My note on Sidney Presentation: Key note: 1) Anything that put downward pressure on honesty, openness, discloser, and learning is bad for business 2) Anything that in practice, have sweet spot in regard rules and standardization. 3) Counting little bad event to predict big event in future, is illusion. We need something quite different The airline that have more number of incident report, is more safe that one that have less reported accident In hospital, 1 of 13 is error. Common approach is to investigate what cause it (human error, not following rules, communication error, etc) and put more resource on that. However, if we investigate why 12 of 13 are going right. The study show that it will show the same causes. What's the different? The different in dynamic and complex system to success is not in the absent of negative, but in present of capacity Speak up to concern, reward to speaking up (uncertain and delay) reward for shutting off is direct and certain. If you not own the problem (not part of operation), the pressure for speaking is low/different Discussion about sweet spot in rules. Full autonomy vs full clog of rules To understand how thing go wrong in complex and dynamic is to track the capacity how things go right Example: Abraham Wald (bomber plane that have survive after being shot): put armor at place where no hole because that plane are the one that not coming back If I want to understand how incident will happen, learn how stuff get done (despite of the constrain), understand how success is created it will take you where failure come from.
My note on Sidney Presentation:
Key note:
1) Anything that put downward pressure on honesty, openness, discloser, and learning is bad for business
2) Anything that in practice, have sweet spot in regard rules and standardization.
3) Counting little bad event to predict big event in future, is illusion. We need something quite different
The airline that have more number of incident report, is more safe that one that have less reported accident
In hospital, 1 of 13 is error. Common approach is to investigate what cause it (human error, not following rules, communication error, etc) and put more resource on that.
However, if we investigate why 12 of 13 are going right. The study show that it will show the same causes.
What's the different?
The different in dynamic and complex system to success is not in the absent of negative, but in present of capacity
Speak up to concern, reward to speaking up (uncertain and delay) reward for shutting off is direct and certain.
If you not own the problem (not part of operation), the pressure for speaking is low/different
Discussion about sweet spot in rules.
Full autonomy vs full clog of rules
To understand how thing go wrong in complex and dynamic is to track the capacity how things go right
Example: Abraham Wald (bomber plane that have survive after being shot): put armor at place where no hole because that plane are the one that not coming back
If I want to understand how incident will happen, learn how stuff get done (despite of the constrain), understand how success is created it will take you where failure come from.
I have lost count of the number of people to whom i've sent this video