A challenge to knowledge
managers: Correcting repeated
failures to learn
Alan McLucas
alan.mclucas@codarra.com.au
1
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
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
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
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
Concept (cognitive) Mapping
‘Active smoking, rather than passive
smoking leads to heart disease’
active smoking
… passive smoking
Alan McLucas
alan.mclucas@codarra.com.au
heart disease
6
Concept map - a partial
low HDL/LDL
or temporary view,
a transient object high cholesterol
stress
to aid understanding !
genetic predisposition
active smoking
heart disease
passive smoking
elevated blood
pressure
Alan McLucas
alan.mclucas@codarra.com.au
lack of regular
exercise
7
Black Hawk
Helicopter
Crash Case
Study
Alan McLucas
alan.mclucas@codarra.com.au
8
Alan McLucas
alan.mclucas@codarra.com.au
9
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
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
Recognition-Primed
Decision-Making
(Klein)
12
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