Mastery by Robert Greene

Mastery by Robert GreeneBook Review: Mastery by Robert Greene

“The misery that oppresses you lies not in your profession but in yourself! What man in the world would not find his situation intolerable if he chooses a craft, an art, indeed any form of life, without experiencing an inner calling? Whoever is born with a talent, or to a talent, must surely find in that the most pleasing of occupations! Everything on this earth has its difficult sides! Only some inner drive—pleasure, love—can help us overcome obstacles, prepare a path, and lift us out of the narrow circle in which others tread out their anguished, miserable existences!”


Previous I reviewed a book of the same title by George Leonard. Since Robert Greene covers some of the same ground as George Leonard, it is useful to compare and contrast them.

Both authors emphasize the need for instruction and downplay the success potential of the autodidact. Both authors emphasize the need to surrender to the instructor in the early stages. Both emphasize the need for enormous amount of practice with intentionality. Both emphasize benig highly selective about the pursuit and the instructor.

In many ways, the books are more similar than different, and I would have expected to see Leonard cited in Greene’s book, but that was not the case. That said, there are differences that will make one of the two books better depending on the individual and their needs.

First, Greene specifically separates out and emphasizes social intelligence as a key tool of a Master. I suspect that this would be a point of agreement between the two authors, but Greene makes an entire chapter of it. He compares the long hard road Ignaz Semmelweis made for himself in getting other doctors to wash their hands. Despite anticipating the revolutionary germ theory of disease he is not necessarily numbered among the greats of the medical profession, and he did not see his theories adopted broadly within his lifetime. On the other hand William Harvey adroitly involved others and worked behind the scenes to revolutionize our understanding of the function of the heart, seeing within his own lifetime an about-face in accepted medical theory.

Greene emphasizes social intelligence because the lack of it causes drama and distraction that prevent Masters from realizing their visions: it is a key differentiator. “Seeing people as they are” avoids two errors. The error of the child is in idealizing those around them, which leads to being let down or surprised by competitive self-interest. The error of the adolescent is to overemphasize the flaws, which hinders cooperative efforts. The socially mature individual does not feel the need to rush to judgment and allows their judgments, when formed, to be changed by new evidence. [Game theory on selection of cooperative and competitive strategies would have much to add to Greene’s discussion, but it is not mentioned.]

A second difference is that Greene recommends specific preparation for the eventual break with your initial instructor, be it clean or messy. He recommends picking out character flaws and even dwelling on them early on, during the surrender phase, to mentally prepare. This may sound cruel or Machievellian, but many future Masters get to the point where they have established themselves, and further submission to their old instructor will only hold them back.

A third difference is Greene’s case studies tend toward the intellectual while Leonard’s case studies tended toward the physical and athletic worlds.

Fourth, Greene breaks up the Path to Mastery into phases, each with their unique angles. For example, the Apprentice surrenders and submits to their Master and internalizes their approaches exactly. The practitioner of the Creative-Active phase specializes, finds the most profitable problem to work on and improving their weaknesses. The final step to attain Mastery involves playing to strengths, broadening their perspective, and developing “fingertip feel.”

Fifth, Greene has a more brutal, frank, and Machiavellian feel. Leonard’s writing leans optimism and idealism. Someone may be turned off by one and relate better to the other.

[This 3-stage model is quite similar to the shu-ha-ri concept from The Toyota Way to Lean Leadership.]

Those acquainted with Greene’s work will know that after advocating a certain approach he will end with a Reversal. The Reversal usually describes a situation in which the principle does not apply. Reversals are included in Mastery, but they are much weaker than in previous books. Greene states in several places that there are no Reversals and then reiterates the consequence of failure to comply with the key principles. The book would have been better if Reversals had been excluded and the content integrated back into the chapter.

Either Mastery would be a most worthwhile investment. As I mentioned, which one is better will depend on the individual. Each author brings a unique angle to the subject, and most of the truly “core” principles are quite similar. [My personal, complete notes include many cross-references.]

Key Concepts

Key concepts are either recurring themes or strong individual points made with a fairly general application. Books with a more theoretical bent will have more “key concepts.”

  • Mastery involves three phases:
    1. Apprenticeship is characterized by confusion, fear, excitement. One is an outsider and a student. The objective is to learn the rules that others have set. One’s vision of the field or the art is partial.
    2. The Creative-Active phase is characterized by experimentation. One is a practitioner. The objective is to introduce individuality into our practice. One’s vision becomes comprehensive.
    3. Mastery is characterized by instinctual performance. Ideas seem to come out of nowhere. The rules are so well internalized that they can be broken or rewritten to dramatic effect. One’s vision becomes transcendent. Intuitive insights are available upon demand.
  • “[The] brain that we possess is the work of six million years of development, and more than anything else, this evolution of the brain was designed to lead us to mastery, the latent power within us all.”
  • “The moment you rest, thinking that you have attained the level you desire, a part of your mind enters a phase of decay. You lose your hard-earned creativity and others begin to sense it.”
  • Don’t search for mentors until you have acquired some elementary skills on your own. The mentors will not want to waste their time with those who will never exceed them because they do not take initiative.
  • “You must not allow yourself to feel any guilt when the time comes to assert yourself. Instead… you should feel resentful and even angry about his desire to hold you back, using such emotions to help you leave him…”
  • The “deadly realities” of social intelligence is that you will encounter people who are are envious, conformist, rigid, self-obsessed, lazy, flaky, and passive-aggressive.
    • To acquire social intelligence, “speak through your work”, craft an appropriate public persona, learn to see yourself as others see you, and learn to suffer fools gladly.
  • Strategies for the Creative-Active phase: develop your ability to live with uncertainty, look for the “open field” where you can specialize and have little competition, work on your weaknesses, and submerge your individuality in a frenzy of learning and absorption so that you can emerge later with your own unique voice.
  • Strategies for Mastery: play to your strengths, broaden your perspective, and hone your skills to the point that they are “natural.”

Publisher’s Blurb

From the dust jacket:

The ultimate form of power is mastery. After a lifetime spent studying the laws of power, Robert Greene recognized the path to mastery traveled by all the most powerful people of the past and present: the ability to focus deeply on a subject that compels them and then to pursue a challenging but clear course that is described here for the first time. It sounds so simply, yet mastery—and the power that comes with it—eludes many of us. This book shares this secret with the world, debunking once and for all our culture’s many myths about genius and showing that each of us has within us the potential to be a Master if we choose to follow this path to greatness.

As Greene discovered in his years of research for the international bestseller The 48 Laws of Power, many of the world’s most successful people were not obviously destined for achievement. As a child, Charles Darwin was a middling student at best. What did he do to become one of the most influential scientists of all time? He pursued the same path by which Leonardo da Vinci, an illegitimate son and social outcast, forged his way to becoming a Master of both art and invention. First, both were keenly devoted to their areas of interest. Like Benjamin Franklin, Henry Ford, architect Santiago Calatrava, and other Masters profiled here, they committed themselves to rigorous apprenticeships with mentors who could initiate them into the hidden knowledge that comes from years of experience.

Then they absorbed the Master’s power. Through analyses of the lives of Michael Faraday, Frank Lloyd Wright, Carl Jung, robotics pioneer Yoky Matsuoka, and others, Greene shows how these Masters internalized their mentors’ knowledge but pushed beyond to surpass them in brilliance. Next, like Benjamin Franklin, they mastered the art of social intelligence, navigating smoothly the networks needed to make allies and avoid unnecessary battles.

Yet those who have conquered their fields do not become complacent. Instead they expand their knowledge to related subjects, fueling their minds with the ability to make new associations between ideas. Like Mozart, the Wright brothers, and computer-engineering guru and tech entrepreneur Paul Graham, such pursuit has enabled them to upend the rules of their fields, shaping those fields in radical and profound ways. Finally, those who continue on this path attain such a high level of intuition that they are able, like Albert Einstein, boxing coach Freddie Roach, and U.S. Air Force ace fighter pilot Cesar Rodriguez, to become true Masters.

If other books have described what happens to the brain after 10,000 hours of study, Mastery reveals what happens after 20,000 hours—the level reached by Einstein, Darwin, and the nine contemporary Masters interviewed for this book. These contemporary Masters are men and women from all socioeconomic backgrounds and ethnicities. As Greene argues convincingly, the potential for Mastery lies within each of us. Learn the secrets of the path you must follow. Unlock the passion within you and become a Master.

Table of Contents


The Ultimate Power

The Evolution of Mastery

Keys to Mastery

I. Discover Your Calling: Your Life’s Task

The Hidden Force

Keys to Mastery

Strategies for Finding Your Life’s Task

  1. Return to your origins—The primal inclination strategy
  2. Occupy the perfect niche—The Darwinian strategy
  3. Avoid the false path—The rebellion strategy
  4. Let go of the past—The adaptation strategy
  5. Find your way back—The life-or-death strategy


II. Submit to Reality: The Ideal Apprenticeship

The First Transformation

Keys to Mastery

Strategies for Completing the Ideal Apprenticeship

  1. Value learning over money
  2. Keep expanding your horizons
  3. Revert to a feeling of inferiority
  4. Trust the process
  5. Move toward resistance and pain
  6. Apprentice yourself in failure
  7. Combine the “how” and the “what”
  8. Advance through trial and error


III. Absorb the Master’s Power: The Mentor Dynamic

The Alchemy of Knowledge

Keys to Mastery

Strategies for Deepening the Mentor Relationship

  1. Choose the mentor according to your needs and inclinations
  2. Gaze deep into the mentor’s mirror
  3. Transfigure their ideas
  4. Create a back-and-forth dynamic


IV. See People as They Are: Social Intelligence

Thinking Inside

Keys to Mastery

Strategies for Acquiring Social Intelligence

  1. Speak through your work
  2. Craft the appropriate persona
  3. See yourself as others see you
  4. Suffer fools gladly


V. Awaken the Dimensional Mind: The Creative-Active

The Second Transformation

Keys to Mastery

Strategies for the Creative-Active Phase

  1. The Authentic Voice
  2. The Fact of Great Yield
  3. Mechanical Intelligence
  4. Natural Powers
  5. The Open Field
  6. The High End
  7. The Evolutionary Hijack
  8. Dimensional Thinking
  9. Alchemical Creativity and the Unconscious


VI. Fuse the Intuitive with the Rational: Mastery

The Third Transformation

Keys to Mastery

Strategies for Attaining Mastery

  1. Connect to your environment—Primal Powers
  2. Play to your strengths—Supreme Focus
  3. Transform yourself through practice—The Fingertip Feel
  4. Internalize the details—The Life Force
  5. Widen your vision—The Global Perspective
  6. Synthesize all forms of knowledge—The Universal Man/Woman


Contemporary Master Biographies


Selected Bibliography


Key Terms from the Index

adaptability, alienation, ancestors (early human), animals, anomalies, apprenticeship, Apprenticeship Phase, architecture, autism, books, brain, Calatrava (Santiago), career path, childhood, Christianity, Creative-Active Phase, creative process, creative thinking, criticism, dance, Darwin (Charles), detachment, Dimensional Mind, dreams, Edison (Thomas Alva), Einstein (Albert), electromagnetism, emotions, empathy, entrepreneurs, Everett (Daniel), evolution (theory of), failure, Faraday (Michael), Fernández (Teresita), focus, Franklin (Benjamin), Futch (Eddie), Goethe (Johann Wolfgang von), Grandin (Temple), hands, Harvard University, human behavior, human beings, identification, inclination, independence, intelligence, internalization, intuition, knowledge, language, Leonardo da Vinci, Life’s Task, Literature, masks (social), mastery, mentoring, mentors, Mozart (Wolfgang Amadeus), nature, neuroscience, observation, parents, persistence, political behavior (politicking), practice, Proust (Marcel), Ramachandran, Roach (Freddie), science, self, self-apprenticeship, serendipity, skills, social intelligence, technology, thinking, time, transformation, visual thinking, Zenji (Hakunin)

The Toyota Way to Lean Leadership by Jeffrey Liker

The Toyota Way to Lean Leadership by Jeffrey LikerBook Review: The Toyota Way to Lean Leadership: Achieving and Sustaining Excellence through Leadership Development by Jeffrey Liker

“No institution can possibly survive if it needs geniuses or supermen to manage it. It must be organized in such as way as to be able to get along under a leadership composed of average human beings.”

—Peter Drucker (chapter 4 opening quote)

Key Concepts

Key concepts are either recurring themes or strong individual points made with a fairly general application. Books with a more theoretical bent will have more “key concepts.”

  • Traditional American companies expect their leaders to show big results quickly. Those who do not are replaced by outsiders. At Toyota, leaders are gradually grown from within the company, and their development is seen as a career pursuit, not merely six weeks or so of formal training. This development comes more through critical reflection than directives.
  • In the Toyota system, getting results is important (just like in American), but much more emphasis is placed on the way in which results are obtained. Leaders are judged both by the results they obtain and their leadership process.
  • Shu-Ha-Ri layered learning describes a cycle [not a linear process] that leads to both mastery and continual innovation.
    • Shu means “to protect” and involves unquestioning obedience on the part of the student to the master. This has become stereotyped as “Japanese” but it is only the beginning.
    • Ha means “to break away” and represents a reduction in direct supervision, but continuing to follow the initial method very closely.
    • Ri means “freedom to create.” The student in the Ri phase has transferred the best practice from their consciousness to instinctive movement. Now they are free to introduce variations that may improve the process.
  • Leadership development forms a “T”: first, deep-rooted expertise is developed in a speciality area. Next, leadership skills are broadened in areas where the leader is inexperienced.
  • Temporary gains from lean efforts are easy, but sustained efforts require leadership development.
  • Kaizen is a daily activity, not an “event.” Kaizen must be lead by the lowest possible supervisors, not the senior leader. They try to keep understanding of processes and improvements in the work group itself. (Thus it would be very odd for a group of engineers to descend from corporate, make changes without significant input, and leave.) There are two kinds of kaizen:
    1. Maintenance kaizen “is the process of reacting to the inevitable… to bring the system back to the standard.”
    2. Improvement kaizen for “raising the bar.”
  • American leadership is focused on creating an executive change agent who drives change by force of personality and will. Even enlightened leadership focuses on how to convince employees to “sign on.” In contrast Toyota allows gemba employees (line & maintenance workers) to truly lead efforts.
  • Flattening hierarchies is not (necessarily) “lean.” Giving workers more autonomy without providing support and direction is not a proven path to success. [One typical consequence was described here.]
  • There are three differences between Toyota implementation and the typical approach to Management By Objectives (MBO):
    1. Toyota develops objectives by a rigorous process of data gathering and consensus building. (Objectives are not dictated by the CEO).
    2. Setting goals and targets is a two-way communication.
    3. Leadership is instituted so that lower levels have the improvement skills to meet the goals.
  • The Japanese custom of “face saving” is applied mostly to “outsiders.” With “insiders” discussions can be very direct and blunt. Otherwise, helping others improve would not be possible.
  • The road to systematic improvement begins with these questions:
    1. “Is there a shared vision of True North in your organization?”
    2. “Do we have leaders in place who are willing to take on challenges with a positive mindset and develop themselves?”
    3. “Are leaders at all levels embracing their roles as teachers, developing others to lead the way in the future?”
    4. “Are leaders at all levels using a rigorous process to solve the right problems step by step?”
    5. “Does the company have an environment in which aligned targets for improvement are developed and good ideas for achieving those targets are shared across the organization?”
    6. “Do we use major challenges from the environment to further strengthen our leadership and our company to work toward a long-term vision?”

Useful Features

Useful features are like pages, diagrams, or tables that one might bookmark or dog-ear for quick reference. Books oriented toward application will generally have more “useful features.”

  • Conventional Models of Leadership versus Toyota Way Leadership (pp. 31-2)
  • Toyota Work Group Structure (p. 135)

Publisher’s Blurb

From the dust jacket:

Toyota. The name signifies greatness—world-class cars and game-changing business thinking. One key to the Toyota Motor Company’s unprecedented success is its famous production system and its lesser-known product development program. These strategies consider the end user at every turn and have become the model for the global lean business movement. All too often, organizations adopting lean miss the most critical ingredient—lean leadership.

Toyota makes enormous investments in carefully selecting and intensively developing leaders who fit its unique philosophy and culture. Thanks to the company’s lean leadership approach, explains Toyota Way author Jeffrey Liker and former Toyota executive Gary Convis, the celebrated carmaker has set into motion a drive for continuous improvement at all levels of its business. This has allowed for:

  • Constant Growth: Toyota increased profitability for 58 consecutive years—slowing down only in the face of 2008’s worldwide financial difficulties, the recall crisis, and the worst Japanese earthquake of the century.
  • Unstoppable Inventiveness: Toyota’s approach to innovating thinking and problem solving has resulted in top industry ratings and incredible customer satisfaction, while allowing the company to weather these three crises in rapid succession and to come out stronger.
  • Strong Branding and Respect: Toyota’s reputation was instrumental in the company’s ability to withstand the recalls-driven media storm of 2010.

And what a storm it was! But what looked to some to be a sinking ship is once again running under a full head of steam. Perhaps the Toyota culture had weakened, but lean leadership was the beacon that showed the way back.

In fact, writes Liker, the company is “as good and perhaps a better model for lean leadership than it ever has been.” Indeed, Toyota wiull soon be celebrating 80 years of innovation and growth. Yet, Industry Week reports that just 2 percents of companies using lean processes likewise claim to have had long-term success. What the other 98 percent lack is unified leadership with a common method and philosophy.

If you want to get lean, you have to take it to the leadership level. The Toyota Way to Lean Leadership shows you how.

Table of Contents

Foreword by Akio Toyoda

Prologue: Toyota as a Model in Light of a Period of Intense Challenges

Introduction: The Roots of Toyota’s Global Business Leadership

Chapter 1: Leading in the Toyota Way: A Lifelong Journey

Chapter 2: Self-Development: Reliably Identifying and Coaching Developing Leaders at the Gemba

Chapter 3: Coach and Develop Others

Chapter 4: Daily Kaizen: Continually Developing Leadership from the Bottom Up

Chapter 5: Hoshin Kanri: Align Vision, Goals, and Plans for Continuous Improvement

Chapter 6: Toyota Leadership Turning Around Dana Corporation

Chapter 7: Learning from Toyota Leadership




Key Terms from the Index

A3 problem solving, bottom-up leadership, Bryant (Marty), challenge(s), coaching and developing others, Convis (Gary), Dana Holding Corporation, gemba, genchi genbutsu, hoshin kanri, innovation, Japanese culture, Javid (Vahid), just-in-time production (JIT), kaizen, Kopkowski (Ed), leadership, leadership development model, McKee (Brandt), metrics, minomi, NUMMI, Ohno (Taiichi), Plan-Do-Check-Act (PDCA) cycle, problem solving, recession, responsibility, self-development, sensei, shu ha ri, standardized work, Toyoda (Akio), Toyodo (Sakichi), Toyota, Toyota Motor Manufacturing Kentucky (TMMK), Toyota Production System (TPS), Toyota Way leadership, training, True North, vision creation, visual management, work groups

Risk: A Very Short Introduction by Baruch Fischhoff

Risk: A Very Short Introduction by Baruch FischhoffBook Review: Risk: A Very Short Introduction by Baruch Fischhoff

“The foundations of risk and Risk lie in decision theory, which articulates concepts whose emergence must have begun with the first human thought about uncertain choices.”

—Baruch Fischhoff

Risk management is a significant topic in today’s manufacturing operations. Personal safety, process safety, environmental compliance, market conditions, talent acquisition and management, capital investment, and investors/government/public relations are just a few of the risk categories faced purely by participating in “the game.”

Risk: A Very Short Introduction is a less a practical guide for those interested in industrial risk management than a theoretical work addressing policy-making and risk analysis.

Key Concepts

Key concepts are either recurring themes or strong individual points made with a fairly general application. Books with a more theoretical bent will have more “key concepts.”

  • Risk is what threatens that which we value. What we do about them depends on:
    1. the options we have
    2. the outcomes we value
    3. our beliefs about the outcomes that might follow from each option
  • Three perspectives on decision theory:
    1. Logical/normative analysis, identifying choices that we would make, if we were fully informed, fully in touch with our values, and followed consistent rules
    2. Descriptive study of the imperfect ways in which people really do make choices
    3. Prescriptive/interventionary approach to bridge the gap between the normative ideal and the descriptive reality.
  • “Comparing a specific risk to a general threshold is a job for risk analysts. However, setting that threshold is a task for policy-makers…”
  • “[Societies] reveal their deepest values in the priorities they set among physical and symbolic risks.”

Publisher’s Blurb

From the dust jacket:

We find risks everywhere—from genetically modified crops, medical malpractice, and stem-cell therapy to heartbreak, identity theft, and robbery. Risks can be imposed on us or arise from our own acts.

Using concepts from decision theory and behavioral decision research, this Very Short Introduction examines the social and psychological contexts that define risks and the role of science in analyzing them. Showing what science has learned about how people deal with risks, and applying this knowledge to diverse everyday examples, Baruch Fischhoff and John Kadvany demonstrate how we move from understanding a risk to making choices in our lives.

Table of Contents


Chapter 1: Risk Decisions

Chapter 2: Defining Risk

Chapter 3: Analyzing Risk

Chapter 4: Making Risk Decisions

Chapter 5: Risk Perception

Chapter 6: Risk Communication

Chapter 7: Risk, Culture, and Society

Key Terms from the Index

acceptable risk, adolescents, cancer, causation, certainty, children, climate change, confidence (over-, under-), decision rules, decision theory (analysis), ecology, economics, emotion (affect), error, experts, fairness (equality, justice), framing, fables, heuristic, HIV/AIDS, influence, informed choice, insurance, Kahneman (D.), medicine, mortality, pregnancy, probability, rationality, regulation (standards), risk, sacred values, sex, smoking, statistics, valued outcome, war, water, wellbeing

Weekend Reading: The Challenge Process and the Instant Referendum

Weekend Reading: Miscellaneous Classic BooksThe links below are provided because I believe they have some merit in terms of being interesting, innovative, challenging, persuasive, or informative. Inclusion here neither implies that I agree with everything written, nor that I support most of the author’s conclusions, nor that I think the authors themselves are precisely or directionally correct in their overall approach to the subject. Comments in [ ] brackets are my own.

How to Draw and Judge Quadrant Diagrams [Trust me: this is better than it sounds]

Every Leader Needs a Challenger in Chief

Sizing up the nightlife [How does the judgment of a doorman at a nightclub apply to informal social hierarchy?]

MindTools for personal accountability, professionalism, and preserving integrity

Contrarian Corner:

Confronted with Attractive Female Opponents, Male Chess Players Take Greater Risks [Armed with this knowledge, perhaps strategic compensation in the conservative/defensive direction would be advantageous if the principle extends to business.]

After crunching the numbers, Google’s SVP concludes that college GPA has no correlation to work performance

Cause-and-effect: How clear is it really?

The “Instant Referendum” Revolution

Weekend Reading: Management Pseudoscience

Weekend Reading: Miscellaneous Classic BooksBeware Management Pseudoscience: Popularization usually dilutes practices and they stifle innovation

How to help your intern [or contractor] get permanent employment

MindTools for Teams: Leader-Member Exchange (LMX) Theory, Team Briefings

The Gervais Principle and The Office According to The Office: Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 [This is really long, but worth it.]

Moving the needle, the “big arrow”, succession planning, and undiscussables: what senior leaders should be talking about

Managing Maintenance Error by James Reason

Managing Maintenance Error by James ReasonBook Review: Managing Maintenance Error: A Practical Guide by James Reason

If some evil genius were given the job of creating an activity guaranteed to produce an abundance of errors, he or she would probably come up with something that involved the frequent removal and replacement of varied components, often carried out in cramped and poorly lit spaces with less-than-adequate tools, and usually under severe time pressure. [The] people who wrote the manuals and procedures rarely if ever carried out the activity under real-life conditions. [Those] who started a job need not necessarily be the ones required to finish it. A further twist might be that a number of different groups work on the same item of equipment either simultaneously or sequentially, or both together.

Small wonder, then, that maintenance-related activities attract far more than their fair share of human performance problems.

—James Reason, author

An indulgent attitude to non-compliance is usually a price worth paying to find out what really happened.

—Trevor Kletz, author of What Went Wrong?

When I was in high school, I had a very short time to run to my locker, drop off books and notes, grab new books and notes, and get to my next class. I also had to navigate a maze of people standing in the way talking and oblivious to their surroundings. (Sound familiar?) There were also severe sanctions for “tardiness” and therefore strong incentives for punctuality.

So I got very used to operating the combination lock quickly. I did this three or four times per day, five days per week. Like most, I could walk up to my locker and open it with barely a glance at the actual combination lock. Though the memory has faded I don’t think I exaggerate much if I boast that I could enter the three numbers consistently and repeatably in at most 1.5 seconds.

One day, I got to my locker and tried to remember the combination, and I couldn’t. It was completely gone. I tried a dozen times or more. My neighbors came and went. But I was unable to get my locker open. After four or five minutes I was finally able to recall my combination and move on.

Why did this happen? Was it some kind of extreme time pressure? There was time pressure, was I was not unduly stressed at the time. Am I mentally defective? I rather doubt that I am the only person on earth to whom this has happened. It happened to some of my friends and it may have happened to you. What about similar situations: could it happen to an experienced and conscientious chemical plant operator? To a consultant or teacher delivering a speech they’ve done a hundred times before? To a maintenance mechanic rebuilding the same kind of pump for the thousandth time?

Reason’s Managing Maintenance Error is an excellent launching point for exploring this subject. This book is very in touch with reality. I have reviewed portions of it with maintenance supervisors and mechanics and they all get “that look” on their face as they express their amazement that the passage or diagram was so accurate.

If you have ever concluded an incident investigation by suggesting “more training” or “changing procedures” then the information in this book will help you become a more thorough investigator.

Key Concepts

Key concepts are either recurring themes or strong individual points made with a fairly general application. Books with a more theoretical bent will have more “key concepts.”

  • Maintenance is an error-prone activity for reasons provided in the quote at the top of the page.
  • We provide defenses to protect systems from errors (such as procedures), but these defenses are imperfect. If the gaps in the barriers line up just right, and an error occurs, we have accidents. The more redundancy we have in preventing errors, the less likely they are to occur.
  • Conscious attention is slow and error-prone, but very flexible. There are three levels of performance depending upon how much conscious attention is required:
    1. Skill-Based performance is quick and automatic, and is well suited for routine situations. Skill-based errors include recognition failures, memory failures, and slips.
    2. Rule-Based performance involves pattern-matching for trained-for and prepared-for problems. “Rule-based mistakes typically involve incorrect assumptions or bad habits.”
    3. Knowledge-Based performance is conscious, slow, and effortful attempts to solve new or novel problems. “Knowledge-based errors can reflect failed problem solving or a lack of system knowledge.”
  • On Adaptability: “The very adaptability of maintenance workers is part of the problem. If the right stand is not available, another can be made to fit, if the correct tool is not available, perhaps one can be made… If maintenance workers stopped work when a piece of equipment was not available, the problem would be more obvious to management. But a can-do attitude often prevents this.” [The “solution” is tool maintenance and management, not just exhorting maintenance with slogans “not to take shortcuts.”]
  • On Fatigue:
    • After 18 hours, mental/physical performance degradations are consistent with a Blood Alcohol Content (BAC) of 0.05.
    • After 23 hours, performance is equivalent to a BAC of 0.12.
    • Fatigued individuals are not always aware that their performance has degraded.
  • On Violations:
    • Violations are deliberate acts: people weight the costs and benefits of non-compliance and judge the perceived benefits as exceeding the perceived costs.
    • The management challenge is not to increase costs of violations with stiffer penalties, but to increase the perceived benefits of compliance.
    • The change process for procedures must be expedient enough that changes are not slow and cumbersome. This results in “black books” that show how the job is really done.
  • Every incident tells us something about weaknesses in our system. Therefore, it is important that people report their mistakes. But this is challenging since people do not readily confess their own blunders. Therefore, a supportive culture is necessary to extract maximum learning from events.
  • There are three components to errors and mishaps:
    1. Causal factors: our greatest “leverage point” for preventing errors
    2. Timing: very little can be done about the timing when errors come together to create mishaps or reducing the rate of error beyond a certain point
    3. Consequences: since errors and mishaps occur, organizations need to plan to mitigate their consequences
  • Noncompliance with procedures provides a clue to unacceptable behavior, but does not establish it. Sanctioning an individual for noncompliant behavior when it was influenced by management factors (tools not available, manuals outdated or wrong, or incomprehensible procedures) works against a culture of trust and a culture of safety. Therefore, prevailing circumstances must be considered when weighing the applications of sanctions.
  • The John Carroll model of the four stages of organizational learning:
    1. Local stage: Single-loop learning and an emphasis on individual accountability rather than organizational factors.
    2. Control stage: Emphasizes compliance with rules and reduction of variation. Well-suited to stable environments, but not so effective in dynamic and turbulent environments.
    3. Open stage: An uncomfortable stage where a variety of viewpoints are applied to situations. Wide recognition that “the world is not so simple” that quick and easy fixes can be applied to everything.
    4. Deep learning stage: More tolerance for short-term difficulties and more resources given over to learning. Bad things are expected and planned for. Intelligent wariness replaces skeptical helplessness.
  • It is no good to rely on the “paper trail” if what happens in reality does not match the documents.

Useful Features

Useful features are like pages, diagrams, or tables that one might bookmark or dog-ear for quick reference. Books oriented toward application will generally have more “useful features.”

  • Torch Beam Model of Human Attention (p. 23)
  • Using the Activity Space to Define the Three Performance Levels (p. 29)
  • Relationship Between Arousal and Quality of Performance (p. 33)
  • Four Personality Types Based Upon Introversion-Extraversion and Stable-Unstable Dimensions (p. 35)
  • Latent Failure Pathway (p. 90)
  • Summary of Error Management Principles (p. 101)
  • Task Step Checklist (p. 127)
  • Ten Criteria for a Good Reminder (p. 131)
  • Distinguishing Between Single-Loop and Double-Loop Organizational Learning (p. 151)
  • Description of the Four-Stage Model of Organizational Learning (pp. 154-5)
  • Three Types of Safety Culture [Good, Bad, and Ugly] (pp. 157-8)
  • Common Features of Safety and Quality Management Systems (p. 162)
  • Human Performance Awareness Checklist (pp. 168-70)
  • Checklist for Assessing Institutional Resilience [CAIR] (pp. 171-3)

Publisher’s Blurb

From the back cover:

From the Preface: “In many industries, safety and reliability have been improved by the automation of tasks previously performed by humans. But maintenance is not so easy to automate. So long as we rely on human hands and minds to maintain our technology, we face the irony that maintenance is a significant – some say major – cause of failures.

“The central contention of this book is that while the risk of maintenance error can never be eliminated entirely, it can be managed more effectively. Maintenance personnel and their managers need to understand why maintenance errors occur, and how the risk of error can be controlled. We are confident that this book will be useful to all… who manage, supervise, or carry out maintenance activities in a wide range of activities.”

This down-to-earth practitioner’s guide to managing maintenance error, written in the authors’ highly readable style. It deals with human risks generally and the special human performance problems in maintenance, as well as providing an engineer’s guide to understanding and addressing the thread of maintenance error. After reviewing the types of error and violation and the conditions that provoke them, the authors set out the broader picture, illustrated by examples of three system failures.

Central to the book is a comprehensive review of error management, followed by chapters on:

  • Managing the person, the task and the team;
  • The workplace and the organization;
  • Creating a safe culture.

The readership includes maintenance engineering staff and safety officers and all those in responsible roles in critical and systems-reliant environments, including transportation, nuclear and conventional power, extractive and other chemical processing and manufacturing industries and medicine.

Table of Contents

List of Figures

List of Tables


Chapter 1: Human Performance Problems in Maintenance

Chapter 2: The Human Risks

Chapter 3: The Fundamentals of Human Performance

Chapter 4: The Varieties of Error

Chapter 5: Local Error-Provoking Factors

Chapter 6: Three System Failures and a Model of Organizational Accidents

Chapter 7: Principles of Error Management

Chapter 8: Person and Team Measures

Chapter 9: Workplace and Task Measures

Chapter 10: Organizational Measures

Chapter 11: Safety Culture

Chapter 12: Making it Happen: The Management of Error Management


Key Terms from the Index

accidents, aircraft, attention, blame and human error, Clapham Junction Rail incident, Embraer-120, error management, errors, fatigue, human error, human performance, maintenance activities, maintenance errors, memory, models, MRM (Maintenance Resource Management), omissions, organizational learning, procedures, resilience, safety culture, safety management systems, shift work, skills, systems, violations

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