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Pattern Disruption: Don’t Start with ‘Why’

In the northern latitudes, Mother Nature is deeply vested in a cycle of pattern disruption. The four seasons change the ecosystems and habitats. As the seasons shift in New York, the lake that I live on moves from a warm thermocline with colder layers on the bottom and warmer water on top to the opposite. In the coldest months, the top of the lake freezes entirely. The ground freezes, too, while the monarch butterflies leave and many of the birds fly south.

But even those pattern disruptions – the four seasons – become a rhythm, an expected ritual during which we trade lawnmowers for snowblowers and put away the outdoor furniture, only to reverse those actions when the weather becomes warm once again.

You may already know that the human brain loves rituals and patterns. That’s because the brain is challenged by any unexpected disruptions and must work harder to address them. At only 2% to 3% of a person’s body weight, the brain utilizes more than a quarter of all the body’s resources, essentially making it a gas hog. Using heuristics, or rule-of-thumb reasoning, makes thinking quick and easy with low cognitive load – which pleases the brain.

In the book “Thinking, Fast and Slow,” author Daniel Kahneman describes the human brain as having two systems. System 1 uses shortcuts and heuristics to make quick decisions. System 2 is slower, engaging in deeper, more deliberate thought. Because the brain wants to operate with the lowest cognitive load possible, we like things that make immediate sense, and they don’t even have to be correct; we accept them when they seem to be logical and then we move on. It’s not surprising, then, that as soon as we find a ritual that makes sense to us, we build fortresses around it to hold that ritual or belief safe. Take religion, for example. If we are Catholic and believe in Catholic rituals, we build Catholic churches. If we are Methodist and believe in Methodist rituals, we build Methodist churches. Muslims build mosques, followers of Judaism build temples, and so forth. Humans love rituals because they please our brains and help us make sense of the world.

Why Not Start with ‘Why’?
Simon Sinek is well-known for his book titled “Start with Why: How Great Leaders Inspire Everyone to Take Action.” And in analyzing incidents, we often use the 5 Whys. There’s a reason asking why is so popular, and that’s because it seems like a logical approach when trying to determine the causal factors behind an incident. But does using that particular word produce the answers we’re looking for?

Asking why makes sense to us because it has become a ritual in our industry – and that is a problem. As noted above, when something makes sense to our System 1 brain, we move on because it seems logical, even if it’s not correct. Kahneman’s math problems in “Thinking, Fast and Slow” are good examples of this. Here’s one of those examples to consider: Five machines can make five widgets in five minutes. How long does it take 100 machines to make 100 widgets? The first number to jump to many people’s minds is 100 minutes – although the correct answer is five minutes. But once the wrong answer enters your mind, your System 1 brain is done. It doesn’t want you to expend energy calculating for a different answer since it already has one it believes is logical.

And so it is with starting with why. Doing so sounds reasonable and simple, not to mention that we have created an entire incident investigation system around asking why. That means it must be the correct ritual, right? Here’s something else to think about: The research and logic behind James Reason’s Swiss cheese model are sound, but the model with all the holes in the cheese lining up is not entirely sound. We love that model because it is easy to understand. All we need to do is adjust the cheese or add more layers to prevent an occurrence from happening again. However, the reality is that the Swiss cheese model is modeling an anomaly. Events don’t often happen in a straight line, and it is exceedingly rare that all the holes line up. But we still create layers of protection for something that likely will not happen.

Start with ‘How’ and ‘What’
Instead of asking why something happened, perhaps we should start by asking how it happened – and then pinpoint the small course corrections that would have eliminated the event altogether. The time we spend on controlling risk might be better spent on predicting risk since that is what the human brain is designed to do. Humans operate in autopilot mode during much of our day, acting subconsciously based on our life experience. There is one problem, though. When we haven’t had certain experiences, we are considered experientially blind to the potential outcomes of those experiences. That means our brain does not subconsciously consider how to mitigate those potential outcomes. So, what caused something to happen may be as simple as we didn’t know or believe it could happen.

As a species, we can choose our rituals. Keep in mind, however, that our power to change the future exists only in the present. The trouble with asking why is that it puts us in the past. Yes, we can learn from our mistakes. The problem is language. As soon as we start asking why questions, the person to whom the questions are directed moves toward becoming defensive. Defending our position usually requires us to justify and rationalize why something made sense to us – when it’s possible that we simply didn’t know how things might turn out due to our experiential blindness. Those why questions mean we are now spending lots of time in the past. Asking “how” and “what” questions, on the other hand, moves us into forward thinking. Our choice of language can both open and close doors.

Here’s an example of a “clean” language question that might be asked after an incident has occurred: When you decided to use that piece of equipment, what was that for, and what did you want to have happen? Note that asking questions using the words and phrasing that have come from the person you are asking opens the door to a psychologically safe conversation. On the other hand, when we ask why questions – that we often already know the answer to – or when we lean toward our predetermined beliefs, we are adding our bias to the conversation. And again, why questions automatically create a defensive posture in the person being questioned regardless of our intentions. It is easy for a person to interpret “Why did that make sense to you at the time?” as “Why would that have made sense to you at the time?” The latter question adds judgment with use of the word “would.” Our brains can easily convert the question to a feeling of shame or blame.

Implying or flat-out telling people that they are lazy, unintelligent or incompetent puts them in both defense mode and a lower cognitive state – neither of which does anything to foster a productive conversation that will help determine what happened to allow an incident to occur. Further, consider for a moment that the implied message of, say, putting everyone in cut-resistant gloves is this: If our workers were capable of learning to not cut themselves, we wouldn’t have to force them to wear these gloves. Now, let me ask you, when your child burned their hand on that hot pan in the kitchen, did you mandate that they wear flame-resistant gloves from that day forward?

In truth, it is rare that any of our workers are lazy, unintelligent or incompetent. By using language that displays curiosity and interest, rather than judgment and blame, we are operating closer to our highest potential.

One Small Change
If you were to take an improv class, you would likely learn that two of the best words to create conversational flow are “Yes, and …” (e.g., “Yes, and when your team made that decision, what did you think was going to happen next?”). The ritual we have adopted in our industry – asking why – may be outdated and not as effective as asking how and what. Incident investigations should not solely be about figuring out what we did wrong; they should also be about understanding what was driving the decisions behind the actions. More than 40 years of being a ski instructor has taught me not to focus on what a skier is doing wrong but instead on the small movement or adjustment the skier needs to make to improve.

With pattern disruption, you make one small change and everything else changes. Change nothing and, well, nothing changes. So, if you want to effect change, consider starting with a change in language – because sometimes language can set us back in our effort to move forward.

About the Author: Bill Martin, CUSP, NRP, RN, DIMM, is the president and CEO of Think Tank Project LLC ( He has held previous roles as a lineman, line supervisor, project manager and safety director.

Author’s Note: This article was inspired by “Leadership is Language: The Hidden Power of What You Say – and What You Don’t” by L. David Marquet.


Bill Martin, CUSP, NRP, RN, DIMM

President and CEO of Think Tank Project LLC 30+ Years Electric Utility, 10 years with an Electrical Contractor. Includes Tree Trimmer, Lineman, Line Foreman, Line Supervisor, Project Manager for Cable Make-Ready and Bare Hand/ Live Line, Safety Director, Safety Consultant. Simultaneous Medical Career: Paramedic, Nationally Registered Paramedic, Paramedic Course Instructor Coordinator, Critical Care Paramedic, 21 years Flying on a Critical Care Helicopter, Registered Nurse, Cardiology Nurse, Advanced Wilderness Life Support, Diploma in Mountain Medicine.