Week 6

Question 1

Early warning systems of disaster

Answer 1

System signals - are late signals

• Scope creep
• Milestone slippages
• escalations
• rework

Behavior signals
- communication
- decision making: same problem, same sollution
- Control: shoot the messenger
- Leadership: divide and conquer
Mindset signals
- illusion of transparency
- Illusion of control (we are invincible)
- group think

Question 2

Do’s and Don’ts

Answer 2

Don’t follow the instructions

use the surgeon’s or the minstrels approach

Question 3

Surgeon’s approach

Answer 3

• Replace joint problem solving by expert problem solving
• Put on complete or partial amnesia, and let the expert solve the immediate problem
• Three stages
  o Stop the bleeding. The blood is trust & understanding
  o Repair the system.
  o Redesign the system so it cannot happen again
• Surgeon is cool, distant, rational and analytical.
• Triage: three groups in disaster
  1: will die anyway
  3: can heal by themselves
  2: Needs your attention => the bleeders
• How to stop the bleeding
  o Direct losses caused by this bleeder
  o What are the losses if we do nothing
  o What is the loss leverage(2/1)
  o Emergency care
  o Emergency care leverage for this bleeder (4/ 2) => lowest leverage you want]
  o Repair the worst ones, with the greatest chance of success

Question 4

Minstrels approach

Answer 4

Restore joint problem solving by ignite joint learning capability
- Three steps:
o Improve mutual understanding => story sharing
o Improve joint learning => incident response
o Increase mutual trust => joint hunting

• No real power, just influence people’s mindset

Question 5

Story sharing

Answer 5

o Let them draw a line of where things were good and where things were bad over time

Question 6

Incident response

Answer 6

react to a incident calmly, don’t accuse, just learn from it

Question 7

Joint hunting

Answer 7

going out exploring, vaguely knowing what will be there, prepare yourself on a
target about what you want to learn