Category Archives: Execution

Asiana Flight 214 followup

The following excerpts are from Wikipedia regarding Flight 214. What they do is reinforce the paradigm that the Aviation industry is a complex adaptive system (CAS) with many agents like the NTSB and ALPA who interact with each other. The imposed fine of $500K reconfirms the need to Act when in the Chaotic domain but more importantly, Sense and Respond to the needs of all people impacted by communicating your actions clearly and quickly.

“Shortly after the accident, the National Transportation Safety Board (NTSB) used Twitter and YouTube to inform the public about the investigation and quickly publish quotes from press conferences. NTSB first tweeted about Asiana 214 less than one hour after the crash. One hour after that, the NTSB announced via Twitter that officials would hold a press conference at Reagan Airport Hangar 6 before departing for San Francisco. Less than 12 hours after the crash, the NTSB released a photo showing investigators conducting their first site assessment.

Air Line Pilots Association

On July 9, 2013, the Air Line Pilots Association (ALPA) criticized the NTSB for releasing “incomplete, out-of-context information” that gave the impression that pilot error was entirely to blame.

NTSB Chairman Hersman responded: “The information we’re providing is consistent with our procedures and processes … One of the hallmarks of the NTSB is our transparency.  We work for the traveling public. There are a lot of organizations and groups that have advocates. We are the advocate for the traveling public. We believe it’s important to show our work and tell people what we are doing.”  Answering ALPA’s criticism, NTSB spokeswoman Kelly Nantel also said the agency routinely provided factual updates during investigations. “For the public to have confidence in the investigative process, transparency and accuracy are critical,” Nantel said.

On July 11, 2013, in a follow-up press release without criticizing the NTSB, ALPA gave a general warning against speculation.

Fines

On February 25, 2014 the U.S. Department of Transportation (DOT) fined Asiana Airlines US$500,000 for failing to keep victims and family of victims updated on the crash.”

 

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.

When a disaster happens, will it be fast recovery or swarming?

Last month’s blog was about Act in the Cynefin Framework’s Chaotic domain.  Be aware you cannot remain in the Chaotic domain as long as you want. If you are not proactively trying to get out it, somebody or something else will be taking action as Asiana Airlines learned.

How you decide to Sense and Respond? We can show 2 proactive strategies:

Resilience as Cynefin DynamicsStrategy A is a fast recovery back to the Ordered side. It assumes you know what went wrong and have a solution documented in a disaster plan ready to be executed.

If it’s not clearly understand what caused the problem and/or you don’t have a ready-made solution in place,  then Strategy B is preferred. This is a “swarming” strategy perfected by Mother Nature’s little creatures, in particular, ants.

AntsIf the path to a food supply is unexpectedly blocked, ants don’t stop working and convene a meeting like humans do. There are no boss ants that command and control. Individual ants are empowered to immediately start probing to find a new path to the food target. Not just one ant, but many participate. Once a new path is found, communication is quickly passed along and a new route is established.

This is Resilience – the ability to bounce back after taking a hit. 

When a disaster happens, how fast do you act?

In the Cynefin framework, we place unexpected negative events into the Chaotic domain. The solution methodology is to Act-Sense-Respond. When a disaster produces personal injuries and fatalities, Act is about initially rendering the situation as safe as possible and stabilizing conditions to prevent additional life-threatening events from occurring.

Whenever a disaster happens, we go into “damage control” mode. We think were in control because we determine what information will be released, when and by whom. Distributing information to the right channels is a key action under Act. We try our best to limit the damage not only to our people and equipment but to our brand, reputation, and credibility. In other terms, we attempt to protect our level of trust with customers/clients, media, general public.

In the latter stages of the 20th century, breakthroughs in information technology meant we had to learn how to quickly communicate because news traveled really fast. In today’s 21st century, news can spread even faster, wider, and cheaper by anyone who can tweet, upload a Facebook or Google+ photo, blog, etc. The damage control window has literally shrunk from hours to minutes to seconds.

This month we sadly experienced a tragedy at SFO when Asian Airlines flight 214 crashed. I recently reviewed slides produced by SimpliFlying, an aviation consultancy focused on crisis management. Their 2013 July 06 timeline of events is mind boggling:

11:27am: Plane makes impact at SFO
11.28am: First photo from a Google employee boarding another flight hits Twitter (within 30 secs!)
11.30am: Emergency slides deployed
11.45am: First photo from a passenger posted on Path, Facebook and Twitter
11.56am: Norwegian journalists asks for permission to use photo from first posters. Tons of other requests follow
1.20pm: Boeing issues statement via Twitter
2.04pm: SFO Fire Department speaks to the press
3.00pm: NTSB holds press conference, and keeps updating Twitter with photos
3.39pm: Asiana Airlines statement released
3.40pm: White House releases statement
8.43pm: First Asiana Press release (6.43am Korea time)

Although Asiana Airlines first Facebook update was welcomed, they did not provide regular updates and didn’t bother replying to tweets. Bottom line was their stock price and brand took huge hits. Essentially they were ill prepared to Act properly.

“In the age of the connected traveller, airlines do not have 20 minutes, but rather 20 seconds to respond to a crisis situation. Asiana Airlines clearly was not ready for this situation that ensued online. But each airline and airport needs to build social media into its standard operating procedures for crises management.”

If you encounter a disaster, how fast are you able to act? Does your emergency restoration plan include social media channels? Do you need to rewrite your Business Disaster Recovery SOPs?

If you choose to revisit or rewrite, what paradigm will you be in? If it’s Systems Thinking, your view is to control information. Have little regard for what others say and only release information when you are ready. Like Asiana Airlines.  If you’re in the Complexity & Sense-Making paradigm, you realize you cannot control but only can influence. You join and participate in the connected network that’s already fast at work commenting on your disaster.

That’s Act. How you decide to Sense and Respond will be subsequently covered.

Manage things, Lead People

As a manager and later a consultant, I have been involved with helping people deal with change. My first formal exposure in change methodologies occurred when I was trained by ODR. Founded by Darryl Conner in 1974, ODR held licenses with the major consulting firms from the mid-80s to late 90s. His book Managing at the Speed of Change became a must read for ERP clients.

So that we have a common understanding, let’s use Wikipedia’s definition:

“Change management is a structured approach to shifting/transitioning individuals, teams, and organizations from a current state to a desired future state. It is an organizational process aimed at helping employees to accept and embrace changes in their current business environment.”

There were many methods, templates, charts, diagrams, and forms endeavouring to cover all avenues one would encounter in change management. As a linear, sequential type person, I felt like I had hit the jackpot and won the prize at the end of the rainbow. I was taught the who, when, where, why and hows and became a SME – subject matter expert. FYI, in the consulting world, being a SME is no longer kosher; you are now called a SMS – subject matter specialist. Why? To avoid possibly being sued by a client if big-time projects go badly wrong. Thank you, legal beagles.

Does the preceding sound like the Complicated Domain to you? Change Management was viewed as complicated yet quite manageable. Sense what’s happening using assessments and surveys. Analyze the feedback. Respond with the appropriate packaged solution. Very Ordered side.

If employee backlash or unpredictable behaviour edging on chaos arose, just steer them back on track. One of the more interesting statements I heard was: “We first try to change the person. If that doesn’t work, then we change the person.” It’s a rather subtle way of saying if you don’t get onboard with the program you’re terminated.

What does this mean for CE practitioners who might find themselves involved in a change initiative? I have a couple of ideas to share.

Manage Things, Lead People 
I first heard this from Stephen Covey and it’s been a real favourite of mine. It recognizes that non-human objects (inanimate and living) adhere to logical cause & effect rules. Flip the switch; the light goes on. Press the button, the motor stops. Stimulus-response amoeba behaviour. Simple Domain stuff.

However, when dealing with humans, it’s an entirely different ball game. People have the ability to think, make choices, and choose to behave accordingly. Since we cannot manage/control people, that leaves leading them. Conceivably, they may choose not to listen and go their own way. As leaders, we hope to influence their choosing by giving them positive or negative consequences and acting as models of desired behaviour. Unpredictable behaviour, no understood link between cause and effect? Sounds like Complex Domain to me. Consider Probing as a Stimulus. Sense behaviour changing and patterns forming. Respond by accelerating or dampening stimulation. Rinse, and repeat (sorry about that…)

CE Leadership vs Management

Change Leadership
We have been playing around with the Cynefin framework by creating model variations and testing resonance with clients. One such variation advocates the Ordered side is Management and the Unordered side is all about Leadership. It’s having the desire to get “out of the box” and courage to declare “Enough is enough!” But it’s also having consideration and respect for others who are quite comfortable doing same old, same old. All the more reason why I feel small safe-fail experiments are much more tenable than massive change efforts.

We’re also putting out the notion that most of the time one wants to be on the Ordered Side where life is stable, predictable, easily fixable, and in steady state mode. When you finally come to grips you can’t solve today’s problems using present methods, you take the lead to venture to the Complex Domain As leader, you initiate a search and rally followers to find a new solution that will change the paradigm. 

Change Management
I’m not throwing Change Management out of my toolkit. I occasionally do project management work for clients when the subject of change management is discussed. In this case we are talking about modifying tasks, reallocating resources, issuing change orders. You know, things that don’t think but just get moved around on a spreadsheet or Gantt chart. But if I do hear some whining or screaming from project team members, it’s a signal to shift into a Change Leadership role.

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.