Chapter 1 – A Story of a Failure
Conklin uses stories of failure to show that outcomes are usually caused by this, not a single mistake.
What is a combination of factors (or multiple system conditions)?
The Titanic is used as an example to show that failures are not caused by one event, but by this.
What is a chain of decisions and conditions?
A pre-accident investigation focuses on this instead of waiting for incidents to occur.
What is potential risk (or what could go wrong)?
Conklin argues that workers don’t cause failure—they do this instead.
What is trigger failure?
Conklin emphasizes that change is constant, but this must happen for change to be effective.
What is managing change?
The key lesson from failure stories is that hindsight makes events look this way, even though they weren’t this at the time.
What is obvious (or predictable)?
Before the Titanic sank, many decisions made sense at the time—this reflects Conklin’s idea of:
What is local rationality?
In aviation, accidents are described as the unexpected combination of this normal condition.
What is normal variability?
This idea explains that system weaknesses already exist, and workers interacting with them can expose them.
What is latent conditions (or hidden system weaknesses)?
The case study shows that even leaders struggle because of this common issue during change.
What is lack of alignment (or different mental models/opinions)?