Joe's Jottings
Jottings Number 68, Reply E, by Lon Badgett, Ed Brenegar, Mariann Jelinek, Kent Myers, David Hurst:
Date: Thu, 23 Jan 97 10:37:02 -0800
Two amplifications on human error 1. System reliability is the total of the multiplied reliability of each componant. Thus the system reliability of a machine with three parts a,b, and c, is (reliability a) x (reliability b) x (reliability c). Most people, however, will intuitively attempt to add the chances of failure of each componant or each step in a process to establish the overall odds of failure or accident potential. (reliability a) + (reliability b) + (reliability c). 2. It is normally very easy to find the reliability of each componant in a machine. It is normally very difficult to find all the componants of an interactive process between groups of people. It is not math that stands in our way but awareness. -- Lon Badgett lonbadgett@aol.com
Joe raises an important issue concerning the relationship between technology
and community. The Amish have developed a rather sophisticated approach to
measuring the impact of technology. Unfortunately, outside a community like
that, technology has much more an individualist focus. Modern technology are
adult toys, so to speak, and have their strengths and weaknesses.
My question concerns how we measure community. How do we know when a
community is healthy. I have arrived at the conclusion that a healthy
community involves at a minimum three communal conditions. First, that
people find a people, place, history, and/or a set of values in which they
find a genunie sense of "affiliation." Secondly, that they experience a
genuine sense of acceptance, dignity, respect and love, "affection" or real,
mutual caring for one another. Thirdly, that people find themselves
affirmed in what they individually have to offer to the community as a
whole. Whether it be their wisdom, money, physical labor or participation
in collaborative efforts to build their community, they find their
contributions and lives affirmed and appreciated.
Now, if assuming these are some basic conditions for a healthy community,
what types of technology are needed to enhance each person's experience of
participation in that community. I remember years ago, there was this view
perpetrated that TV would become the next great town meeting place. Well, I
think that prospect has not proven to be realized. But what we are engaging
in through this mailing list, could well become just that sort of meeting
place, though on a global scale. Ironic, isn't it, that we could well find
greater community with people on different continents than the person in the
next office, or next house on the street.
Finally, in our home we have made a conscious technological choice not to
subscribe to cable TV. It was hard to lose C-SPAN, CNN and ESPN, but the
quiet and time for family community interaction has been enhanced as a
result. The Amish may be on to something.
Thanks Joe for your provocative musings. Keep it up.
Ed Brenegar
Leadership Resources
Hendersonville, NC 28791
704/693-0720 voice/fax
Email: brenegar@bulldog.unca.edu
--
Edwin Brenegar III
Huzzah! for Phil Capper's commentary on Normal Accidents!
The irreducible error fraction has been reduced substantially - to
miniscule proportions - in companies like Motorola, where, in one instance,
literally millions of transactions in shipping were carried out without
error. These efforts were part of a real quality push that had been
systematically built into corporate culture over a period of years, and were
driven by workers who wished to offer the contribution of THEIR error-work
to the efforts of others (that is, it wasn't "demanded" by seniors).
The complexity of building such a cultural system is enormous,
which is one reason why so few companies undertake it (or even understand
it), let alone accomplish it. Yet the benefits, to the company, its
employees, its stockholders and clients, are enormous, and not just
financial. The consummate expertise of those who operate without error is
both apparent to them, allowing them to feel good about themselves, and
apparent to management, which values them the more. Such expertise positions
workers and the company to manage change (they really know their stuff, so
they can sensibly contribute to change procedures): there's less "panic
mode," less sense that any change will spell disaster. Then too, since
workers have already demonstrated their expertise, willingness and
achievement, the emotional load is lessened all around - and cognitive
psychology tells us that being terrified isn't a good base for change,
anyhow: it tends to lead to premature closure, narrowing of perspective, and
force-fitting of perception into the expected boxes.
Thanks, Joe and Phil, for instigating some interesting thoughts!
Sam
Mariann Jelinek, Ph.D.
Richard C. Kraemer Professor of
Business Administration
Graduate School of Business | The only real, enduring strategic
advantage College of Williiam and Mary |comes from changing the game.
P.O. Box 8795
Williamsburg, VA 23185-8795
(804) 221-2882 FAX: (804) 229-6135 --
Mariann Jelinek
As an aside, I'd like to give some background on the phrase "normal
accidents". Sam knows this context, but others might be in the dark. Please
continue discussing culture.
Charles Perrow examines systemic characteristics of large scale technologies
whose failure can be devastating. "Linear" technologies, such as dams and
ship navigation, are potentially controllable. Ways have been found to
organize the control of dams, and dams rarely fail for either human or
technological reasons. Ship navigation is generally the same type of
technology, but organizations fail in this area. Perrow tells some
fascinating stories about headstrong captains who know for hours that they
are on a collision course, yet collide anyway. He argues that ship
navigation is correctable with better organization.
Other kinds of technology are "tightly coupled". This includes chemical
process plants and nuclear reactors. He finds that interactions in these
systems can never be fully understood, and that organizations don't have the
capacity to stop runaway problems. Accidents are "normal" in such systems.
This isn't much of an issue if the tightly coupled systems are small scale,
but modern society keeps building big ones. One might think that chemical
processing has been with us for a long time, so it must be safe, but Perrow
gives several cases of chemical plants that had no trouble for many years
and then exploded for no obvious reason.
Perrow isn't entirely fatalistic. Big linear technologies are fine with him
as long as they have good organization, and it is possible to develop good
organization. But some big technology is bad due to systemic
characteristics. Organization can mitigate risks in these systems, but
significant risk remains. Failures in these systems are almost always
blamed on human operators, which he finds foolish. Regardless of whether an
operator makes a mistake, it is the design of the system that locks out
corrections and creates the devastating consequences. An organization can
never be so perfect as to keep up with this type of technology.
As I recall, Perrow discusses some ways that have been tried to improve the
designs. For example, there are new designs for "inherently safe" reactors.
(Ironically, these reactors can't be build because there is reluctance to
deal with the unknown in this kind of technology). But he finds that some
processes just can't be linearized, and he recommends a social choice to
limit those technologies.
--
Kent Myers myersk@us.net
Hi Kent,
In a message dated 97-01-21 23:08:59 EST, you write:
" Ways have been found to organize the control of dams, and dams rarely fail
for
either human or technological reasons. Ship navigation is generally the
same type of technology, but organizations fail in this area. Perrow tells
some fascinating stories about headstrong captains who know for hours that
they are on a collision course, yet collide anyway. He argues that ship
navigation is correctable with better organization.
" Other kinds of technology are "tightly coupled". "
Floodplain dwellers in California might not agree with Perrow! Loose coupled
systems can become "tightly coupled". For example the inhabitants of the
Saguenay region of Quebec experienced catastrophic flooding in July last
year because the flood control system seems to have become "tightly
coupled", destroying the resilience of the system. Contributory factors seem
to have been water levels being kept high to satisfy boaters and fishers,
industry reluctance to lower levels of company dams and "waste" water and
decision makers going on holiday. As a result when a downpour hit the region
the dams had little safety margin and when some overflowed the entire system
collapsed.
Best wishes,
David Hurst
Speaker, Writer and Consultant on Management
Author of "Crisis & Renewal: Meeting the Challenge of Organizational Change"
(HBS Press, 1995) McGraw-Hill
Ryerson - Crisis & Renewal
--
DHurst1046@aol.com
Learning-org -- An Internet Dialog on Learning Organizations
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