A challenge to knowledge managers: Correcting repeated failures to learn

1. A challenge to knowledge managers: Correcting repeated failures to learn Alan McLucas alan.mclucas@codarra.com.au 1

2. Why We Make ‘Bad’ Decisions • Inherent massive complexity C > 1013 (Kline) • Ability to reliably solve problems C < 5(Kline) • Limited cognitive capability re dynamic behaviour (Sterman, Morecroft, Kleinmuntz…) • Bounded rationality (Simon, Argyris) • Erroneous mental models (Senge), personal constructs (Kelly) or inappropriate use of heuristics (Gigerenzer) • Restrictive ‘Systems of Meaning’ (Flood) • Politics and ‘Systems of Knowledge-Power’ (Flood) Alan McLucas alan.mclucas@codarra.com.au 2

3. Pre-conditions for Disaster Litany of systemic failures at all levels in organisations involved A breakdown in communications Existence of a ‘culture of denial’ - no problems to worry about Failure to understand critical systemic influences Failure to learn Failure to manage risks Alan McLucas alan.mclucas@codarra.com.au 3

4. CASE STUDIES • 18 soldiers killed and12 injured when two Black Hawk helicopters collided during a routine exercise • A 1kg fragment of steel killed a spectator who was 430 metres away among the watching crowd of over 30,000 • A fire in the engine room of HMAS WESTRALIA resulted in the deaths of four Naval personnel. • Explosion and fire at Esso’s Longford Gas Plant No.1 in Sep 98 caused the death of two workers and injuries to eight others . Alan McLucas alan.mclucas@codarra.com.au 4

5. Selection of Case Studies • Drawn from real-life ‘messy’ problems • Had to be extensively documented • Needed to be reported with high levels of objectivity and reliability • Able to withstand legal and public scrutiny Alan McLucas alan.mclucas@codarra.com.au 5

6. active smoking … passive smoking heart disease Concept (cognitive) Mapping ‘Active smoking, rather than passive smoking leads to heart disease’ Alan McLucas alan.mclucas@codarra.com.au 6

7. high cholesterol elevated blood pressure low HDL/LDL active smoking heart disease stress lack of regular exercise passive smoking Concept map - a partial or temporary view, a transient object to aid understanding ! genetic pre- disposition Alan McLucas alan.mclucas@codarra.com.au 7

8. Black Hawk Helicopter Crash Case Study Alan McLucas alan.mclucas@codarra.com.au 8

9. Alan McLucas alan.mclucas@codarra.com.au 9

10. Concept Mapping - Conclusions • Concept maps, in each case studied, exhibited very similar structures. • Critical ‘core’ nodes in each concept map could be summarised as … failure to understand, failure to learn and, hence, failure to manage risks. • Focusing management effort on critical ‘core’ nodes might well have averted these disasters - but who would have known? Alan McLucas alan.mclucas@codarra.com.au 10

11. Concept Mapping - Conclusions • Managers and decision-makers have an underdeveloped appreciation of the nature of the complexity with which they must deal. • Techniques demonstrated here can enhance understanding, learning and management of risks in complex environments. • Greatest gains are to be made in correcting the worst failure: repeated failure to learn. Alan McLucas alan.mclucas@codarra.com.au 11

12. Recognition-Primed Decision-Making (Klein) 12

13. Challenge to Knowledge Managers • Understand the strengths and weaknesses of naturalistic decision-making. • Recognise systemic structures underlying complex problems. • Ability to identify critical nodes, ‘pressure points’ or ‘leverage points’ - where to apply management effort to produce a big change. • Understanding the dynamics that produce counter-intuitive behaviour in problems and elude our strategies to correct them. Alan McLucas alan.mclucas@codarra.com.au 13