Great book written in 1989 by West German Professor Dorner. This is a good introduction into System dynamics and System thinking. The book gives several mental models of how people "attack" complex problems and why they often fail. Dorner describes several psychological experiments that help to differentiate "bad decision maker" from "good decision makers," as well as mental traps that lead to failures. Based on this analysis he presents his model of decomposition and planning. At the end of the book Dorner quotes Clausewitz that "...War is not an infinite mass of minor events... War consists rather of single, great, decisive actions, each of which needs to be handled individually." Such "strategic thinking" requires far greater expenditure of mental energy argues Dorner.
Dorner ends his book with the thought that "...If we cannot form a picture of a temporal configuration, we cannot adjust our thinking and actions to take that temporal pattern into account... We human being are creature of the present. But the world today must learn to think in temporal configuration."
The book is easy to read and comprehend. I gave it to my 15 years old son to read it. Hopefully he will use my advise to read it earlier in his life.
Wednesday, May 26, 2010
"The Field Guide to Understanding Human Error" by Sidney Dekker
I met Professor Dekker couple of weeks ago during his visit to Engineering System Division at MIT.
He is definitely one of the most intelligent and sharp thinking persons I have ever met. I was impressed with his clarity and speed of thought. I could catch with his speed of thinking only after he made an iterative loop in his argument.
There are two major themes that are reflected throughout his book. First is that human error is not the cause but a symptom of a trouble. Accepting this notion is first step towards New view of human error, which can never be the conclusion of an investigation, but rather its starting point. Understanding error means reconstructing the context in which such decision was made. "Human error problem is an organizational problem. This means that understanding human error hinges in understanding the organizational context in which people work."
People tend to react post factum and backwardly reconstruct sequence of events in a linear manner. In the aftermath of an accident, one can easily list logical arguments how and why people should have foreseen and prevented the upcoming events. We easily judge people, who failed to take proper actions. We focus on their personal shortcomings such as absence of proper training and experience, health conditions and hours of proper sleep, etc. We usually tend to focus our attention on people who happened to be closest to the accident in term of time and space.
Second theme of the book is forward looking metal model, which focuses on preventing accidents in the future rather than analyzing the accident with a hindsight bias. Hindsight gives the investigators better and more complete information in comparison to people who made the decision prior to the failure. It provides with facts that become midpoints in the linear logic flow that the investigator reconstructs. As we walk backwards, each facts is perceive not as an "intersection point" with a list of equally valid choices, but rather as point of the process when/where incorrect decision was recorded. Hindsight bias exaggerates the importance of the recorded facts versus other events that are not directly related to the specific accident.
The author compares three accident models (1) the sequence-of-event, (2) the epidemiological model and (3) the system model. He argues that the latter is a holistic approach that looks at accidents as emerging form interactions between system components and processes, rather than failures within them.
Dekker warns against "quick fixes" and misuse of technical labels, which do not describe the gap between reality and our judgments, whereas "safety improvements come from organizations monitoring and understanding the gap between procedures and practice." He concludes that "a safety culture is a culture that allow the boss to hear bad news."
He is definitely one of the most intelligent and sharp thinking persons I have ever met. I was impressed with his clarity and speed of thought. I could catch with his speed of thinking only after he made an iterative loop in his argument.
There are two major themes that are reflected throughout his book. First is that human error is not the cause but a symptom of a trouble. Accepting this notion is first step towards New view of human error, which can never be the conclusion of an investigation, but rather its starting point. Understanding error means reconstructing the context in which such decision was made. "Human error problem is an organizational problem. This means that understanding human error hinges in understanding the organizational context in which people work."
People tend to react post factum and backwardly reconstruct sequence of events in a linear manner. In the aftermath of an accident, one can easily list logical arguments how and why people should have foreseen and prevented the upcoming events. We easily judge people, who failed to take proper actions. We focus on their personal shortcomings such as absence of proper training and experience, health conditions and hours of proper sleep, etc. We usually tend to focus our attention on people who happened to be closest to the accident in term of time and space.
Second theme of the book is forward looking metal model, which focuses on preventing accidents in the future rather than analyzing the accident with a hindsight bias. Hindsight gives the investigators better and more complete information in comparison to people who made the decision prior to the failure. It provides with facts that become midpoints in the linear logic flow that the investigator reconstructs. As we walk backwards, each facts is perceive not as an "intersection point" with a list of equally valid choices, but rather as point of the process when/where incorrect decision was recorded. Hindsight bias exaggerates the importance of the recorded facts versus other events that are not directly related to the specific accident.
The author compares three accident models (1) the sequence-of-event, (2) the epidemiological model and (3) the system model. He argues that the latter is a holistic approach that looks at accidents as emerging form interactions between system components and processes, rather than failures within them.
Dekker warns against "quick fixes" and misuse of technical labels, which do not describe the gap between reality and our judgments, whereas "safety improvements come from organizations monitoring and understanding the gap between procedures and practice." He concludes that "a safety culture is a culture that allow the boss to hear bad news."
Tim Brown on Change by Design
I've got the book after Tim Brown's video lecture at Sloan MIT at the end of spring semester. The book is full of so many great and original design ideas. It was hard to concentrate while reading this book, because you want to close it in mid-sentence and try to change the world around you. Here are some marvelous quotes from the book:
"Design has the power to enrich our lives by engaging our emotions through image, form, texture, color, sound, and smell. ... design thinking points to the next step: we can use our empathy and understanding of people to design experience that create opportunities for active engagement and participation."
"Unlike a prepared script or an operational manual, [blueprint] connects the customer experience and the business opportunity. Every detail holds the potential to sour a relationship... but only few offer possibilities for an experience that is distinctive, emotionally gratifying, and memorable. The blue-print is at one and the same time a high-level strategy document and a fine-grained analysis of the details that matter."
"Design can help to improve our lives in the present. Design thinking can help us chart a path into the future."
"Instead of an inflexible, hierarchical process that is designed once and executed many times, we must imagine how we might create highly flexible, constantly evolving system in which each exchanges between participants is an opportunity for empathy, insight, innovation and implementation."
"Design has the power to enrich our lives by engaging our emotions through image, form, texture, color, sound, and smell. ... design thinking points to the next step: we can use our empathy and understanding of people to design experience that create opportunities for active engagement and participation."
"Unlike a prepared script or an operational manual, [blueprint] connects the customer experience and the business opportunity. Every detail holds the potential to sour a relationship... but only few offer possibilities for an experience that is distinctive, emotionally gratifying, and memorable. The blue-print is at one and the same time a high-level strategy document and a fine-grained analysis of the details that matter."
"Design can help to improve our lives in the present. Design thinking can help us chart a path into the future."
"Instead of an inflexible, hierarchical process that is designed once and executed many times, we must imagine how we might create highly flexible, constantly evolving system in which each exchanges between participants is an opportunity for empathy, insight, innovation and implementation."
Thursday, May 20, 2010
Principle 42
"Instead of an inflexible, hierarchical process that is designed once and executed many times, we must imagine how we might create highly flexible, constantly evolving system in which each exchange between participants is an opportunity for empathy, insight, innovation and implementation" (Tim Brown, 2009).
Principle 41
"Design can help to improve our lives in the present. Design thinking can help us chart a path into the future" (Tim Brown, 2009).
Wednesday, April 28, 2010
MIT is discussing Should Google Leave China
http://events.mit.edu/event.html?id=11610639
My good friend Edward Steinfeld, Associate Professor of Political Science at MIT (http://web.mit.edu/polisci/faculty/E.Steinfeld.html) is moderating the discussion at MIT today.
The panelists of the discussion are (1) David Clark, Senior Research Scientist, Computer Science and Artificial Intelligence Laboratory, (2) Yasheng Huang, China Program Professor in International Management, Sloan School, (3) Craig Simons, Knight Science Journalism Fellow and (4) Xiaojian Zhao, Knight Science Journalist Fellow.
I am curious about the delicate dilemmas that the moderator will try to address.
Congress, Goldman Sachs and the Hindsight Bias
Being a student of System safety I could not ignore the public hearing that is taking place in the US Senate on Goldman’s handling of high-risk mortgage business in 2007.
The bigger is the failure or the devastation caused by an accident the more difficult it is to reconstruct the preceding events, processes and systematic factors. In the case of Goldman, its handling of highly securitized mortgage deal called Abacus, is overshadowed by even larger devastation of the financial crisis that went far beyond the Wall Street. The public outrage with the economic crisis that has been boiling for the last two years has suddenly found actual addressee, Goldman Sachs Group, thanks to the SEC’s investigation and the independent inquire by the Senate’s Permanent Subcommittee on Investigations.
Goldman’s interaction during the hearing fuels the outrage even further as it treats testimonies of its executives as part of the group’s upcoming legal battle with the SEC. By fighting against possible legal litigations and denying any wrongdoing, Goldman gets deeper into the trap of becoming the villain, who in public’s eyes is blamed for the financial crisis. On top of that, the tug of war between two parties in the Congress makes the Goldman’s hearing major strategic battle that will allow the ruling party push its bill on financial regulations.
The goal of this essay is not to defend Goldman, but to explain the phenomena of hindsight bias. As people try to make sense in such confusing environment, it is easier to focus one’s attention on specific individuals and become bias towards the end result. Sidney Dekker, the Swedish system safety expert, describes the hindsight bias in form of four different, but interrelated reactions: (1) Retrospective, (2) Counterfactual, (3) Judgmental and (4) Proximal (The Field Guide to Understanding Human Error, 2006).
People tend to react post factum and backwardly reconstruct sequence of events in a linear manner. In the aftermath of an accident, one can easily list logical arguments how and why people should have foreseen and prevented the upcoming events. We easily judge people, who failed to take proper actions. We focus on their personal shortcomings such as absence of proper training and experience, health conditions and hours of proper sleep, etc. We usually tend to focus our attention on people who happened to be closest to the accident in term of time and space. In the case of Goldman Sachs, Fabrice Tourre was designated as the sacrificial lamb, who will be slaughtered to satisfy the crowd.
Hindsight gives the investigators better and more complete information in comparison to people who made the decision prior to the failure. It provides with facts that become midpoints in the linear logic flow that the investigator reconstructs. As we walk backwards, each facts is perceive not as an “intersection point” with a list of equally valid choices, but rather as point of the process when/where incorrect decision was recorded. Hindsight bias exaggerates the importance of the recorded facts versus other events that are not directly related to the specific accident.
Specific sequence of events shapes its post-factum interpretation. It connects events in specific post factual manner. What Sidney Dekker calls tunnel vs. zigzag. The tunnel vision that the bias creates, oversimplify the history of the accident, with linear logical flow and binary (right and wrong) choices. As part of the oversimplification process, causality of events are oversimplified as well. As the result, the hindsight prevents us from differentiating between what is know after the accident and what was known by people prior and during the accidents.
What are the objectives of the Congress and the SEC? Get more popularity with the public; re-direct public dissatisfaction toward the Wall Street; take down Goldman Sachs; push for new regulations; etc? As in any other accident investigation, the public, the Congress and the SEC will focus on assigning blame on particular individual instead of focusing on learning the root causes, especially if the objectives of the blame are so vague.
The bigger is the failure or the devastation caused by an accident the more difficult it is to reconstruct the preceding events, processes and systematic factors. In the case of Goldman, its handling of highly securitized mortgage deal called Abacus, is overshadowed by even larger devastation of the financial crisis that went far beyond the Wall Street. The public outrage with the economic crisis that has been boiling for the last two years has suddenly found actual addressee, Goldman Sachs Group, thanks to the SEC’s investigation and the independent inquire by the Senate’s Permanent Subcommittee on Investigations.
Goldman’s interaction during the hearing fuels the outrage even further as it treats testimonies of its executives as part of the group’s upcoming legal battle with the SEC. By fighting against possible legal litigations and denying any wrongdoing, Goldman gets deeper into the trap of becoming the villain, who in public’s eyes is blamed for the financial crisis. On top of that, the tug of war between two parties in the Congress makes the Goldman’s hearing major strategic battle that will allow the ruling party push its bill on financial regulations.
The goal of this essay is not to defend Goldman, but to explain the phenomena of hindsight bias. As people try to make sense in such confusing environment, it is easier to focus one’s attention on specific individuals and become bias towards the end result. Sidney Dekker, the Swedish system safety expert, describes the hindsight bias in form of four different, but interrelated reactions: (1) Retrospective, (2) Counterfactual, (3) Judgmental and (4) Proximal (The Field Guide to Understanding Human Error, 2006).
People tend to react post factum and backwardly reconstruct sequence of events in a linear manner. In the aftermath of an accident, one can easily list logical arguments how and why people should have foreseen and prevented the upcoming events. We easily judge people, who failed to take proper actions. We focus on their personal shortcomings such as absence of proper training and experience, health conditions and hours of proper sleep, etc. We usually tend to focus our attention on people who happened to be closest to the accident in term of time and space. In the case of Goldman Sachs, Fabrice Tourre was designated as the sacrificial lamb, who will be slaughtered to satisfy the crowd.
Hindsight gives the investigators better and more complete information in comparison to people who made the decision prior to the failure. It provides with facts that become midpoints in the linear logic flow that the investigator reconstructs. As we walk backwards, each facts is perceive not as an “intersection point” with a list of equally valid choices, but rather as point of the process when/where incorrect decision was recorded. Hindsight bias exaggerates the importance of the recorded facts versus other events that are not directly related to the specific accident.
Specific sequence of events shapes its post-factum interpretation. It connects events in specific post factual manner. What Sidney Dekker calls tunnel vs. zigzag. The tunnel vision that the bias creates, oversimplify the history of the accident, with linear logical flow and binary (right and wrong) choices. As part of the oversimplification process, causality of events are oversimplified as well. As the result, the hindsight prevents us from differentiating between what is know after the accident and what was known by people prior and during the accidents.
What are the objectives of the Congress and the SEC? Get more popularity with the public; re-direct public dissatisfaction toward the Wall Street; take down Goldman Sachs; push for new regulations; etc? As in any other accident investigation, the public, the Congress and the SEC will focus on assigning blame on particular individual instead of focusing on learning the root causes, especially if the objectives of the blame are so vague.
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