Category Archives: Sense-making

My story: A day with Sidney Dekker

A story is an accounting of an event as experienced through the eyes, ears, cognitive biases, and paradigms of one person. This is my story about attending the Day with Sidney Dekker ’ at the Vancouver Convention Centre on Friday September 19 2014.  The seminar was sponsored by the Lower Mainland chapter of CSSE (Canadian Society of Safety Engineering). I initially heard about the seminar through my associations with RHLN and the HFCoP.

I was aware that Sidney Dekker (SD) uses very few visual slides and provides no handouts. So I came fully prepared to take copious notes with my trusty iPad Air. This not a play-by-play (or a blow-by-blow if you take in SD’s strong opinions on HR, smart managers bent on controlling dumb workers, etc.)  I’ve shifted content around to align my thinking and work I’ve done co-developing our Resilient Safety Culture course with Cognitive-Edge. My comments are in square brackets and italics.

SD: Goal today is to teach you think about intractable issues in safety
SD: Don’t believe a word I say; indulge me today then go find out for yourself
SD: We care when bad people make mistakes but we should care more when good people make mistakes and why they do

Where are we today in safety thinking?

Here is a recent article  announcing a new safety breakthrough []
LIJ medical center has implemented a safety solution that will be all to end all
A remote video auditing (RVA) in a surgical room developed by Arrowsight []

RVA monitors status every 2 minutes for tools left in patients, OR team mistakes
Patient Safety improved to a near perfect score
Culture of safety and trust is palpable among the surgical team
Real-time feedback on a  smartphone
RVA is based on the “bad apple” theory and model and an underlying assumption there is a general lack of vigilence
Question: Who looks at the video?
Ans: Independent auditor who will cost money. Trade-off tension created between improving safety or keeping costs down
Assumption: He who watches knows best so OR team members are the losers
Audience question: What if the RVA devices weren’t physically installed but just announced; strategy is to put in people’s minds that someone is watching to avoid complacency
SD: have not found any empirical evidence that being watched improves safety. But it does change behaviour to look good for the camera
Audience question: Could the real purpose of the RVA be to protect the hospital’s ass during litigation cases?
SD: Very good point! [safety, cost, litigation form a SenseMaker™ triad to attach meaning to a story]
One possible RVA benefit: Coaching & Learning
If the video watchers are the performers, then feedback is useful for learning purposes
Airline pilots can ask to replay the data of a landing but only do so on the understanding there are serious protections in place – no punitive action can be a consequence of reviewing data
Conclusion: Solutions like RVA give the illusion of perfect resolution
How did we historically arrive at the way we look at safety and risk today?
[Reference SD’s latest book released June 2014:  “Safety Differently” which is an update of “Ten Questions About Human Error: A New View of Human Factors and System Safety”]
[SD’s safety timeline aligns the S-curve diagram developed by Dave Snowden]

Late Victorian Era

Beginning of measurement (Germany, UK) to makes things visible
Discover industrial revolution kills a lot of people, including children
Growing concern with enormous injury and fatality problem
Scholars begin to look at models
1905 Rockwell: pure accidents (events that cannot be anticipated) seldom happen; someone has blundered or reversed a law of nature
Eric Farmer: carelessness or lack of attention of the worker
Oxford Human Factor definition: physical, mental, or moral shortcoming of the individual that predisposes the person

We still promote this archaic view today in programs like Hearts & Mind [how Shell and the Energy Institute promote world class HSE]
campaigns with posters, banners, slogans
FAITH-BASED safety approach vs. science-based

In 2014, can’t talk about physical handicaps but are allowed to for mental and moral (Hearts and Minds) human deficiencies
SD: I find it offensive to be treated as an infantile

1911 Frederick Taylor introduced Scientific Management to balance the production of pigs, cattle
Frank Gilbreth conducted time and motion studies
Problem isn’t the individual but planning, organizing, and managing
Scientific method is to decompose into parts and find 1 best solution [also known as Linear Reductionism]
Need to stay with 1 best method (LIJ’s RVA follows this 1911 edict)
Focus on the non-compliant individual using line supervision to manage dumb workers
Do not let people to work heuristically [rule of thumb] but adamantly adhere to the 1 best method
We are still following the Tayloristic approach
Example: Safety culture quote in 2000: “It is generally acknowledged that human frailty lies behind the majority of our accidents. Although many of these have been anticipated by rules, procedures, some people don’t do what they are supposed to do. They are circumventing the multiple defences that management has created.”

It’s no longer just a Newton-Cartesian world

        Closed system, no external forces that impinge on the unit
        Linear cause & effect relationships exist
        Predictable, stable, repeatable work environment
        Checklists, procedures are okay
        Compliance with 1 best method is acceptable

Now we know the world is complex, full of perturbations, and not a closed system 

[Science-based thinking has led to complex adaptive systems (CAS)]

SD’s story as an airline pilot
Place a paper cup on the flaps (resilience vs. non-compliance) because resilience is needed to finish the design of the aircraft by the operators
Alway a gap between Work-as-imagined vs Work-as-done [connects with Erik Hollnagel’s Safety-II]
James Reason calls the gap a non-compliance violation; we can also call that gap Resilience – people have to adapt to the local conditions using their experience, knowledge, judgement

SD: We pay people more money who have experience. Why?  Because the 1 best method may not work
There is no checklist to follow
Taylorism is limited and can’t go beyond standardization

Audience question: Bathtub curve model for accidents – more accidents involving younger and older workers. Why does this occur?
SD: Younger workers are beaten to comply but often are not told why so lack understanding
Gen Y doesn’t believe in authority and sources of knowledge (prefer to ask a crowd, not an individual)
SD: Older worker research suggests expertise doesn’t create safety awareness. They know how close they can come to the margin but if they go over the line, slower to act. [links with Richard Cook’s Going Solid / Margin of Manoeuvre concept]

This is not complacency (a motivational issue) but an attenuation towards risk. Also may not be aware the margins have moved (example: in electric utility work, wood cross-arm materials have changed). Unlearning, teaching the old dog new tricks is difficult.[Master builder/Apprenticeship model: While effective for passing on tacit knowledge, danger lies in old guys becoming stale and passing on myths and old paradigms]

1920s & 1930s – advent of Technology & animation of Taylorism

World is fixed, technology will solve the problems of the world
Focus on the person using rewards and punishment, little understanding of deep ethical implications
People just need to conform to technology, machines, devices [think of Charlie Chaplin’s Modern Times movie]

Today: Behaviour-based Safety (BBS) programs still follow this paradigm re controlling human behaviour
Example: mandatory drug testing policy. What does this do to an organization?
In a warehouse, worker is made to wear a different coloured vest (a dunce cap)
“You are the sucker who lost this month’s safety bonus!” What happens to trust, bonding?

Accident Proneness theory (UK, Germany 1925)

Thesis is based on data and similar to Bad Apply theory
[read John Burnham’s book ]
Data showed some people more involved in accidents than others (eg. 25% cause 55%)
Idea was to target these individuals
Aligned with the eugenic thinking in the 1920s (Ghost of the time/spirit/zeitgeist)
        Identify who is fit and weed out (exterminate) the unfit [think Nazism]
Theory development carried on up the WWII
Question: what is the fundamental statistical flaw with this theory?
Answer: We all do the same kind of work therefore we all have the same probability of incurring an accident
Essentially comparing apples with oranges
We know better – individual differences exist in risk tolerance
SD: current debate in medical journal: data shows 3% of surgeons causing majority of deaths
Similar article in UK 20% causing 80%
So, should we get rid of these accident-prone surgeons?
No, because the 3% may include the docs who are willing to take the risk to try something new to save a life

WWII Technologies

Nuclear, radar, rocketry, computers
Created  a host of new complexities, new usability issues

Example: Improvements to the B17 bomber
Hydraulic gear and flap technology introduced
However, belly-flop landings happened
Presumed cause was dumb pilots who required more training, checklists, and punishment
Would like to remove these reckless accident-prone pilots damaging the planes
However, pilots are in short supply plus give them a break – they have been shot at by the enemy trying to kill them
Shifted focus from human failure to design flaws. Why do 2 switches in dashboard look the same?
In 1943 redesigned switch to prevent bellyflopping
Message: Human error is systemically connected and predictability so to the features of tools and products that people use. Bad design induces errors. Better to intervene in the context of people’s work.

Safety thinking begins to change: What happens in the head is acutely important.
Now interested in cognitive psychology [intuition, reasoning, decision-making] not just behavioural psychology [what can be observed]
Today: Just Culture policy (human error, at-risk behaviour, reckless behaviour)

After lunch exercise: Greek airport 1770m long

Perceived problem: breaking EU rules by taxiing too close to the road
White line – displaced threshold – don’t land before this line
Need to rapidly taxi back to the terminal to unload for productivity reasons (plane on-the-ground costs money)
Vehicular traffic light is not synced with plane landing (i.e., random event)

Question: How do you stop non-compliant behaviour if you are the regulator? How might you mitigate the risk?
SD: Select a solution approach with choices including Taylorism, Just Culture, Safety by Design
Several solutions heard from the audience but no one-best

SD: Conformity and compliance rules are not the answer, human judgment required
Situation is constantly changing – Tarmac gets hot in afternoon; air rises so may need to come in at a lower angle. At evening when cooler, approach angle will change
[Reinforces the nature of a CAS where agents like weather can impact  solutions and create emergent, unexpected consequences]
SD concern: Normalization of deviance – continual squeezing of the boundaries and gradual erosion of safety margins
They’re getting away with it but eventually there will be fatal crash
[reminds me of the frog that’s content to sit in the pot of water as the temperature is slowly increased. The frog doesn’t realize it’s slowly cooking to death until it’s too late}
[Discussed in SD’s Drift into Failure book and]
Back to the historical timeline…

1980s Systems Thinking

James Reason’s Swiss Cheese Model undermines our safety efforts
        Put in layers of defence which reinforces the 1940s thinking
        Smarter managers to protect the dumb workers
        Cause and effect linear model of safety
Example: 2003 Columbia space shuttle re-entry
        Normal work was done, not people screwing up (foam maintenance)
        There were no holes according to the Swiss Cheese Model
        Emergence: Piece of insulation foam broke off damaging the wing
Example: 1988 Piper Alpha oil rig
        Prior to accident, recognized as the most outstanding safe and productive oil rig
        Explosion due to leaking gas killing 167
        “I knew everything was right because I never got a report anything was wrong”
       Looking for the holes in the Swiss Cheese Model again
       Delusion of being safe due to accident-free record

Many people carry an idealistic image of safety: a world without harm, pain, suffering
Setting a Zero Harm goal is counter-productive as it suppresses reporting and incents manipulation of the numbers to look good

Abraham Wald example
Question: Where should we put the armour on a WWII bomber?Wrong analysis: Let’s focus on the holes and put armour there to cover them up
Right analysis: Since the plane made it back, there’s no need for armour on the holes!
Safety implication: Holes represent near-miss incidents (bullets that fortunately didn’t down the plane). We shouldn’t be covering the holes but learning from them

Safety management system (SMS)
Don’t rest on your laurels thinking you finally figured it out with a comprehensive SMS
Australian tunnelling example:
Young guy dies working near an airport
There were previous incidents with the contractor but no connection was made
Was doing normal work but decapitated finishing the design
An SMS will never pick this up

Don’t be led astray by the Decoy phenomenon
Only look at what we can count in normal work and ignore other signals
Example: Heinrich triangle – if we place our attention on the little incidents, then we will avoid the big ones (LTA, fatality) [now viewed as a myth like Accident Prone theory]
Some accidents are unavoidable  – Barry Turner 1998 [Man-made Disasters]
Example: Lexington accident [2006 Comair Flight 5191] when both technology and organization failed

Complexity has created huge, intractable problems
In a world of complexity, we can kill people without precursory events
[If we stay with the Swiss Cheese Model idea, then Complexity would see the holes on a layer dynamically moving, appearing, disappearing and layers spinning randomly and melting together to form new holes that were unknowable and unimaginable]


Safety has become a bureaucratic accountability rather than an ethical responsibility
Amount of fraud is mounting as we continue measuring and rewarding the absence of negative incidents
Example: workers killed onsite are flown back home in a private jet to cover up and hide accidents
If we can be innovative and creative to hide injuries and fatalities, why can’t we use novel ways to think about safety differently?
Sense of injustice on the head of the little guy

Advances in Safety by Design
“You’re not lifting properly” compared “the job isn’t designed properly”
An accident is a free lesson, learning opportunity, not a HR performance problem
Singapore example: Green city which to grow must go vertically up. Plants grow on all floors of a tall building. How to maintain?
One approach is to punish the worker if accident occurs
Safety by Design solution is to design wall panels that rotate to maintain plants; no fall equipment needed
You can swat the mosquito but better to drain the swamp

Why can’t we solve today’s problems the same way we solved them back in the early 1900s?

What was valued in the Victorian Era

  1. People are a problem to control
  2. We control through intervention at the level of their behaviour
  3. We define safety as an absence of the Negative

Complexity requires a shift in  what we value today

  1. People are a solution, a resource
  2. Intervene in the context and condition of their work
  3. Instead of measuring and counting negative events, think in terms of the presence of positive things – opportunities, new discoveries, challenges of old ideas

What are the deliverables we should aim for today?

Stop doing work inspections that treat workers like children
It’s arrogant believing that an inspector knows better
Better onsite visit: Tell me about your work. What’s dodgy about your job?
Intervene the job, not the individual’s behaviour.
Collect authentic stories.
[reinforces the practice of Narrative research]

Regulators need to shift their deliverables from engaging reactively (getting involved after the accident has occurred), looking for root causes, and formulating policy constraints
Causes are not things found objectively; causes are constructed by the human mind [and therefore subject to cognitive bias]
Regulators should be proactively co-evolving the system [CAS]
Stop producing accident investigation reports closing with useless recommendations to coach and gain commitment
Reference SD’s book: Field Guide to Investigating accidents – what you look for you will find

Question: Where do we place armour on a WWII bomber if we don’t patch the holes?
Answer: where we can build resilience by enabling the plane to take a few hits and still make it back home
[relates to the perspective of resilience in terms of the Cynefin Framework]

Resilience Engineering deliverables

  1. Do we keep risk awareness alive? Debrief and more debrief on the mental model? Even if things seem to be under control? Who leads the debriefing? Did the supervisor or foreman do a recon before the job starts to lessen surprise? [assessing the situation in the Cynefin Framework Disorder domain]
  2. Count the amount of rework done – can be perceived as a leading indicator although it really lags since initial work had been performed
  3. Create ways for bad news to be communicated without penalty. Stat: 83% of plane accidents occur when pilots are flying and 17% when co-pilots are.  Institute the courage to speak up and say no. Stop bullying to maintain silience. It is a measure of Trust and empowers our people. Develop other ways such as role playing simulations, rotation of managers which identify normalization of deviance (“We may do that here but we don’t do that over there”)
  4. Count the number of fresh perspectives and opinions that are allowed to be aired. Count the number of so-called best practice rules that are intelligently challenged. [purpose of gathering stories in a Human Sensor Network]
  5. Count number or % of time re human-human relationships (not formal inspections) but honest and open conversations that are org hierarchy-free.

Paradigm Shift:

Spend less time and effort on things that go wrong [Safety-I]
Invest more effort on things that go right which is most of the time [Safety-II]

Final message:

Don’t do safety to satisfy Bureaucratic accountability
Do safety for Ethical responsibility reasons

There were over 100 in attendance so theoretically there are over 100 stories that could be told about the day. Some will be similar to mine and my mind is open to accepting some will be quite different (what the heck was Gary smoking?)  But as we know, the key to understanding complexity is Diversity –  the more stories we seek and allow to be heard, the better representation of the real world we have.

A pathetic safety ritual endlessly recycled

Dave Johnson is Associate Publisher and Chief Editor of ISHN, a monthly trade publication targeting key safety, health and industrial hygiene buying influencers at manufacturing facilities of all sizes.  In his July 09 blog (reprinted below), he laments how the C-suite continues to take a reactive rather than proactive approach to safety. Here’s a reposting of my comments.

Let’s help the CEOs change the pathetic ritual

Dave: Your last paragraph says it all. We need to change the ritual. The question is not why or what, but how. One way is to threaten CEOs with huge personal fines or jail time. For instance, in New Zealand a new Health and Safety at Work Act is anticipated to be passed in 2014. The new law will frame duties around a “person conducting a business or undertaking” or “PCBU”. The Bill as currently drafted does not neatly define “PCBU” but the concept would appear to cover employers, principals, directors, even suppliers; that is, people at the top. A tiered penalty regime under the new Act could see a maximum penalty of $3 million for a body corporate and $600,000 and/or 5 years’ imprisonment for an individual. Thrown into jail due to unsafe behaviour by a contractor’s new employee whom you’ve never met would certainly get your attention.

But we know the pattern: Initially CEOs will order more compliance training, inspections, more safety rules. Checkers will be checking checkers. After a few months of no injuries, everyone will relax and as Sidney Dekker cautioned, complacency will set in and the organization will drift to failure. Another way is to provide CEOs with early detection tools with real-time capability. Too often we read comments in an accident report like “I felt something ominous was about to happen” or “I told them but nobody seemed to listen.”

CEOs need to be one of the first, not the last, to hear about a potential hazard identified but not being addressed. We now have the technology to allow an organization to collect stories from the front line and immediately convert them to data points which can be visually displayed. Let’s give CEOs and higher-ups the ability to walk the talk. In addition, we apply a complexity-based approach where traditional RCA investigative methods are limited. Specifically, we need to go “below the water line” when dealing with safety culture issues to understand the why rituals persist. 

Gary Wong
July 16, 2014

G.M.’s CEO is the latest executive to see the light

By Dave Johnson July 9, 2014

Wednesday, June 11, 2014, at the bottom right-hand corner of the section “Business Day” in The New York Times, is a boxed photograph of General Motors’ chief executive Mary T. Barra. The headline: “G.M. Chief Pledges A Commitment to Safety.”

Nothing against Ms. Barra. I’m sure she is sincere and determined in making her pledge. But I just shook my head when I saw this little “sidebar” box and the headline. Once again, we are treated to a CEO committing to safety after disaster strikes, innocent people are killed (so far G.M. has tied 13 deaths and 54 accidents to the defective ignition switch), and a corporation’s reputation is dragged through the media mud. The caption of Ms. Barra’s pic says it all: “…Mary T. Barra told shareholders that the company was making major changes after an investigation of its recall of defective small cars.”

Why do the commitments, the pledges and the changes come down from on high almost invariably after the fact?

You can talk all you want about the need to be proactive about safety, and safety experts have done just that for 20 or 30 or more years. Where has it gotten us, or more precisely, what impact has it had on the corporate world?

Talk all you want
Talk all you want about senior leaders of corporations needing to take an active leadership role in safety. Again, safety experts have lectured and written articles and books about safety leadership for decades. Sorry, but I can’t conjure the picture of most execs reading safety periodical articles and books. I know top organization leaders have stressful jobs with all sorts of pressures and competing demands. But I have a hard time picturing a CEO carving out reading time for a safety book in the evening. Indeed a few exist; former Alcoa CEO Paul O’Neill is the shining example. But they are the exceptions that prove the rule. The National Safety Council’s Campbell Institute of world class safety organizations and CEOs who “get it” are the exceptions, too, I’d assert.

And what is the rule? As a rule, proven again and again ad nauseam, top leaders of large corporations only really get into safety when they’re forced into a reactive mode. For the sake of share price and investor confidence, they speak out to clean up a reputational mess brought about by a widely publicized safety tragedy. Two space shuttles explode. Refineries blow up. Mines cave in. The incident doesn’t have to involve multiple fatalities and damning press coverage. I’ve talked with and listen to more than one plant manager or senior organization leader forced to make that terrible phone call to the family of a worker killed on the job, and who attended the funeral. The same declaration is stressed time and again: “Never again. Never again am I going to be put in the position of going through that emotional trauma. Business school never prepared me for that.”

“In her speech to shareholders, Ms. Barra apologized again to accident victims and their families, and vowed to improve the company’s commitment to safety,” reported The New York Times. “Nothing is more important than the safety of our customers,” she said. “Absolutely nothing.”

Oh really? What about the safety of G.M.’s workers? Oh yes, it’s customers who drive sales and profits, not line workers. This is cold business reality. Who did G.M.’s CEO want to get her safety message across to? She spoke at G.M.’s annual shareholder meeting in Detroit. Shareholders’ confidence needed shoring up. So you have the tough talk, the very infrequent public talk, about safety.

Preaching to the choir
I’ve just returned from the American Society of Safety Engineers annual professional development conference in Orlando. There was a raft of talks on safety leadership, what senior leaders can and should do to get actively involved in safety. There were presentations on the competitive edge safety can give companies. If an operation is run safely, there are fewer absences, better morale, good teamwork, workers watching out for each other, cohesiveness, strong productivity and quality and brand reputations. The classic counter-argument to the business case was also made: safety is an ethical and moral imperative, pure and simple.

But who’s listening to this sound advice and so-called thought leadership? As NIOSH Director Dr. John Howard pointed out in his talk, the ASSE audience, as with any safety conference audience, consists of the true believers who need no convincing. How many MBAs are in the audience?

Too often the moral high ground is swamped by the short-term, quarter-by-quarter financials that CEOs live or die by. Chalk it up to human nature, perhaps. Superior safety performance, as BST’s CEO Colin Duncan said at ASSE, results in nil outcomes. Nothing happens. CEOs are not educated to give thought and energy to outcomes that amount to nothing. So safety is invisible on corner office radar screens until a shock outcome does surface. Then come the regrets, the “if only I had known,” the internal investigation, the blunt, critical findings, the mea culpas, the “never again,” the pledge, the commitment, the vow, the tough talk.

There’s that saying, “Those who do not learn from history are bound to repeat it.” Sadly, and to me infuriatingly, a long history of safety tragedies has not proven to be much of a learning experience for many corporate leaders. “Ah, that won’t happen to us. Our (injury) numbers are far above average.” Still, you won’t have to wait long for the next safety apology to come out of mahogany row. It’s a pathetic ritual endlessly recycled.


Accountants live in the Past

A family milestone was recently achieved when my nephew received his CA designation. Great to see when a lot of sweat and effort ultimately leads to a personal and professional goal.

Chris Cairns CA

The blog heading is not meant to be derogatory; it’s just what accountants primarily do. Their job is to record company history in financial terms, according to GAAP (generally accepted accounting principles). According to Wikipedia, the rules and procedures for reporting under GAAP are complex and have developed over a long period of time. Currently there are more than 150 “pronouncements” as to how to account for different types of transactions. GAAP is slowly being phased out in favour of the International Financial Reporting Standards (IFRS).

Not all CAs stay in the accounting field. In many cases it’s a foundational step that will lead to a successful business, management, IT career.

IMO, the biggest contribution a CA just starting out can make is busting through the “yellow bubble.”  That means not being trapped by existing paradigms but challenging them. The world needs CAs in leadership roles to enable new perspectives and ways of thinking emerge and flourish. Obviously the disruption must be respectful and tactful to avoid ticking off senior CAs who may not realize they have become professionals trapped in their own expertise. In the following video, Dave Snowden explains the phenomenon.

What are some of these accounting paradigms we should challenge?

One of the oldest and most durable (resistive?) paradigms in an organization is the financial system that runs on a fiscal year. It is so strong that other systems such as HR, Planning, Marketing, and Supply Chain align their activities to fiscal quarters. If the fiscal year ends on 31 March, a phenomenon called “March madness” takes place. Cautious for the preceding 11 months, a manager will madly spend to minimize year-end budget variance or in fear of having next year’s budget allotment reduced. To avoid this annual ritual, managers are directed to curve budgets; that is, guess when they expect expenses to be charged.

Anyone who has managed a project extending over one year has encountered accrual accounting. It’s spending time guesstimating what your expenditures will be on a particular date. Think about the times you wanted to proceed but we’re told you had to defer due to budgetary reasons. Alternatively, you were surprised and told to spend money now as there were surplus funds. However, you couldn’t pull it off due to lead time issues.

Why is the 12-month fiscal year a sacred cow? Consider the annual employee appraisal. Does it make sense to reward or punish employees according to some fiscal time schedule? Agile companies don’t; they formally recognize performance immediately.

In companies that have installed an IT ERP Financial systems, the Control of Information paradigm is significantly reinforced. Many CAs and CIOs struggle with the advent of social media software, products of the Complexity/Sense-Making S-curve. It will be fascinating to observe those who try to control information and those to choose to unleash the power of networks. Professor Robert Plant in his HBR article “IT Has Finally Cracked the C-Suite” wrote about a new leadership title Chief Business Technology Officer (CBTO). It’s a paradigm shift for technology leaders who still refer to themselves in terms of “working with the business” rather than using technology to drive business strategy.  “You can tell the ones who will thrive and survive and the ones who won’t,” he says. “It may be a year, it may be four, but many are not going to make it because they are so focused on old-school stuff that their competitors will focus on differentiating them and beat them eventually.”

How might one improve business agility? Small ideas include removing the accruals burden on the project manager and putting the onus on the accountants to estimate the dollars spent. A bigger shift is to dispense with a fiscal year operation and run the total business on a Gantt chart. Adam Laskinsky in his book Inside Apple revealed that the Apple culture has only one budget held by the CFO. Managers are not encumbered by dollar watching and focus full attention on getting their projects done.

The future belongs to companies, to organizations,  and to governments who recognize the need for strategic agility. And there’s a strong possibility they will be led by smart CAs.

Cynefin Simple domain renamed Obvious domain

The Cynefin Framework is a sufficient but always partial view of reality. As additional information arrives and new insights emerge, adjustments are made to reflect the real world.

Recent thinking recognizes that in all 4 domains a few,  simple rules seem to guide behaviour. By “simple”, we mean an action that can be easily carried out.  Examples are applying a rule-of-thumb heuristic, following a straight-forward process, or performing an entrained habit.

Unfortunately, the word “Simple” has been associated with one of the domains. Consequently, Dave Snowden decided to rename Simple domain to Obvious domain. When describing the Cynefin framework in terms of Cause & Effect relationships, “Obvious” carries the same meaning – clear, straight-forward.


Cynefin Cause & Effect


Existing graphics, diagrams, and videos will be updated over time.

Apple buying Beats might be a safe-to-fail experiment

The music industry is a complex adaptive system (CAS). The industry is full of autonomous agents who have good and bad relationships with each other. Behaviours and reactive consequences can build on each other.  Media writers and industry analysts are also agents who are  easily attracted to big events. Their comments and opinions add to the pile and fuel momentum. However the momentum is nonlinear. Interest in the  topic will eventually fall off  as pundits tire and move on or a feverish pitch continues. Alternatively a CAS phenomenon called tipping point occurs. The music industry then changes. It might be small or a huge paradigm shift. It can’t be predicted; it will just emerge . In complexity jargon, the the system doesn’t evolve but co-evolves.  It’s asymmetrical – in other words, there is no reset or UNDO button to go back prior to the event.

While I might have an opinion about Apple buying Beats, I’m more interested in observing music industry behaviour. Here’s one perspective. I’ll use complexity language and apply the Cynefin Framework.

1. Apple is applying Abductive thinking and playing a hunch.

“Let’s buy Beats because the deal might open up some cool serendipitous opportunities. We can also generate some free publicity and let others promote us, and have fun keeping people guessing.  Yeh, it may be a downer if they write we’re nuts. But on the upside they are helping us by driving the competition crazy.”

2. Apple is probing the music industry by conducting a safe-to-fail experiment.

“It’s only $3.2B so we can use some loose change in our pockets. Beats is pulling in $1B annual revenue so really it’s no big big risk.”

3. Apple will monitor agent behaviour and observe what emerges.

“Let’s see what the media guys say.
“Let’s read about researchers guessing what we’re doing.”
“Let’s watch the business analysts  tear their hair out trying to figure out a business case  with a positive NPV. Hah! If they only knew a business case is folly in the Complex domain since predictability is impossible. That’s why we’re playing a hunch which may or may not be another game changer for us.”

4. If the Apple/Beats deal starts going sour, dampen or shut down the experiment.

“Let’s have our people on alert to detect unintended negative consequences. We can dampen the impact by introducing new information and watch the response. If we feel it’s not worth saving, we’ll cut our losses. The benefits gained will be what we learn from the experiment.”

5. If the Apple/Beats deal takes off, accelerate and search for new behaviour patterns to exploit.

“The key agents in the CAS to watch are the consumers. Observing what they buy is easy.  What’s more important is monitoring what they don’t buy.  We want to discover where they are heading and what the is strange attractor. It might be how consumers like to stream music, how they like to listen to music (why only ears?), or simply cool headphones are fashion statements.”

6. Build product/service solutions that  exploit this new pattern opportunity.

“Once we discover and understand the new consumer want, be prepared to move quickly.  Let’s ensure our iTunes Radio people are in the loop as well as the AppleTV and iWatch gangs. Marketing should be ready to use the Freemium business model. We’ll offer the new music  service for free to create barriers of entry to block competitors  who can’t afford to play the new game. It will be similar to our free medical/safety alert service we’ll offer with the iWatch. Free for Basic and then hook ’em with the gotta-have Premium.”

7. Move from the Complex domain to the Complicated Domain to establish order and stability.

“As soon as we’re pretty certain our Betas are viable, we’ll put our engineering  and marketing teams on it to release Version 1. We’ll also start thinking about Version 2. As before, we’ll dispense with ineffective external consumer focus groups. We’ll give every employee the product/service and gather narrative (i.e., stories) about their experiences. After all, employees are consumers and if it’s not great for us, then it won’t be great for the public.

Besides learning from ourselves, let’s use our Human Sensor network to cast  a wide net on emerging new technologies and ideas. Who knows, we might find another Beats out there we can buy to get Version 2 earlier to market.”

Fantasy? Fiction? The outcomes may be guesses but the Probe, Sense, Respond process in the Cynefin Complex Domain isn’t.


When a disaster happens, look for the positive

In last month’s blog I discussed Fast Recovery and Swarming as 2 strategies to exit the Chaotic Domain. These are appropriate when looking for a “fast answer”. A 3rd strategy is asking a “slow question.”

Resilience as Cynefin DynamicsWhile the process flow through the Cynefin Framework is similar to Swarming (Strategy B), the key difference is not looking for a quick solution but attempting to understand the behaviour of agents (humans, machines, events, ideas). The focus is on identifying something positive emerging from the disaster, a serendipitous opportunity worth exploiting.

By conducting safe-to-fail experiments, we can probe the system, monitor agent behaviour, and discover emerging patterns that may lead to improvements in culture, system, process, structure.

Occasions can arise when abductive thinking could yield a positive result. In this type of reasoning, we begin with some commonly well known facts that are already accepted and then works towards an explanation. The vernacular would be playing a hunch.

Snowstorm Repairs

In the electric utility business when the “lights go out”, a trouble crew  is mobilized and the emergency restoration process begins. Smart crews are also on the lookout for serendipitous opportunities. One case involved a winter windstorm causing  a tree branch to fall across the live wires. Upon restoration, the crew leader took it upon himself to contact customers affected by the outage to discuss removal of other potentially hazardous branches. The customers were very willing and approved the trimming. The serendipity arose because these very same customers vehemently resisted in the Fall to have their trees trimmed as part of the routine vegetation maintenance program.  The perception held then was that the trees were in full bloom and aesthetically pleasing; the clearance issues were of no concern. Being out of power for a period of time in the cold winter can shift paradigms.

Why Managers Haven’t Embraced Complexity

This is the title of an article written by Richard Straub in the Harvard Business Review HR Blog. The notion of applying Complexity science to management has been around for over 20 years. So why hasn’t it caught on? Why are managers and leaders reluctant to see the world as it is: non-linear, turbulent, ambiguous, unpredictable, and uncertain? Straub offers 3 reasons:

  1. Managers don’t want to give up control. 
    Today’s dominating business paradigm is Systems Thinking and the control of information. Before that it was Scientific Management and the control of processes. Imagine the resistance put up by those not willing to give up Taylorism and accept emerging ideas like socio-technical systems, learning organizations, etc. Now systems thinkers who once fought an uphill battle to introduce their ideas are being asked to give up their control of information and don’t resist/deny/block but embrace emerging ideas like complexity, networks, cognition. Reluctant managers will eventually change because they will discover that their old methods can’t resolve today’s problems. “Keep at it, try harder” no longer works and becomes a waste of time.
  2. Technology isn’t powerful enough.
    In engineering school I was taught “When in doubt, make a model”. I later realized that students in business and economics were also told the same thing. So we learned early that models were useful to proxy the real world. We didn’t have powerful computers (only slide rules) to perform detailed calculations; therefore, we learned from experienced craftsmen and professionals the “rules of thumb” they successfully deployed. Fast forward to today and consider the computer horsepower we have to create mathematical models to handle real world complexity. The internet, big data analytics, cloud computing, supercomputers et al are rapidly changing the IT landscape. We now know how human sensor networks can turn stories told by humans into data points that can be analyzed and support better decision-making.
  3. The prospect of non-human decision-making is too unnerving.
    If we had infinite computer processing power, would we be able to create a precise model of a complex system such as Health Care? Aviation? Public education? Electric power industry? Physicist Murray Gell-man says no: “The only valid model of a complex system is the system itself.”
    Machines are designed to perform “work-as-imagined.” Because human designers can’t imagine everything, machines are limited in what they can do. Humans are the best agents in a complex system to deal with unknown unknowns, unknowables, and the unimaginable.

Straub makes the point there has been a gradual change in mindset, pushed along by the increasingly evident damage of narrow, simplistic thinking. Here we are 10+ years into the 21st century and note the number of industrial age ideas still being widely used. The public education system continues run on a factory model. Health care remains using a craft model.

The movement from Safety-I to Safety-II hasn’t happened as quickly as we had hoped. In the latter case, perhaps by embracing complexity and applying ideas like the Cynefin framework and narrative inquiry, we will be able to accelerate the operationalizing of Safety-II.

Click here to read the Richard Straub article.

Thinking about Paradigms and Paradigm Shifts

I was initially introduced to the notion of paradigms and paradigm shift by Joel Barker. For me, he was able to take a science phenomenon into the world of business.

From Wikipedia: “The word [paradigm] has come to refer very often now to a thought pattern in any scientific discipline or other epistemological context.” …Since the 1960s, the term [paradigm shift} has also been used in numerous non-scientific contexts to describe a profound change in a fundamental model or perception of events, even though Kuhn himself restricted the use of the term to the hard sciences.”
I can relate to non-scientific contexts. As a FranklinCovey trainer, I introduce the concept of paradigms very early in a 7 Habits of Highly Effective People workshop. 7 Habits is all about changing human behaviour and it starts with the paradigms, the beliefs, the mindsets, we possess. In many cases, the paradigms that people hold dearly are not wrong or incorrect; they are insufficient. In addition, if you become highly skilled at using a hammer, you see every problem as a nail.


I hold a Professional Engineer license. I enjoy analyzing problems, finding cause & effect relations, optimizing choices, and implementing solutions. Life is good. When I can make all the decisions, life is really good. However, when other people get involved (especially stakeholders who are not engineers) I get extremely frustrated. I also like to work in a very linear, sequential fashion. I dislike uncertainities, unknowns, unpredictable behaviours. What’s wrong with people? How can they disagree with me? Why can’t they see it my way? As a budding engineer, this was my attitude. Thankfully I quickly matured and discovered I had tunnel vision. I could only view things from my vantage point. The world was much broader and wider than that. In Cynefin framework terms, my early formative career years clearly put me in the Complicated Domain. In many instances I was able to argue that I was right. However, I was insufficient because I did not recognize the Unordered side where Complexity and Chaos resided. I had read some things about complexity thinking but still didn’t have a complete picture. That changed when I read Dave’s and Mary’s 2007 HBR article Leader’s Framework for Decision Making.

Too Good for your own Good

Whenever I took a course or attended a workshop, I discovered my return to my office was often filled with employee trepidation. “Uh oh! What has Gary learned now that he wants to try out on us?” In later years as a consultant, I would come equipped with tried and proven methods, tools, and templates. Yesterday’s posting about wanting to start an engagement with traditional interviewing is an example. Hey! Why not? It’s worked in the past and therefore, should work just as well again. As experts we need to ensure that we are using the right tools at the right time for the right reasons.
In Cynefin framework terms, it’s perfectly okay to recommend Simple Domain solutions such as Training 101 when a lack of basic skills is the problem. Here we’re dealing with known knowns. We must be aware, however, when we propose resolving a Complex Domain issue using a Complicated Domain approach. It’s that ability to use a hammer well inside us which wants to immediately jump in and start analyzing instead of patiently stepping back and probing the system. It’s getting the client to appreciate that a safety culture problem won’t go away if more rules are written, training is mandated for all, and documenting crew inspections is added to the supervisor’s already overloaded checklist.

I once was asked in a 7 Habits workshop must a perspective change be earth shattering, tsunami-sized to be called a paradigm shift? My opinion was no. Humour, for instance, is a paradigm shift. Standup comedians like Bob Hope, Bill Crosby, Jerry Seinfeld knew how the play the brain to create laughter. Question: What is a paradigm worth? Answer: 20 cents If you aren’t smiling (or groaning), don’t feel bad. It’s just an indication of the patterns that have formed in your brain. I will be exploring how the brain works in a future posting. Plus provide an explanation if you didn’t get the joke.
I’d like to end today’s ramblings with story of a paradigm shift in my own home.

We were at the dinner table with my young daughter, Jennifer, sitting across from me. “Daddy! I can count to 10!’ she proudly exclaimed. “Great, Jen! Show me!” “Okay. 1,2,3,4,5,6,7,8,9,10. See! I did it!” “Good job! Way to go!”
Now being the father who enjoyed giving his kids a challenge, I then asked: “Now, can you count backwards?”
“Sure!” she smiled.
Jen proceeded to jump out of the chair, turn her back to me and confidently shouted: “1,2,3,4,5,6,7,8,9,10. See! I did it!”.
My wife and I hit the floor laughing. Yes, it was a .001 paradigm shift on the Richter scale but one that we will always remember fondly.

U.S. Public School: If it’s not working, just repeat the same mistakes

I recently read about the state of the U.S. public educational school system. What struck me was how powerful old school paradigms are and how people in power are unable to see what is happening. As expert analysts, they are in the Cynefin Framework’s Complicated Domain and suffer from perceptual blindness. Unfortunately they cannot see that existing methods and solutions (i.e., student testing) are not working. However, instead of finding another solution, the direction is to do more testing.

The article was written by Lisa Guisbond, a policy analyst for the National Center for Fair and Open Testing, known as FairTest, a Boston-based organization that aims to improve standardized testing practices and evaluations of students, teachers and schools. Excerpts from her article:

  • As children head back to school after a decade of No Child Left Behind (NCLB), will they benefit from lessons learned from this sweeping and expensive failure? Will schools do anything differently to avoid NCLB’s narrowed curriculum, teaching to the test and stagnant achievement? Sadly, instead of learning from the beastly NCLB, the Obama administration is doubling down on a failed policy.
  • NCLB’s mistakes and coming “reforms” will continue or intensify the damage, not correct it. One reform will increase time and other resources spent on testing instead of unleashing teachers’ and students’ creative potential.
  • NCLB demonstrated many ways that high-stakes standardized testing damages and corrupts education. In addition to narrowing curriculum and encouraging teaching to the test, the NCLB era has produced waves of cheating.
  • Struggling students have been pushed out of school to raise the test score bottom line, with far too many youth entering the prison pipeline. School climate has suffered as fear of failure is passed down from administrators to teachers to students. Many good teachers have chosen to leave rather than comply with drill-and-kill requirements and corrupt their students’ education.
  • Author and lecturer Sir Ken Robinson often speaks about the importance of making mistakes, to learn from them and try again. He says educational standardization and pressure for conformity stunt our children’s growth by teaching them to fear and avoid mistakes. “Conformity and standardization and sitting still and doing multiple-choice questions and being tested at the end — these features of education are inimical to the kind of original thinking and confident imaginations that underpin real innovation,” Robinson says. What we need, he adds, is not “reform” but “revolution.”
  • Olympic gold medalist Usain Bolt credited his teammate, Jamaican runner Yohan “The Beast,” Blake, with helping him improve by beating him in earlier races. The defeats forced Bolt to reflect on what he needed to do differently to improve. Bolt’s victory modeled a powerful lesson: Always try to learn from your mistakes, rather than repeat them.
  • To unleash our children’s potential, we need to unleash the full capacity of teachers and schools. That means acknowledging the mistakes of NCLB, learning from them and fundamentally changing course.

To read Lisa’s article in full, click here.

Intractable Problem: The Public School Factory

“The World has changed. The way we educate our children should too.”

That’s the opening page of BC’s Education plan.

“We need to make education more relevant to reflect the world students now live in, and the world of the future. One of the keys to do that is to personalize learning by putting students at the centre of learning so they can follow their own interests and passions within the topic matter. Teachers must be supported. And families must be involved.”
“Our challenge is clear. We need to make sure education in B.C. meets the needs of B.C. families today and in the future, keeping our young people achieving and thriving in a dynamic, rapidly evolving technological world.”

These are nice words to launch a plan. But as we know, Planning is easy; Execution is the tough part.

The school system is a perfect example of an intractable problem. We typically like to tinker on the surface by making changes to class sizes, budgets, teacher & staff compensation, breaks, and so on. Since the school system is political, much of the debate and noise is about getting votes from taxpayers. But if we really want to make significant improvements, we must go deeper and change the culture and the paradigms.

Some paradigms are so engrained – we don’t even know they are there. What are the Education paradigms we must challenge? For some time I thought I had a fairly good level of awareness. Then I was blown away and sent back to Square 1 by author and lecturer Sir Ken Robinson:

Wow. I never thought about the public school system being based on the Factory model. Now with this paradigm in mind, I can easily think of production line characteristics that apply to schools: date of manufacture, Monday to Friday schedule, testing, standards, extended breaks, for plant maintenance, failure and reject handling. I always wondered when the entire school met in the auditorium it was called “assembly”. Now I understand. I have a recurring dream (nightmare?) about a school bell ringing and being late for class. Now I understand. I was just being prepared for the working world.
One more characteristic to think about: the 9 to 5 working day. One would think if the goal is to be student-centric, we should be matching learning when the student peaks. That might be anytime, like 3 AM in the morning. It’s a belief that the Khan Academy holds by being available 24/7/365. But it’s not a view that is shared by all. As Coalition Avenir Quebec Leader Francois Legault says, having secondary schools operate on a 9-to-5 basis better reflects the schedule of today’s families.
In summary, here are 3 education paradigms and the shifts we need to make:

  1. Separate for efficiency –> End the myth of academic/vocational streaming
  2. Cheating is bad –> Most great learning happens in groups. Collaboration is the stuff of growth
  3. Treat students as products on a factory line –> Reshape the habits of education institutions and the habitats they occupy

My  friend and educator Paul Gagnon told me: “We are on the verge of a major change in the way in which we conceive of and deliver learning. Technology is maturing to the point that individual and customized learning is now a reality- with peak learning periods factored under the umbrella of self-directed, learning just in time and place a major feature. Truly and exciting time to be in education, I can tell you.”

I couldn’t agree with Paul more. Education like healthcare, electric utilities, and safety is undergoing a paradigm shift that technology has enabled. I enjoy reading about pioneers and innovators who have jumped to the new S-curve. I do feel sorry for the Education traditionalists who cling to the factory model not because they want to but because they don’t know they are.