ix With the unexpected becoming a larger chunk of everyday life,
it isn't surprising that we find ourselves interested in resilience and coping.
x This book is about experts in resilient high performance and how they
stay on top of operations... Part of their success stems from their uncommon skill at finding ways to stay mindful about what
is happening. They update their ideas of current situations... They use techniques... that are worth copying because they
ensure faster learning, more alert sensing
p.1 Unexpected events often audit our resilience. They
affect how much we stretch without breaking and then how well we recover. Some of these audits are mild. But others are brutal.
p.2 This book is about organizations, expectations, and mindfulness. Our
basic message is that expectations can get you into trouble unless you create a mindful infrastructure that continually does
all of the following:
- Tracks small failures
- Resists oversimplification
- Remains sensitive to operations
- Maintains capabilities for resilience
- Takes advantage of shifting locations of expertise
Failure to move toward this type of infrastructure magnifies the damage
produced by unexpected events and impairs reliable performance.
p.3 Consider Pat Lagadec's vivid words: "The ability to deal with
a crisis situation is largely dependent on the structures that have been developed before chaos arrives. The
event can in some way be considered as an abrupt and brutal audit: at a moment's notice, everything that was left
unprepared becomes a complex problem, and every weakness comes rushing to the forefront." [Preventing Chaos in a Crisis, p.54,
Patrick Lagadec, Jocelyn Phelps, 1993]
p.8 Small events have large consequences. Small discrepancies give
off small clues that are hard to spot but easy to treat if they are spotted. When clues become much more visible,
they are that much harder to treat. Managing the unexpected often means that people have to make strong responses
to weak signals, something that is counterintuitive and not very "heroic." Normally, we make weak responses to weak
signals and strong responses to strong signals... systems that mismanage the unexpected tend to
ignore small failures, accept simple diagnoses, take frontline operations for granted, neglect capabilities for resilience,
and defer to authorities rather than experts.
p.9,10,14 HROs [JLJ - High Reliability Organizations] are
distinctive because they are preoccupied with failure. They treat any lapse as a symptom that something may be wrong with
the system, something that could have severe consequences if several small errors happened to coincide... Another way HROs
manage for the unexpected is by being reluctant to accept simplifications... less simplification allows you to see more...
HROs develop capabilities to detect, contain, and bounce back from those inevitable errors that are part of an indeterminate
world... Resilience is a combination of keeping errors small and of improvising workarounds that allow the
system to keep functioning. Both of these pathways to resilience demand deep knowledge
p.22 In Chapter Two, we take a closer look at the foundations of resilient,
reliable functioning, namely, the nature of expectations and unexpected events and the ways in which a general capability
for mindful organizing halts the development of unexpected events.
p.24 Can you think of another environment [the author is describing activities
on the deck of an aircraft carrier] that is quite this full of expectations and demands for mindful action? [JLJ - how about
a competitive game, such as chess?]
p.32 Formally, we define mindfulness as "a rich awareness of discriminatory
detail." By that we mean that when people act, they are aware of context, of ways in which details differ (in other words,
they discriminate among details), and of deviations from their expectations... Mindfulness... involves the combination of
ongoing scrutiny of existing expectations, continuous refinement and differentiation of expectations based on newer experiences,
willingness and capability to invent new expectations that make sense of unprecedented events, a more nuanced appreciation
of context and ways to deal with it, and identification of new dimensions of context that improve foresight and current functioning.
p.38 it is impossible to manage any organization solely by means
of mindless control systems that depend on rules, plans, routines, stable categories, and fixed criteria for correct performance...
designers who want to hold dynamic systems together have to organize in ways that evoke mindful work. People
have to adopt a style of mental functioning that enables continuous learning as well as ongoing refinement of expectations.
p.42 To manage the unexpected, organisations need to assess candidly
the expectations that hold them together, the grounds on which they believe these expectations, the things these expectations
keep them from seeing, and their capability for mindful engagement with these expectations. Mindful engagement is
built around five principles that have been inducted from observations of high reliability functioning. These principles fall
into two clusters: principles of anticipation (failure, simplification, operation) and principles of containment (resilience,
expertise).
p.45 To anticipate is to foresee or imagine an eventual unchecked
outcome, based on small disparities. Frequently such sensing means taking a small cue and imagining a scenario in which this
single small marker is the sign of a larger, more harrowing situation. Anticipation, however, is not just an exercise
in sensing; it is also an exercise in stopping the development of undesirable events. The escalation and spread of small discrepancies
are slowed by actions of anticipation and stopped by actions of containment... organizations the persistently have less than
their fair share of accidents seem to be better able to sense significant unexpected events than organizations that have more
accidents.
p.46 to avoid failure, you've first got to embrace it. That's not as crazy
as it sounds. To "embrace" failure means two things for HROs. First, it means that they pay close
attention to weak signals of failure that may be symptoms of larger problems within the system. Second, it means
that the strategies adopted by HROs often spell out mistakes that people don't dare make. Organizations that
look relentlessly for symptoms of malfunctioning, especially when these symptoms can be tied to strategic
mistakes, are better able to create practices that preclude those mistakes.
p.47 The earlier you catch a discrepancy, the more options you have
to deal with it. But the earlier you try to catch an error, the harder it is to spot it.
p.48 What activities, if performed less than adequately, pose the
greatest risks to the well-being of the system?
p.49 Failure detection can also start with a list of expectations. Before
an event... occurs, write down what you think will happen. Be specific.
p.67 reliable outcomes require the capabilities to sense the unexpected
in a stable manner and yet deal with the unexpected in a variable manner. This variation in coping
processes is what we have in mind in the following discussion of principles of containment.
p.67-68 they did not alter their mindful processes of understanding,
evidence collection, detection, evaluation, and revision. These mindful processes became the stable routines that triggered
the variable activities that managed the unexpected.
p.69 Aaron Wildavsky describes the nature of a commitment to resilience:
"The mode of resilience is based on the assumption that unexpected trouble is ubiquitous and unpredictable; and thus accurate
advance information on how to get out of it is in short supply. To learn from error (as opposed to avoiding error altogether)
and to implement that learning through fast negative feedback, which dampens oscillations, are at the forefront of operating
resiliently." Resilient people think mitigation rather than anticipation. They are attentive
to expanding general knowledge, technical facility, and command over resources that relieve, lighten, moderate,
reduce, and decrease surprises.
Formally, resilience is the "capability of a system to maintain
its function and structure in the face of internal and external changes and to degrade gracefully when it must."
Resilience occurs when the system continues to operate despite failures in some of its parts.
p.100 There is a growing recognition that all organisations will
require the same potential for flexible response in order to cope with diverse and rapidly changing competitive
circumstances.
p.102-103 By their very nature, then, audits help create readiness.
But readiness for what? ... First, the audits should help you become more comfortable imagining the unexpected
as it has become an increasing part of the everyday. Second, they should provide a motive to benchmark your firm against
the high reliability organization, which relies heavily on mindfulness to manage the unexpected and maintain relatively error-free
performance. Third, the audits will give you an inventory of your daily practices and reveal the extent to which your
practices incorporate the five principles of mindfulness. The intention is to help you increase your capability
for mindfulness as a means to manage the unexpected... If you increase your capability for mindfulness, many untoward
consequences of the unexpected can be stopped before they get started.
p.106 Use the audit results to diagnose areas that need specific
attention and formulate an action plan... decide what you can do to improve the capacity for mindfulness.
p.107 We suggested that you customize the audits for your unique
context and administer them wisely. The information you gain from administering the audits... is a prime source of
information about... the defenses in place to prevent surprises from getting out of hand.
p.110 You've seen that expectations impose substantial blinders that are
removed only by continuous, mindful efforts that counteract misperceptions. You've seen that mindfulness is about
attentiveness and updating to get the situation right... As a result of your audits, you've spotted some attitudes
and behavior that keep you from being more mindful... But you've also spotted some current attitudes and behaviors... that
promote mindfulness. Those unnoticed assets are more crucial to managing the unexpected than you have realized. The chances
are that you didn't realize they were so important
p.113 Reliability and resilience lie in practices that reduce those
differences in complexity [between systems and their environments]. Wise practices either reduce environmental complexity
or increase system complexity... we have highlighted ways you can improve sensing and acting when faced with complexity. Our
recommendations boil down to this advice: make your system more complicated. That recommendation is based
on a basic principle in system design called the principle of requisite variety.
The principle of requisite variety means essentially that
if you want to cope successfully with a wide variety of inputs, you need a wide variety of responses. If you have less variety
than your inputs, the system could be destroyed.
p.149 Recall crisis expert Pat Lagadec's point in Chapter One that unexpected
events are brutal audits that test structures that have been developed before chaos arrives. Are you ready for a
brutal audit of your capability to act mindfully?
p.150 Remember that reliability is not bankable.
You never get reliability and resilience behind you... You have to keep redoing them.
p.151 Preoccupation with failure involves four questions:
- What needs to go right?
- What could go wrong?
- How could things go wrong?
- What things have gone wrong?
