Managing the Unexpected: Sustained Performance in a Complex World
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Managing the Unexpected: Sustained Performance in a Complex World — Karl E. Weick, Kathleen M. Sutcliffe
You know how the JC loves complexity theory and this one applies it to workplace psychology. These are the people who came up with the idea of “high-reliability organisations” which are organisations which deal particularly well with unexpected incidents.
Don’t ignore minor anomalies
Look out for anomalies: be present to anomalies, oddities and unexpected behaviour or performance in systems which are supposed to be standardised and to run on rails: even seemingly inconsequential things indicate that something deeper may my malfunctioning in a way that turns out to be catastrophic.
Be aware of “normalising” minor anomalies. So the NASA engineers detected minor “blow-by” in the outer o-rings on the Shuttle’s solid-state boosters, whereby hot bases got through the outer layer of protections, but concluded that this must just be within tolerances in certain cases (such as on cold launches). Having concluded that this was normal, then when evidence of further erosion to the inner o-rings emerged, the engineers normalised this too, thus inadvertently systematising certain failure.
So: as part of your risk management approach, have people whose job it is to look out for minor oddities and trace their route causes back to establish that they are indeed just minor events and not symptomatic of a deeper problem. This, needless to say, involves subject matter expertise.
What is the organisation?
There is an extended discussion of what is the organisation, picking up on a theme that the JC has stumbled over in the past. The formal hierarchy; the formal manifestation of the company is not the company. This is a convenient fiction to bolster the importance of those who control that hierarchy; it is nonetheless a conjuring trick — a kin to what Daniel Dennett calls the Cartesian theatre of the brain. The actual “company” subsists in its communications. These are never universal across even a small organisation. They are necessarily lateral, limited, human, social and not centrally co-ordinated or even tracked across the infrastructure.
The larger the organisation, the greater the difference between its hierarchical structure and its actual identity. The JC has worked in very small organisations, where the distinctions between ownership, executive and execution is almost nil, and very large ones where it is stark.
Actions become mistaken
Our actions don’t start out mistaken, but become mistaken over time. Actions that are becoming mistaken are ambiguous by nature so it takes a preoccupation with looking for anomalies to spot this kind of thing.