) rather than addressing
their own immediate shore based operational and engineering "leadership" becomes the norm
and the frontline worker is viewed as a dangerous component of an otherwise perfect system
rather than the reason their imperfect system works perfectly most of the time. This additional
mitigational “arsenal” is a good thing, if companies continue to have these types of blowouts, yet
not if they distract focus from "leading" indicators to "lagging" consequences, as this is foolish
and dangerous of course. The fact that many asked to follow this logic and agree it is true will
not, should only be a further sign of how detrimental the conclusions, of the US Department of
Justice indictments of company men minus even the slightest implications of shore based
leadership, has been to learning the true lessons needed to avoid the type organizational
accidents in the future. Prevention based leadership is focus on our margins and remaining
within operational boundaries and mitigation is always from drifting outside of them. We should
not spin the fact that boundless operations and the myriad mitigations are safe simply because
of low incidence because of the high cost and more importantly because it is not leadership.
The fact is that the handling of the “mitigation” based investigation of the Macondo incident is
bizarre and even schizophrenic because the US Justice system is pursuing indictments and
fines that are aimed at BOTH the frontline workers and organizational causes yet not leadership
and with neither the intent nor the diligence necessary to remove the veil of obscurity that
engineering management hides comfortably behind in these weakest cultures while the
government attorneys can only wish to bring cases against them and must instead go after the
easier cases of prosecuting defenseless frontline workers left dangling before them by authories
in the same corporation. Is the problem with the frontline worker (the followers), or the
engineering management (the supposed leaders), and how can it be both? Even if it is a little of
both how can this ambivalent focus be resolved in this way without careful examination of the
leadership and procedural compliance aspects of the precursors to the accidents in a
situational, instead of attributional scope? We may all wax poetic for “the day we can actually
have accountability” in the leadership of the operations in the most individualistic cultures and
even legislate attempts to hold key leaders accountable with signatures (Well Containment
Plans must be signed by a manager now because of new rules in 30 CFR 250 Subpart D), and
document courses of actions and responsibilities and yet until we can sort through this veil of
obscurity of the inner workings of the precursors of consequence, that define true leadership, in
creating and maintaining corporate culture we are managing by mitigation of our boundless lack
of discipline in focus and efforts. This ambivalent opinion of the causes of this type accident is
common in these type cultures that have a strong sense of individual responsibility and it is
furthermore suggested that some cultures are more susceptible to this type of organizational
leadership and communication failure than others, for example the more "individualistic" cultural
trait as highlighted by Geert Hofstede, in his world renowned studies on culture and its
implications on safety, and the "attributional" culture as highlighted by Dr. Carol Dweck of
Stanford. It seems the highly "individualistic" cultures may have tendencies towards both
"defects" and be highly prone to these types of organizational failures in leadership, learning,
communication and effortful focus on the matter close at hand that are the precursors of
consequence. Individualism tends towards challenges in true communication and coupled with
low PDI can lead to further disparate silos of information, communication, and decentralization
of organization command structure, again, cited by Dr. Hopkins as key to the recent
organizational accidents in our industry. Also, the most individualistic cultures are more prone
to the “unjust” culture as opposed to the “just” culture that examines accidents and incidents in
light of the situation instead of moving too quickly and subjectively to blame of the “individual”
(fundamental attribution error), responsible for procedural compliance of designs of engineering
and operational leadership teams usually sitting in the ivory towers miles away from the dangers
on the frontline. Unfortunately, blaming individuals for organizational failures has no effect
other than to further polarize individuals from a sense of loyalty and duty to the group as a
whole and further complicates communications, order, responsibility and the reliability of the
group as a whole. Transparency and openness most necessary in the healthy function of teams
of engineers, mechanics, technicians and operational team members is compromised by the
very nature of the isolating and threatening nature of the way these cultures learn lessons, or
rather, do not learn them. The 10 countries lowest in UAI in the world are western countries
deeply involved in the oil business and the top three, UK, US, and Australia, comprised the
organizational personnel involved in Macondo and Montaro. Low UAI in those countries has
served those cultures well in terms of innovation and yet has dangerous implications if this
cultural trait is not managed and is ignored by engineering operations management. Coupling
the highly individualistic cultural traits with low Power Distance Indices (PDI in Hofstede's
studies) can lead to a breakdown in supervision and guidance and sever the ties necessary for
frontline workers to be encouraged to "stop work" and call in for guidance and support from
engineering vital during the most complex operations. In fact some of the interesting discussion
surrounding the spectrum of cultural traits in regards to PDI seem eerily close to the causes of
organizational failure at Macondo by Professor Hopkins in his book and reports. For example
low PDI can result in:
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Expect to encounter less centralized and even de-centralized organizations,
divisions, departments, teams and decision-making
Expect a high degree of delegation
Expect subordinates to take initiative
If unforeseen things happen, frontline workers are less inclined to first go to their
direct boss to ask for instruction before acting
Expect your work to not be inspected by a team leader from a low PDI culture.
Probably the worst thing that could be added to a culture naturally laden with the issues
described above would be a tendency to disregard uncertainty and yet if we look at both
extremes of the spectrum of Hofstede’s Uncertainty Avoidance Index (UAI) we most certainly
would expect a statement such as, “It will probably be okay”, to be immediately and diligently
challenged and only be accepted in a culture of extremely low uncertainty avoidance and yet a
careful look at Hofstede’s research shows the British culture of BP to be amongst the lowest
UAI of all nations; bottom 6 in fact. Naturally some will claim the accident was the fault of
American front line workers yet keep in mind that the US is in the bottom 12 in UAI also. So
there really is nowhere to run and hide on this issue. Is it any wonder then, after learning of
these facts of the national cultural traits of the UK that their Long Term Orientation (LTO) index
is amongst the lowest (4th lowest value) in the world? Of course not since that combination of
traits is not sustainable so it would make since that sustainability is not a high priority. The point
isn’t to use cultural traits as condemnation and yet to measure the prevalent cultural traits that
exist in order to prevent the mishaps that are bound to happen otherwise and put the onus on
management and not frontline workers effectively carrying out orders. In light of these cultural
facts BP’s management should definitely endeavor to recognize and aggressively balance this
national cultural trait with preventative measures especially while working in a nation with
equally low numbers on a certain cultural trait. The campaigns are in full gear and the platitudes
abound with more safety slogans and assurances than ever before and yet if developing a
safety culture is of prime importance truly Hofstede’s work in this area should be fresh and
foremost in the minds of managers of the dangerous operations most in need of preventative
measures that facilitate prevention based management.
The recipe for disaster in incidents at Macondo and Montara were organizational and
specifically cultural and so these cultural indices must be carefully understand well first before
hoping to master them. Chasing after lagging indicators and having such weak bonds
"collectively" to those on the front line at the sharp end of the organizational hazard is the
antithesis of leadership in safety and must be recognized before there is even hope of
improvement. In the most complex operations is where lagging mitigation based management
fails and where preventative based mitigation must begin with preventative measures before
preventative management is even remotely possible.
Perhaps the strongest reason that organizations fail to lead and therefore resort to following
lagging indicators and essentially “chasing their own tails” is in the lack of understanding of how
to manage the most important things that comprise the precursors of consequence in these
highly interactively complex and tightly coupled design teams and operations. We only need to
simply ask ourselves, “how can we predict performance while operating without looking at
consequences that are essentially lagging indicators or how we are doing things?” to
understand that research and development in these regards is both insufficient and not oft even
considered. The fact that engineering management ranks are often devoid of any specifically
disciplined focus on the particular nuances of management of complex engineering projects and
mostly consist of nothing more nor different than MBA management programs focusing on
performance controls that have been widely in use in our industry for far too long already.
Namely, the days versus depth curve that is tightly coupled with the Cost versus Days curve
that is compared against the benchmark of past, lagging, performances of other projects that
usually are completely different to the current project in vitally important specific areas and used
as a management control to the horror of observers of the distracting effect this type of
engineering management has on the focus of engineering teams. How then do we manage the
most important leading indicators of performance in our work and do we even have a clue to the
nature of this components? The short answer is that up until now there is nothing done in this
regards and there is little to know science except for a relative few that we will discuss shortly.
We need only look at the definitions of risk in our industry to understand how little has been
done and how confused we seem to be on the actual subject of risk and the components that
actually comprise this most important parameter and component of our industry. We can list the
various equations and proponents of them and debate this yet it makes little difference to these
facts of lacking. Einstein said, Risk = Consequence x Probability yet consequence is a lagging
indicator and probability is based on past performances and other estimations of the future and
therefore this simple equation suffers from both. If we remove “Probability” entirely from the
equation and focus our efforts at leadership on defining the components of “Consequence” in
this equation or as the title portrays, “Precursors of Consequence”, we can act at the origins of
leadership and truly lead. What are the “Precursors of Consequence”? Precursors of
consequence of been defined in the history of risk management hazard awareness precursors
of consequence or exposure to hazard and susceptibility to hazard is the epiclipse of these two
realms and the area in which they coincide and overlap. This is the “breakdown of separation”
that Dr. Hopkins referred to and the is pushing beyond the “envelope” in the lingo of super Mach
flight operations. Consequences result in essence to maintenance of separation between the
load and resistance and hazards and poor consequences emerge from their epiclipse. More
simply, in medical terms, Consequence = Dosage x Susceptibility, in the term dosage could be
diligently broken down further into exposure level because we can be given a dose and we are
more or less exposed to its effects based on issues like dilution or proximity. So in terms of
radiation Consequence = Hazard Exposure x Hazard Level x Susceptibility to Hazard. So the
operational envelope IS the precursors of consequence. In order to LEAD in engineering we
must manage the precursors of consequence, yet this isn’t as simple as an equation. In order
to lead the precursors of consequence we must first know what the precursors of consequence
are. In engineering precursors of consequence, the operational envelope, is typically load
versus resistance. Yeah we must be exposed to the load that our structures are not exposed to
we do not have to resist the concept of exposure were exposed to load and are structures must
resist our exposure to the load. Similarly the wellbore we drill in order to construct a well is also
exposed to natural loads of the earth mainly as pore pressure and in situ stresses. Our buffers
and margins and susceptibilities are intricately intertwined and going into the complications of
our natural, physical and human barriers isn’t the point of this chapter or Precursors of
Consequence and yet it is that we must manage our FOCUS on precisely these Precursors of
Consequence because from these precursors hazard itself emerges. The concept of the
Tactical Triangle is used in sports performance and it manages the thoughts and efforts of the
athlete. The concept focuses on three elements: Consciousness, Sub-consciousness and
Confidence; conscious effort, subconscious effort and the leading indicator of confidence rather
than the lagging indicator of confidence (let’s leave that to explain in more detail later on). Our
skillsets and the detailed steps we perform routinely can be distracting to the conscious focus
we must maintain on detecting flaws in the system an namely that is, as we just explained
before, the precursors of consequence or the operational envelope that is our exposure and
resistance to loads and the hazards that emerge from any “breakdown in separation” between
these two. Just as when a teenager drives, the insurance companies know they are at high risk
since the beginning driver has not yet put the actual mechanical and coordination skills of
turning the steering wheel and moving the feet for the gas pedal and to apply the precise
amount of pressure to the break into the subconscious so that their conscious effort can be
focused on the efforts required to maintain “separation” between their car and others including
also between the lines comprising driving lanes, curbs, stop signs, traffic signals and maps and
other necessary cognitive loads all distracting from the most important focus in safety; the
operational envelope of keeping separation between loads and resistance or in driving this is
keeping distance between our car and other objects. Yes, we have mitigations like bumpers
and safety belts and traffic statistics yet everyone knows that leadership is the best prevention
in traffic safety and focus on the flight envelope that includes the physical limits of the car we
drive, the lack of predictability of the environment around our car, and the complex interactivity
of us and them, as well as our ability to focus on maintaining the “separation” or “margin” during
moments of higher cognitive loads like during merging to other lanes in turnpikes on freeways,
or in busy intersections or even in crowded parking lots. In these environments a screaming
child, loud radio or a text message can be the tipping point that moves our “cognitive load” into
the epiclipse with our “cognitive capability” or “ability”. Experience understands that cognitive
loads and resistance are as vital as physical loads and resistance. The physical barriers of the
wellbore are the hydrostatic and the BOPE controls and yet humans maintain both and thus
both are susceptible to the cognitive operational envelope of cognitive load and resistance. This
is a lot to digest and yet this is where our CONSCIOUS focus must be on projects. Our
subconscious must be busy doing the actual routines elements of our jobs like turning the
steering wheel and stepping on the brake. Confidence in our process is believing that if we
focus our efforts on these items closely, instead of the outcome, the result will be satisfactory.
This concept may not be perfectly clear until we consider the difference in performance controls
of the MBA style and these precursors of consequence. Focusing on outcome oriented, lagging
indicators, is in direct contrast to focusing on process oriented, leading indicators, and is the
goal of explaining sufficiently to be completely understood in this chapter.
So now the we have defined one element of leadership by focusing on the precursors of
consequence we must also delve diligently into understanding that in order to manage and lead
we must measure focus and effort and direct both. Management may be to measure and yet
leadership is to manage and direct efforts, and focus and to build and maintain teams that are
competent in skills and adequate in experience and energy so as to be able to focus conscious
efforts on the operational envelopes and perform routine duties in the subconscious and
maintain confidence in the process. This may be complex yet it is much more clearly linked to
improvements in performance and leadership than tracking lagging indicators and campaigns to
win over the hearts and minds of frontline workers with platitudes and slogans than win over
neither the minds nor hearts since they have no practical significance to the duties in the line of
sight of the worker’s conscious nor subconscious efforts and even less significance to their
confidence in the system.
So now we have discussed the need to lead and the things that must be led and these are
efforts and focus and confidence. Confidence is a sales job yet we must lead a culture by
creating processes that inspire confidence and not the other way around. People know when
we are involved in a process that will work. At times we may need this explained and then we
can see directly that the process is practical and effective and exactly the precursor of success.
Managing effort
This whole concept of “managing effort” might better be summarized for engineers as
“Engineering Effort Vectors”. As explained before we must not only measure effort in order to
manage it we must lead effort by directing it as well. This is summarized as “measuring effort
scalars” and involves a concept that students about to entire the job market are all to aware of
and employers need to become more savvy on and consciously effortful in distinguishing
themselves and their recruits in. Engineers know a scalar quantity if without direction and this is
the best way to measure effort and let’s break this down and explain both why this is significant
and how this may be done. Effort in the wrong direction is as bad as no effort at all or even
worse. Companies that hire based on GPA are not getting the most diligent assessment of the
effort and focus scalar since they are only getting a superficial measure of effort, focus,
discipline and diligence vectors. Four components that are not necessarily considered are that:
1. School is effort focused on the goals of the student, namely to get good grades
and a good job and speak nothing to the ability of the student or person that will
be asked to commit themselves to the goal of the employer. This change in
direction may or may not be assessed by coursework that is done based on
selfish goals of the student. Simply put, grades do not measure the cultural trait
2.
3.
4.
5.
of “individualistic” versus “collectivistic” nature or desire to subvert goals from
selfish, or individualistic intent to those of a larger group. And there is evidence
that this is not only cultural and yet also more motivational and contrived. Only
an effort “vector” is assessed and there is no evidence of the effort “scalar” that
can be directed in a superficial assessment of a candidate engineer based solely
on performance in school.
School is effort that is focused by the teacher and the curriculum and the student
is instructed what to read, what exercises to do, and what will be covered on the
test so the students ability to self focus efforts, or create his/her own effort vector
is not necessarily assessed by grades in school. Only a focus “vector” is
assessed and there is no evidence of the focus “scalar” that can be directed in a
superficial assessment of a candidate engineer based solely on performance in
school.
Namely discipline is the ability to focus efforts correctly without guidance beyond
personal experience and scholarship. Operational envelopes can become
unstructured and nebulous and requires diligent, effortful focus and confidence in
order to maintain discipline and school and grades simply do not necessarily
assess this. Only a discipline vector is assessed and there is no evidence of the
discipline scalar, that is more character based, that can be directed in a
superficial assessment of a candidate engineer based solely on performance in
school.
Diligence is a measure of an effort over time and teachers that will more often
than not set into the curriculum and instruction to students as to “how deeply” to
investigate concepts and ideas also direct space and in fact the textbook is the
basic limit to the amount of diligence required. While the students diligence to do
the reading and study is a measure of the diligence vector the assessment is
limited in both direction and scope since this is dictated to the student generally.
Confidence is generally the only scalar quantity that is clearly a result of a college
education and that is because repeatedly the student is shown that focused and
effortful study results in good outcomes. This is true confidence as opposed to
superficial arrogance and is fierce determination in humble efforts here and now
with confidence in an undetermined outcome at a later space and time.
Clearly we see the need to assess scholars on the scalar level (precursory to directed effort) in
order to distinguish effort scalars that can be given direction and focus scalars that can be
directed to focus on requirements and discipline and diligence to be able to self direct diligent
focus on their duty level and this is key to their ability to not be distracted from a focus on the
operational envelope of the duty they are charged with. Grades are effort vectors, focus vectors
and do not necessarily assess the two most important parameters of success diligence and
discipline. We must work hard to find and hire effort, focus, discipline and diligence scalars
(scholars) that can be employed, directed, supported and relied upon by diligently distinguishing
between the notions of leading and lagging indicators.
Red Adair is quoted as saying, “If you think a professional is expensive, wait until you hire an
amateur”. A similar wise tale goes like this, “A consultant is hired to fix a complex system and
the man shows up in a finely tailor suit and after carefully looking over the facility he walks over
to a specific component, takes out a tiny hammer and carefully and gentle pings a spot on a
panel and the entire system begins working. The entire process takes only a minute or two.
The consultant details his $100,000 bill as follows:
Hammer to strike panel
$50
Time to strike panel
$50
Knowing where to strike
$99,900
Thank you for your repeat business!”
Both stories relate to the importance of “directed focus and effort”. Direction makes scalar effort
and scalar focus, vectors. Our processes must measure, direct and thus create focus vectors
and effort vectors.
A quick note on the component of diligence as it relates to engineering effort, performance,
safety and ultimately success and its contrast to the unfortunate byproduct of focus on lagging
indicators of performance control mainly used in engineering management in the past and the
fact that a popular book of wisdom is quoted from as saying, “The plans of the diligent lead to
profit as surely as haste leads to waste”, and in essence putting “Diligence and Haste” as polar
opposites and thus this note is highlighting the importance of diligence and suggesting that
diligence itself combines the scalar quantities we’ve just discussed, effort, focus, direction, and
discipline, into one concept. Another wise saying is, “Wisdom is before the understanding one
yet the fool looks to the ends of the earth”. Now, firstly there is a component of both space and
time in that saying. The “ends of the earth” is in reference to the boundaries created as the
earth revolves and “races” around its rotational axis and also time as our time system is in fact
precisely and exactly how long this takes. There is a no more clearly, simply and widely
disseminated statement of safety and leadership principles than this. The operational envelop
contains the leading indicators of our leadership and we must focus on these, measure them
and manage them to maintain our operational safety margin and prevent the breakdown in
separation between our operations and the “envelope” that protects them. This couples nicely
with the previous statement on “haste” and reinforces that a focus on time and outcome is the
polar opposite of the local focus in time and space on “diligent” “efforts” here and now before us.
Instead of focusing on outcome and the time aspects of money and there existence at the “ends
of the earth” in time and space management must “control” using confidence measures.
Confidence in our operations is a strong function of diligent efforts focused on precursors of
consequence. Confidence is likewise completely defined in regards to its control function in
leadership and process by a saying, “Do right and have confidence (exact quote needed)” yet
“lean not on our own understanding” this implies to be confident yet not that we know everything
yet that if we keep value the “collective” wisdom of history and people around the world (time
and space) and keep open minds, value cooperation, and consultation with others, and
diligently focus efforts on the precursors of consequence closest in front of us we should be
confident. From experience, many find this is precisely true and in fact the only way to have
and maintain true confidence in our corporations and move above and beyond campaign
slogans that are superficial, mitigation based, and essentially “con artistry”. “One who is slack in
his work is the master of destruction”. Again, the principle of “effort vector” of Dr. Dweck, “effort”
focused on “one’s work”, is indicated as “wisdom” and a leadership value. The detailed proof of
this leadership concept is not “far fetched”, yet precisely the opposite, it is closest at hand in
space and time, and can and will be presented in due time by others amongst us or even by
myself, if it is desired.
Boundless focus
Focus on performance over efforts
Basing risk on performance over efforts
The ways of limitlessness (mitigation based)
Spin Doctoring of haste (explaining mitigations away based on duplicitous rationalization)
Within bounds
Balance is simply the space between upper and lower bounds the middle is safest and
balance can have width and it's called buffer or margin this is the loci of foci this is the
operational envelope we must focus our conscious efforts on since the epiclipse of hazard
emerges here and now.
Too much effort with no distance or insight vision is on the same level as much distance or
insight with less effort; we must optimize and work in the balance and widen it's margins this is
the focus of engineering management optimization
Seems simple yet big deal since effort versus superficiality is like elliptical: 2
categories: distance. Effort
Who is right? The fact is in engineering it's effort that is necessary for work thoughts invoke
mental effort that is metaphysical whereas physical work involves both. So there is a place for
distance yet twice important is effort. Dr carol Dweck says
Distance is lagging effort can be measured here and now and is therefore leading
So you see effort is worth and effort management IS LEADERSHIP
Grades are effort vectors
We must work hard to find and hire effort scalars and diligently distinguish between the two
notions Lagging mitigation based and leading prevention based management by diligent effort in
preventative measures and this means measuring leading indicators and not simply making
rules that prevent nothing.
Proverbs
1:7 The fear of the Lord is the beginning of knowledge; fools despise wisdom and discipline.
1:10-16 My son, if sinners entice you, do not consent; if they say, "Come with us; let us lie in
wait for blood; let us hide for the innocent, without cause; let us swallow them up alive like the
grave, and the whole ones like those who descend into the pit. We will find all precious
possessions; we will fill our houses with plunder. Cast your lot among us; we will all have one
purse my son, do not go on the way with them; restrain your foot from their path, for their feet
run to evil, and they hasten to shed blood. (unjust culture “in group” that cultivates the injustice
using the fundamental attribution error and making sure this principle is disseminated so they
can cut the costs of the diligent planning without regard to cost so the “out group” the frontline
workers can be blamed for all accidents)
2:7-15 He lays up sound wisdom for the upright, a shield for those who walk in integrity; to keep
the paths of justice, and watch the way of His pious. Then you shall understand righteousness,
justice, and equity, every good path. When wisdom comes into your heart, and knowledge shall
be pleasant to your soul, thought shall watch over you; discretion shall guard you, to save you
from an evil way. From a man who speaks perversity; [from] those who forsake the ways of
uprightness, to go on ways of darkness; [from] those who rejoice to do evil (operate without
focus on the operational envelope) and delight in the perversity of evil (delight in how “lucky”
they are to be successful despite the due diligence and process of effortful, vigilant focus on the
operational envelope), who are crooked in their ways and perverse in their paths.
3:1-35 My son, forget not My instruction, and may your heart keep My commandments; for they
shall add length of days and years of life and peace to you. Kindness and truth shall not leave
you; bind them upon your neck (self discipline, effort, diligence), inscribe them upon the tablet of
your heart; and find favor and good understanding in the sight of God and man. Trust in the
Lord with all your heart and do not rely upon your understanding. Do not be wise in your own
sight; fear the Lord and turn away from evil (boundless operational focus; distraction from the
bounds of the operational envelope), it shall be healing for your navel and marrow for your
bones. Honor the Lord from your substance and from the first of all your grain, and your barns
shall be filled with plenty, and your vats will overflow with new wine. My son, despise not the
discipline of the Lord, and do not abhor His chastening, or the Lord chastens the one He loves,
as a father placates a son. Fortunate is the man who has found wisdom and a man who gives
forth discernment, for its commerce is better than the commerce of silver, and its gain [is better]
than fine gold; it is more precious than pearls, and all your desirable things cannot be compared
to it. Length of days is in its right hand; in its left hand are riches and honor. Its ways are ways
of pleasantness, and all its paths are peace. It is a tree of life for those who grasp it, and those
who draw near it are fortunate. The Lord founded the earth with wisdom, established the
heavens with discernment. With His knowledge the depths were split, and the heavens drip
dew. My son, let them not depart from your eyes; guard sound wisdom and thought, and they
shall be life for your soul, and grace for your neck. Then you shall go securely on your way, and
your foot shall not stumble. If you lie down, you shall not fear, and when you lie down, your
sleep shall be sweet. Be not afraid of sudden terror, or of the darkness of the wicked when it
will come. For the Lord shall be your trust, and He shall keep your foot from being caught. Do
not withhold good from the one who needs it when you have power in your hand to do it. Do not
say to your fellow, "Go and return, and tomorrow I will give," though you have it with you.
Devise no harm against your fellow, when he dwells securely with you. Do not quarrel with
anyone without cause, if he did you no harm. Do not envy a man of violence and do not choose
any of his ways; for the perverse is an abomination to the Lord, but His counsel is with the
upright. The curse of the Lord is in the wicked man's house, but He shall bless the dwelling of
the righteous. If to the scoffers, he will scoff; but to the humble, he evokes grace. The wise
shall inherit honor, but the fools take disgrace as their portion.
4:7 The beginning of wisdom [is to] acquire wisdom, and with all your possession acquire
understanding.
4:13 Take fast hold of discipline, do not let it loose; guard it, for it is your life.
4:25-27 Let your eyes look forward, and let your eyelids look straight ahead of you. Weigh the
path of your feet, and all your ways will be established. Turn neither right nor left; keep your
feet from evil.
6:16-18 There are six things that the Lord hates, and the seventh is an abomination of
His soul; Haughty eyes, a lying tongue, and hands that shed innocent blood; a heart that
thinks thoughts of violence; feet that hasten to run to evil; one who] speaks lies with
false testimony and incites quarrels among brothers.
6:6-8 Go to the ant, you sluggard; see her ways and become wise, for she has no chief,
overseer, or ruler; yet she prepares her bread in the summer; she gathers her food in the
harvest, for she has no chief, overseer, or ruler; (Discipline vector; or Self Discipline)
:9 Better is he who is lightly esteemed but is a slave to himself than one who is honored but
lacks bread.
8:10 Take my discipline and not silver; knowledge is chosen above gold.
8:13 Fear of the Lord is to hate evil, haughtiness, pride, the way of evil, and a perverse mouth;
[these] I hate.
8:18 Riches and honor are with me, powerful wealth and charity. (Choose discipline and
knowledge before gold and silver and yet get powerful wealth and charity that is better; or both;
the point is operations must be focused on understanding and operational envelope and the
discipline to stay within it instead of the prize at the end; no matter what and trust the outcome
will be great)
8:12 In the way of righteousness I will go, in the midst of the paths of justice (inside the
operational envelope)
8:24 I was created when there were yet no deeps, when there were no fountains replete with
water. (arrogant engineers think they know more than the wisdom of God that was here before
deepwater?)
8:32 And now, my children, hearken to me, and fortunate are those who observe my ways. (the
ways inside the operational envelope.
10:17 The one keeps discipline preserves life, but he who forsakes reproof misleads.
14:8 The wisdom of a cunning man is to understand his way, but the folly of the fools is deceit.
(measures his way; pre-drill operational loads in casing design fully measured)
14:10 One's heart knows the bitterness of his soul, and in his joy no stranger shall mingle.
(painstaking efforts preclude those that simply want glory without the effort; superficiality; fixed
mindsets)
14:12 There is a way that seems right to a man, but its end is ways of death. (we must have
others inspect the big picture of our detailed work; we must have balance on our teams)
14:15 A fool believes everything, but a cunning man understands his steps. (we must check our
notions and concepts against practical experimental data and in every way possible with
diligence and with humble open minds.)
14:16 A wise man fears and turns away from evil (boundless operation), but a fool passes
vigorously and slips. (a fool discounts the dangers of operating too close or even beyond preset
safety margins and even mocks those he sees as being timid with “fear” of the evil or even a
coward is the implication, “who cares, will probably be okay”; we must “fear” the operational
boundary so that we are diligently focused on them)
14:22 Will they who plan evil not go astray? But kindness and truth come to those who plan
good.
14:23 In every toil there will be gain, but a word of the lips is only for loss.
14:24 The crown of the wise is their wealth; the folly of the foolish is folly. (Fools see time,
money and diligent effort spent on acquiring understanding and wisdom as foolish waste since
“luck” is on their side and yet they are wrong and headed for ruin)
14:25 A true witness saves lives, but he who speaks lies is [a man of] deceit. (CHAINS: we must
support confidential reporting of unsafe operations or foolish misfocus or lack of effort our
boundless operations because Proverbs 17:12 “It is safer to meet a bear robbed of her cubs
than to confront a fool caught in foolishness.”, therefore we need confidential reporting.)
14:27 The fear of the Lord is a spring of life, to turn away from the snares of death. (reference
Proverbs 14:16 (above) where here it is clear to commend those with “fear” as opposed to the
evil ones that mock this type of man and the bounds of good discipline he lives and works
within; operational envelope well within safety margins)
14:29 He who is slow to anger is of great understanding, but he who is quick-tempered selects
folly.
15:1 A gentle reply turns away wrath, but a distressing word stirs up anger. (clearly the manner
in which we speak to each other has implications for the team and whether we behave foolishly
or not (see proverb 14:29) and there is a reason these two proverbs are close together. If we
reply gently we can lead others away from folly.)
15:2 The tongue of the wise enhances knowledge, but the mouth of the fools pours out folly.
15:3 The eyes of the Lord are everywhere, viewing the evil and the good. (the destructive nature
of foolish statements and gossip is well known and people victim of this may feel helpless and
yet this isn’t true and this proverb makes it clear that although the victim feels alone and that no
one else sees what is happening God does and you will be protected via the mysterious ways of
God)
15:4 A healing tongue is a tree of life, but if there is perverseness in it, it causes destruction by
wind. (speaking can help yet it must be honest, measured and wise)
15:5 A fool despises the discipline of his father, but he who keeps reproof will become cunning.
(how much clearer can discipline and wisdom be tied together?)
15:9 The way of a wicked man is an abomination of the Lord, but He loves him who pursues
righteousness. (“pursue” implies effortful commitment to find the right ways of doing things;
which is clearly to operate within the operational envelope with fear and focus on maintaining
separation between operational ways and their loads and the resistance of the material and
people we interact with)
15:10 Harsh discipline will come to him who forsakes the way; he who hates reproof shall die.
(sure its brutal the death and damage of accidents and people bringing these tragedies up time
and again and yet this is the way of life and instruction and we must not “hate reproof” and yet
we must learn from it and let it guide our life and ways (Proverbs 10:17 The one keeps discipline
preserves life, but he who forsakes reproof misleads.))
15:12 A scorner does not like being reproved; he does not go to the wise. (is a leading indicator
to spot scorning?)
15:13-15 A merry heart makes a cheerful face, but by sadness of heart comes a breaking spirit.
The heart of an understanding person seeks knowledge, but the mouth of fools befriends folly.
All the days of a poor man are wretched, but he who has a cheerful heart always has a feast.
(there is a subtle lesson here about attitude and countenance towards others and its ultimate
effect on success.)
15:16 Better a little with the fear of the Lord, than a great treasury and turmoil with it. (wow!
More wisdom on boundaries of even success!; this makes “fear of the Lord” and more important
leading indicator than the controller of a company uses from Harvard MBA schools)
15:18 A man of wrath stirs up quarrels, but he who is slow to anger abates strife. (quarrels are
no good for teams and communications and are distractions to the focus and efforts we must
have. So a diligent and observant assessment and measurement of peoples’ behavior is clearly
a leading indicator and a management tool.)
15:19 The way of a lazy man is like a hedge of thorns, but the path of the upright is even. (effort)
15:22 Plans are foiled for lack of counsel, but they are established through many advisers. (be
open minded, and humble and put effort into seeking out and sorting through the advice of
others)
15:24 The path of life is above the intelligent person, in order that he turn away from the grave
below. (we must always seek spiritually higher ways of doing things; refine our plans; ourselves)
15:28 The heart of a righteous man thinks to answer, but the mouth of the wicked pours out
evils. (clearly our talk within our organizations and within teams on projects is vital and we
should consider, measure and minimize our speaking; BREVCOM)
15:30 The light of the eyes makes the heart happy; good news fattens the bone. (there is a true
need for ascetics within our organizations and offices and field sites; take pictures; take a break
and look out the window and see the beauty of a flowing river or a vegetable garden and make
the heart happy for it cleanses the sadness of the heart and increases our health; then get back
to the focus and efforts)
15:31-33 The ear that listens to reproof of life shall lodge among the wise. He who rejects
discipline despises his life, but he who hearkens to reproof acquires sense. The fear of the Lord
is the discipline of wisdom, and before honor there is humility. (Seeking honor versus humility is
the theme of Dr. Dweck’s landmark educational studies were focused on and they agree with
these proverbs)
16:1 The preparations of the heart are man's, but the answer of the tongue is from the Lord. (is
the true measure of humility found in speech?)
16:2 All ways of man are pure in his eyes, but the Lord counts the spirits. (there is nothing more
here and now than the spirit that brings us together and keeps us together on our projects; how
do we measure this? Perhaps the last proverb suggests we listen intently)
16:3 Commit your affairs to the Lord, and your plans will be established. (The secret to planning
a well construction project; commit to the betterment of the whole and not simply the interests of
the “in group” or the general individualistic drive.
16:4 The Lord made everything for His praise-even the wicked man for the day of evil. (we
shouldn’t complain too much about the people that do not act as they should for they are
created for making the good man look better and point to the source of his goodness; God)
16:5 Everyone of haughty heart is an abomination of the Lord; hand to hand he will not go
unpunished. (arrogance versus humility)
16:6 With loving-kindness and truth will iniquity be expiated, and through fear of the Lord turn
away from evil. (we will focus on boundaries if we fear the Lord and those that fear the Lord will
survive mock and scorn from evil ones with efforts at loving kindness and truth)
16:7 When the Lord accepts a person's ways, He will cause even his enemies to make peace
with him. (enemies may be a measure of how much the Lord accepts our ways)
16:8 Better a little with righteousness than great revenues with injustice. (a clear boundary for
business and again better than a Harvard MBA)
16:9 A man's heart plans his way, but the Lord prepares his step. (we plan and write procedures
and yet God is responsible for how well we execute our operations)
16:10 The balance and scales of justice are the Lord's; all the weights in the bag are His work.
(justice requires wisdom, diligence, efforts, righteousness and commitment to the group as a
whole and situational attribution given to accidents and mistakes)
16:17 The highway of the upright is to turn away from evil; he who guards his soul watches his
way. (how much clearer can focus on the operational envelope be stated as the exact wisdom
of proverbs? We must steer our operational loads away from the resistance strength of our
barriers or conversely we must steer our barrier towards loads that do not exceed them. “He
who guards his soul watches his way” We must focus on the here and now in light of where we
are going because that is the exact location that hazard emerges. Ie emergencies happen
precisely there.)
16:18 Before destruction comes pride, and before stumbling [comes] a haughty spirit. (why?
Read above. Do we have proof of this? Macondo blowout was immediately after the more or
less same crew drilled the deepest well in deepwater on record which was of course a great
source of “pride” for that team. Also, they were receiving a safety award, the day of the
disaster. So is a source of pride a potential hazard? Yes, of course, so this is a leading
indicator to look for and manage.)
16:19 It is better to be of humble spirit with the lowly than to divide the spoils with the haughty.
(common theme emphasized)
16:20 He who considers a matter will find good, and he who trusts in the Lord is fortunate.
(Another reiteration that we must weigh our ways in the here and now before we will have
confidence in the outcome)
16:21 The wise-hearted shall be called understanding; and the sweetness of speech increases
learning. ( a learning organization will speak sweetly to one another and be respectful of the
wise and not mocking of them as fearful or timid)
16:27 An ungodly man digs up evil, and on his lips is a kind of searing fire. (By definition drilling
a well removes a barrier to flow (good) and replaces it with a sufficient barrier (good) or an
insufficient barrier (evil); if evil=exceeding bounds and we dig this up, this strikes close to the
danger of drilling when the pore pressure exceeds our hydrodynamic and/or hydrostatic barrier.
Ungodly is defined as “without heights” or possibly without successful PPFG estimation from the
highest sources and due diligence and due process.
16:28 A perverse man incites quarrel, and a grumbler alienates the Lord. (we must measure our
words and actions carefully in order to not incite a quarrel)
16:29 A man of violence entices his neighbor and leads him on a way that is not good. (we
should not let lacking standards in terms of load resistance of our operations and the margin of
safety nor in our commitment to be kind, honest and peaceful with people in our organization
and on our teams and projects.
16:30 He winks his eyes to think perverse thoughts; he purses his lips, bringing evil to pass. (Is
winking how evildoers entice us to join their ranks?)
16:32 One who is slow to anger is better than a mighty man, and one who rules over his spirit [is
better] than one who conquers a city. (might isn’t physical and superficial it is spiritual; this is
akin to the fixed versus humble; arrogance/pedigree(or past results; outcome orientation) vs
effort, mindset comparison)
17:9 He who conceals transgression seeks love, but he who harps on a matter alienates the
Lord. (if a person sins against us and we forgive them if they are contrite and not remind them
of it they will love it. Therefore we should see transgressions against us as opportunities to win
the love of others)
17:10 The humility caused by the rebuke of an understanding person [is more effective] than a
hundred blows to a fool. (This clearly teaches the need to distinguish between humility and folly
before we decide how to confront a person as a manager)
17:14 The beginning of strife is like letting out water, and before you are exposed, abandon the
quarrel. (stop a quarrel before the flow from a small leak erodes and bursts the dam)
17:15 He who vindicates the wicked and condemns the righteous-both are an abomination to
the Lord. (clearly a warning against superficial judgment and the need for situational attribution
in judgment and the Just Culture)
17:17 At all times, love a friend, for he is born a brother for adversity. (we should be friendly and
kind and make friends even if we do not see the utility or need for it is for adversity in the future)
17:19 He who delights in transgression delights in quarrels; he who speaks haughtily seeks
disaster. (Quarrelsome people can make teamwork difficult yet arrogant people can cause
disasters)
17:20 He who is of a perverse heart will find no good, and he who has a hypocritical tongue will
fall into evil. (do not behave in a way that suggests one has higher standards or more noble
beliefs than is the case in order to distinguish superiority over others or we may become lacking
of discipline. This is akin to pride, arrogance, and duplicity leading to evil and corruption or
basicly the five things God hates)
17:24 Wisdom is directly in front of an understanding man, but the eyes of a fool are at the end
of the earth. (This means an understanding man realizes that small efforts amount to a great
deal and have patience in regards to time and effort yet the fool is impatient and only sees the
great effort required and cannot focus on small steps necessary to accomplish big task. This
also refers to focus on efforts close at hand and not the outcome. Because the outcome
distracts us, discourages us or makes us arrogant; all bad in light of true wisdom)
17:26 To punish also the righteous man is not good-to strike the generous who possess
uprightness. (Justice entails diligent distinction between the wrong and right person. Situational
assessments must be patiently engaged in order to establish a Just Culture; better to let a few
bad go free than to punish one good person)
18:9 Even one who is slack in his work is akin to the destroyer. (Effort is the opposite; the
greatest guard against destruction is effort; it is the main value of process safety)
18:12 Before ruin, a man's heart becomes haughty, but before honor there is humility. (proverbs
clearly implies disasters are the cause of arrogance and humility is the safeguard against
accidents. This is a leading trait and indicator)
18:13 He who answers a word before he understands-it is foolishness for him and an
embarrassment.
18:14 A man's spirit will sustain his illness, but a broken spirit-who will bear it? (the spirit of a
mighty man does not take worry to heart, but accepts with joy and love whatever befalls him; he
doesn’t lose his strength)
18:15 An understanding heart will acquire knowledge, and the ear of the wise will seek
knowledge. (listen for knowledge and move within earshot of it)
18:16 A man's gift will make room for him, and it will lead him before the great. (Charity)
18:17 He who pleads his case first seems just, but his neighbor comes and searches him out.
(we can claim anything we want and yet the truth will be know. We must put the efforts in place
of all we claim to know, understand or achieve; we must back up our marketing efforts and our
resumes with diligent effort focused on the tasks at hand to achieve the ultimate goal.)
18:20 With the fruit of his mouth does a man's stomach become sated; with the produce of his
lips he is sated.
18:21 Death and life are in the hand of the tongue, and those who love it will eat its produce.
18:23 A poor man speaks with supplications, but a rich man replies with impudence. (this
teaches us how to speak to a superior position; despite their shortness or alacrity in answering
us; this is the way it is and should be; do not lean on our own understanding yet trust God
knows best the reasons why we must tolerate this fact)
19:16 He who keeps a commandment keeps his soul; he who despises his ways will die.
19:22 The attraction to a man is his kindness, and a poor man is better than a liar.
19:23 Fear of the Lord is for life, and he will rest satisfied, not to be visited by evil.
19:25 Beat a scorner, and a simple man will gain cunning; reprove a man of understanding, and
he will understand knowledge.
20:18 Plans with counsel will be established, and with strategies wage war.