Mindfulness and fighting wild fires, and the value of simulations for training

Professor Karl Weick at the University of Michigan has written extensively on the need for "mindfulness" in emergency situations, such as, literally, fighting forest fires.

A mindful crew or crew-chief will be aware that they are operating on a mental model, and that model may be incorrect, so they must be alert to even very small signs that they have completely misconstrued the situation.

There are lessons here, on a longer time scale, for every leader, civilian or military.

Here are some public documents on the subject.

http://www.wy.blm.gov/fireuse/2009mtg/presentations/HROs-mindfulness.ppt

Teaching Mindfulness to Wildland Firefighters (Fire Management Today, Spring 2008, Dave Thomas)

For the last 3 years I have taught half-day workshops, conducted 1-hour lectures, and provided general awareness speeches about the Weick/ Sutcliffe model of High Reliability Organizing as described in their book Managing the Unexpected: Assuring High Performance in an Age of Complexity.

This article is a series of musings, conjectures, and recommendations pulled from this teaching experience. My intent is to pass on some of the lessons that I have learned teaching High Reliability Organizing, and to pose recommendations for further study...

Today, however, mainly due to the heating of the Earth through global warming and a build up of fuels -firefighters are working within an environmental framework of weather and fuel never experienced before. Errors that we might have "got away with" in the past could more easily become catastrophic today....

Next, I explain the irrationality (mindlessness) of always learning our primary safety lessons through trial and error. It is our job to be better at anticipating errors before they occur, before a brutal audit forces us to notice the discrepant events in the fire environment. The following quotation, which reinforces this view, is taken from French disaster expert Pat Lagadec:

"The ability to deal with a crisis situation is largely dependent on structures that have been developed before chaos arrives. The event can ... be considered an abrupt brutal audit: at a moment's notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront."...

High Reliability Organizing

NEW! France-USA High Reliability Organizing in Incident Management Teams Project
Just like NYPD detective "Popeye" Doyle, who traveled to Marseilles in the 1970s hit movie “the French Connection” so too, did a Forest Service NIMO team this past December. Only it wasn’t for crime busting this time. It was a landmark match-up between two French and American Incident Management Teams to capture what makes these teams so successful in complex, rapidly changing, stressful situations. It is hypothesized that they exhibit many of the behaviors that directly align with high reliability organizing (HRO) concepts and principles.

( More to come)


More information:

The France-USA HRO Project (French Web Site, from Bouches du Rhone with video)
http://hro-fires.com/exercices_live.html

High-Reliability Organizing - Roberts, with Weick and Sutcliff:
http://www.wildfirelessons.net/HRO.aspx

Center for Catastrophic Risk Management, Berkely CA
http://ccrm.berkeley.edu

Communication and Information technologies:
New tools for DISASTER management
Jean-Michel DUMAZ (1)
Bouches-du-Rhône Fire Department – MARSEILLE - FRANCE
2nd International Conference on Urban Disaster Reduction
November 27~29, 2007

The Bouches du Rhône
Fire Department


Wade

Wanted - Leadership on jobs? Ok, here you go!

The New York Times has an editorial today titled "Leadership on jobs".

In part that article says:

September was ... the longest unbroken stretch of losses since record-keeping began in 1939 — ... And that understates the damage. ..

The unemployment rate for September ... also understates the damage. It would have been higher but for the fact that 571,000 people dropped out of the work force last month — in general, it’s assumed, because they’ve despaired of finding work. If they had kept looking, they would have been counted as unemployed.

The combination of a rising unemployment rate and a quickening pace of labor-force dropouts is especially worrisome. ... For adult men, who have been particularly hard hit by job loss in this recession, the employment rate fell to ... its lowest level since the government began keeping track ....

===
And for adult African American men, the odds of finding a job that justifies staying in school are now effectively zero.

The Times continues

====

A shrinking labor force represents a tremendous waste of talent and potential, a loss of value that will not be entirely retrievable. Widespread joblessness among men is particularly devastating for the economy and many families, because men tend to earn more than women and to have jobs offering health insurance.

To make matters worse, unemployment among men and women is proving relentless. ...over a third have been out of work for ..., the highest percentage of long-term unemployment on record. By the end of the year, benefits will expire for more than one million unemployed workers. ...

===

and finally

====

The real work, however, lies ahead. Economic recovery will not automatically replace the jobs that have been lost so far in this recession. Nor will higher levels of learning and skill — necessary as they are — magically create jobs, especially in the numbers that are needed.

... Congress and the administration also have not done enough to directly create jobs.

==

OK. I agree that a lack of jobs is a serious problem, and finding a way for the unemployed to continue to eat and pay the rent without resorting to a life of crime is an urgent need and a moral imperative.

BUT, at the same time, we also need to look at the problem that most of the "jobs" that ARE out there are walking disasters that justify their own Dilbert cartoon strip. People show up for "work", mess around all day, have depressing and incredibly hostile "meetings", get paid and go home. During the day they sort of "follow orders" that make no sense, working on projects or products that have no future, in a sort of simulation of actual productive work. Everyone knows its just a matter of time until the company folds and the new pink slip arrives, and most of their energy is spent either trying to figure out what their next job will be, or doing their best to destroy the work of those around them so maybe those people will get laid off FIRST as times get rough and there is more and more "work" for fewer and fewer people to do. Meanwhile, upper management appears to have lost all contact with reality, as well as their own imperative to actually "show up" for "work". There seems to be no relationship between ultimate survival of the firm, or actually delivering quality goods and services to actual paying customers that meet actual needs, and the tasks that fill each day.

How bad is it? In white collar offices, the phrase "I'm going home so I can get some work done" is commonplace and makes perfect sense -- because the American "workplace" is the LAST place on earth where actually useful, productive work can be carried out.

Tragically, this is NOT a cartoon strip. Here's the truth -- if the government expends huge resources to create MORE "jobs" like these, it will only complete the task of destroying the entire American productive engine. In the long run, unless we are actually creatively producing goods and services that meet important needs, we will all go out of business.

The shattered dreams of those without jobs only masks the shattered dreams of those WITH jobs, that they might do something meaningful with their lives, not just claw and fight to survive one more day on a sinking ship that everyone keeps on pretending is floating.

The workplace continues to be a haven for "workplace abuse", a parallel to domestic abuse. It is not unusual for a boss to feel he has the right, if not the obligation, to yell at, cut down, and humiliate the "workers". It is not unusual for a boss to demand over and over that people "work harder" while having no accountability for the work making any sense or being efficient or effective. And, as the staff is cut even more to make it more "lean", it is not unusual to demand that workers give up evenings and weekends to deal with crises that could have been avoided if management had done its job and planned better or even with compassion.

So the workplace is depressing, and worse than simply non-productive -- it is as one person described it to me, a "life-sucking" world that produces sham goods and services at a tremendous cost in human suffering, depression, anxiety, and associated illnesses such as obesity and diabetes. It's only a miracle that there is as little visible workplace blow-back violence as there is, and I suspect that is largely due to the fact that the most psychologically abused workers are in such a state of hopeless helplessness that they can't even get organized to fight back. They are told to stop complaining and "be glad you HAVE a job!"

At the same time, there are now some great examples of what human beings can do together in totally different contexts. Highly productive, energizing, creative work can be done, with an actual joy in doing it. Some people look forward to "going to work" and spending the day slaying dragons with their co-workers in victory after victory.

This is not simply "icing" on a cake. In my own reading of things, the whole reason "the economy" is in trouble, and shedding "jobs" and entire companies if not entire industries, is that that pruning of dead wood is a healthy response of the national body to this disgusting and useless pretense of work. Also, it seems to me, that if THIS problem of pretend creation of wealth is not addressed, it's not just companies, but entire COUNTRIES, that will be pruned from the global body.

This is, at the core, an economic downstream effect of a spiritual problem -- we've lost our bearings as to why we are here, and what we should be doing while we are alive.

There is no way, in my reading of this, that people can simply create "more jobs" or "better paying jobs with better benefits" unless the question is addressed of what the heck kind of task all those "person-hours" are dedicated to accomplishing. More, better paying jobs is a downstream effect that will arrive AFTER we focus our collective national person-hours on the RIGHT tasks, not this collection of socially meaningless, and valueless, goals and objectives.''

The efforts the collective national workforce are putting out are not valued, precisely because they don't justify a high value, and are, in face valueless.

The erosion of jobs, companies, and at the rate we're going, entire cultures and countries, only reflects this loss of direction and lack of an uplifting focus on a long-term spiritual level.

We need jobs, yes, but we need jobs that produce, as output, sustainable improvements in our society, and, that are produced by creating vital environments, full of life and vitality and mutual support and encouragement, where people help each other focus on and be caught up in the immense joy of working productively on important issues, and succeeding at overcoming obstacles in getting there.

We are essentially attempting to power our "economy" by running on our starter engines, instead of utilizing our true capacity for enormously productive work that we are born with -- our capacity to plug into a community of others and find ourselves mobilized, motivated, energized, and empowered as the full creative life-generating power of the universe finds a channel through us to others and flows through that channel.

We have it entirely backwards. Humans can't build an economy, and then, when that is in place, move up Maslow's Hierarchy to start working on a community. We need the community first and the purpose and empowering engine to float the economy.

That is not something that will come "later", in some way, "after we get jobs at all." Where there is no spirit, there shall be no life, to paraphrase T.S. Eliot, paraphrasing the Bible. What we HAVE is dry, lifeless bones, where the wind blows across empty fields, with the plow abandoned across the furrow, to further paraphrase TSE, "our lives unwelcome, our deaths unmentioned in the Times."

Eliot saw exactly this during the last great world-wide depression. Here's a section from his poem "Choruses from the Rock." What's crucial is not that he saw the problem, but that he also saw, through the symptoms, what the actual underlying problem was, and therefore how to address it and fix it.

After 50 years or so of pondering this question, I agree with him. Here's a few snippets of that poem, slightly rearranged. This was written in 1934.

But you, have you built well,
that you now sit helpless in a ruined house?
Where many are born to idleness,
to frittered lives and squalid deaths,
embittered scorn in honey-less hives?
What life have you if you have not life together?
There is no life that is not in community,
And no community not lived in praise of GOD.

And now you live dispersed on ribbon roads,
And no man knows or cares who is his neighbor,
Unless his neighbor makes too much disturbance.

Will you leave my people forgetful and forgotten
To idleness, labor, and delirious stupor?
In a street of scattered brick where the goat climbs,
Where My Word is unspoken.

And the wind shall say: "Here were decent godless people:
Their only monument the asphalt road
And a thousand lost golf balls.

We build in vain unless the LORD build with us.
Can you keep the City that the LORD keeps not with you?
A thousand policemen directing the traffic
Cannot tell you why you come or where you go.

When the Stranger says: 'What is the meaning of this city?'
Do you huddle close together because you love each other?'
What will you answer? 'We all dwell together
To make money from each other'? or 'This is a community'?

O weariness of men who turn from GOD
To the grandeur of your mind and the glory of your action...
Engaged in devising the perfect refrigerator.

Though you forget the way to the Temple,
There is one who remembers the way to your door:
Life you may evade, but Death you shall not.

A larger section of that poem, which I posted in October, 2007 when the Michigan state government shut down briefly, being unable to come up with a budget, is here.

The entire poem is difficult to find on-line, and there are many postings of small portions of it which give no indication that there are parts missing. But, I did find it in images so you can read it. The whole poem can be found here, along with most of the rest of Eliot's poems.

Eliot carries his thoughts into a Christian reverie, but don't be put off by that if you are not Christian -- there is nothing in the core thought that is not really universal, and could equally well be a Moslem or Jewish or Hindu reconnection with the spirit of life that animates this planet, and is willing to animate us, if we only turn to it and let that happen.

(Side-bar: I'm not sure that atheists, regardless how well intended or well educated, can connect with this type of wireless broadcast power to make it through the day. Looking at how "collegial" most university campuses tend to be among educated, atheistic faculty and scientists, there is little evidence that "community" is a driving value, or a sufficient reason to rise above petty squabbles or let go of long-standing bitter grudges. The drive to compete and noticeable sag in energy and increase in green envy when someone ELSE succeeds or looks good is not a strong sign of an academic "community". )

This poem is worth reading and rereading. The "new bricks" reference is what inspired the name of this weblog, by the way, and is in the hopeful section of the poem,

Yet nothing is impossible, nothing,
to men of faith and conviction.
Let us therefore make perfect our will.
O GOD, help us.

The soul of Man must quicken to creation.
Out of the formless stone,
when the artist united himself with stone,
Spring always new forms of life.

The LORD who created must wish us to create
And employ our creation again in His service.

The lights fade; in the semi-darkness
the voices of the WORKMEN
are heard chanting.

In the vacant places
We will build with new bricks
There are hands and machines
and clay for new brick
and lime for new mortar.

Where the bricks are fallen
We will build with new stone

Where the beams are rotten
We will build with new timbers

Where the Word is unspoken
We will build with new speech

There is work together
A Church for all
And a job for each
Every man to his work.

THIS is ultimately what "learning organizations" and "positive deviance" are about -- envisioning meaning and plugging into the resultant power to build new life, if we can break our eyes away from death and open our hearts to the joyous creation of life in the face of all odds.

Wade

U.S. Army as a learning organization

I've praised the U.S. Army as a model "learning organization" that has evolved a way to ask "hard questions" and internally debate extremely contentious issues, and to learn from its "mistakes" and improve next time.

Please note that I am very carefully trying to avoid stating any position regarding what decisions got made, in the interest of focusing on the underlying process of decision-making and mental-model adaptation itself. How did that work? Did it work well? How could it be tweaked so it would work better, not just for one specific instance, but in the general case, from now on?

In short, what can we learn from this experience that will be a permanent step upwards in how we make important decisions collectively, as a country, with both free-speech and a command structure to balance. What can we learn that we can apply to any organization's leadership?

The "unity" above the "diversity" of these two almost-opposing interests is the theme. Where is the sweet spot that we can rise-above the conflict and satisfy both interests without compromising either?

That's the serious question all sides should agree is worth asking.

Then, when we're done looking at the smaller problem we need to spin to a different lens and look at the larger question of how the American people and Congress worked in terms of utilizing information, interests, and politics to make the decisions involved. Did that work? Are people happy, looking back? Can that be improved? Can we learn something?

If so, what? If not, why not?

Is something interfering with our ability to learn from the past and adapt to the future? If so, what is it? What can we do about it? As with "the Toyota Way", we need to do what we were discouraged from doing in grade school, and keep on asking "Why?" at least 5 times trying to dig back to "root-causes" and go far enough to find the upstream things that can, in fact, be changed.

The lesson we should have learned from looking at Toyota's spectacular performance, and the "Making the Impossible Possible" video, is that mostly what is in the way tends to be simply cynicism and the incorrect belief that "nothing can be done" and "We have to live with that." Toyota's lesson in "lean processing" is "No you don't. In fact you must not put up with it. Stop and fix it!"

It often turns out that the cynicism is both unjustified and unsupportable. Change can happen, over time, a little bit at a time, with persistent efforts by everyone. Toyota has proved that.

Maybe, there are better ways and better models for us consulting with each other to make hard decisions about emotionally charged issues.

So, today's NY Times has a relevant article that hits many of those points, particularly the dynamic tension between keeping the command and control structure (and the US Constitution) in place, but also keeping the flow of surprising news going upward, so that we're not trying to violate the basic law of cybernetics and operate with the eyes disconnected from the hand.

For those at my talk Friday, here's the relevant image:


I added emphasis to the excerpts below.


At an Army School for Officers, Blunt Talk about Iraq
New York Times
October 14, 2007
by Elisabeth Bumiller

FORT LEAVENWORTH, Kan. — Here at the intellectual center of the United States Army, two elite officers were deep in debate at lunch on a recent day over who bore more responsibility for mistakes in Iraq — the former defense secretary, Donald H. Rumsfeld, or the generals who acquiesced to him.

No, Major Montague shot back, it was more complicated: the Joint Chiefs of Staff and the top commanders were part of the decision to send in a small invasion force and not enough troops for the occupation. Only Gen. Eric K. Shinseki, the Army chief of staff who was sidelined after he told Congress that it would take several hundred thousand troops in Iraq, spoke up in public.

“You didn’t hear any of them at the time, other than General Shinseki, screaming, saying that this was untenable,” Major Montague said.

... Here at the base on the bluffs above the Missouri River,... rising young officers are on a different journey — an outspoken re-examination of their role in Iraq.

Discussions between a New York Times reporter and dozens of young majors in five Leavenworth classrooms over two days — all unusual for their frankness in an Army that has traditionally presented a facade of solidarity to the outside world — showed a divide in opinion. Officers were split over whether Mr. Rumsfeld, the military leaders or both deserved blame for what they said were the major errors in the war: ...

But the consensus was that not even after Vietnam was the Army’s internal criticism as harsh or the second-guessing so painful, and that airing the arguments on the record, as sanctioned by Leavenworth’s senior commanders, was part of a concerted effort to force change.

On one level, second-guessing is institutionalized at Leavenworth, home to the Combined Arms Center, a research center that includes the Command and General Staff College for midcareer officers, the School of Advanced Military Studies for the most elite and the Center for Army Lessons Learned, which collects and disseminates battlefield data.

...The goal at Leavenworth is to adapt the Army to the changing battlefield without repeating the mistakes of the past.

Much of the debate at Leavenworth has centered on a scathing article, “A Failure in Generalship,” written last May for Armed Forces Journal by Lt. Col. Paul Yingling, an Iraq veteran and deputy commander of the Third Armored Cavalry Regiment who holds a master’s degree in political science from the University of Chicago. “If the general remains silent while the statesman commits a nation to war with insufficient means, he shares culpability for the results,” Colonel Yingling wrote.

The article has been required class reading at Leavenworth, where young officers debate whether Colonel Yingling was right to question senior commanders ...

Discussions nonetheless focused on where young officers might draw a “red line,” the point at which they would defy a command from the civilians — the president and the defense secretary — who lead the military.

“We have an obligation that if our civilian leaders give us an order, unless it is illegal, immoral or unethical, then we’re supposed to execute it, and to not do so would be considered insubordinate,” said Major Timothy Jacobsen, another student. “How do you define what is truly illegal, immoral or unethical? At what point do you cross that threshold where this is no longer right, I need to raise my hand or resign or go to the media?”

But Colonel Fontenot, who commanded a battalion in the Persian Gulf war and a brigade in Bosnia and has since retired, said he questioned whether Americans really wanted a four-star general to stand up publicly and say no to the president of a nation where civilians control the armed forces.

For the sake of argument, a question was posed: If enough four-star generals had done that, would it have stopped the war?

“Yeah, we’d call it a coup d’etat,” Colonel Fontenot said. “Do you want to have a coup d’etat? You kind of have to decide what you want. Do you like the Constitution, or are you so upset about the Iraq war that you’re willing to dismiss the Constitution in just this one instance and hopefully things will be O.K.? I don’t think so.”

Some of the young officers were unimpressed by retired officers who spoke up against Mr. Rumsfeld in April 2006. The retired generals had little to lose, they argued, and their words would have mattered more had they been on active duty. “Why didn’t you do that while you were still in uniform?” Maj. James Hardaway, 36, asked.

Yet, Major Hardaway said, General Shinseki had shown there was a great cost, at least under Mr. Rumsfeld. “Evidence shows that when you do do that in uniform, bad things can happen,” he said. “So, it’s sort of a dichotomy of, should I do the right thing, even if I get punished?”

One question that silenced many of the officers was a simple one: Should the war have been fought?

“That’s a big, open question,” General Caldwell said after a long pause.

So has everyone simply stopped thinking?

A few recent posts have been about my observation in my class that some students weren't engaged, more than I expected. I was aware that I might be over-generalizing.

But, in the last two weeks, while finishing my last paper and dealing with a hospital stay, I ran across two other authors with similar recent observations - one for undergraduates, and one for medical residents. They both are equally puzzled as to whether they are just noticing this, or whether something real has changed in the just last few years.

Since the early Greeks, at least, every generation seems to feel the next generation isn't really doing very well, so we have to start with some skepticism.

But, for what it's worth, here's a brief summary of two recent books.

My Freshman Year - What a Professor learned by Becoming a Student, is by a cultural anthropology professor (pseudonym Rebekah Nathan) who put it this way:

After more than fifteen years of university teaching, I found that students had become increasingly confusing to me. Why don't undergraduates ever drop by for my office hours unless they are in dire trouble in a course? ... How could some of my students never take a note during my big lecture class? ...

Are students today different? Doesn't it seem like they're .. cheating more? Ruder? Less motivated?... Why is the experience of leading class discussion sometimes like pulling teeth? Why won't my students read the assigned readings so we can have a decent class discussion? [emphasis added].

Here' some excerpts from the book How Doctors Think, by Jerome Groopman, M.D. Dr. Groopman "holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and is chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston. He has published more than 150 scientific articles and is a staff writer at The New Yorker."

The idea for his book came to him, as he describes it, in 2004. He continues:

I follow a Socratic method in the discussion, encouraging the [medical ] students and [medical ] residents to challenge each other, and challenge me, with their ideas. But at the end of rounds on that September morning I found myself feeling disturbed. I was concerned about the lack of give-and-take among the trainees....[they] all too often failed to question cogently or listen carefully or observe keenly.... Something was profoundly wrong with the way they were learning to solve clinical puzzles and care for people. [emphasis added]

He also asks himself if this isn't just the same old intergenerational bias, and concludes:

But on reflection I saw that there were also major flaws in my own medical training. What distinguished my learning from the learning of my young trainees was the nature of the deficiency, the type of flaw.

Dr. Groopman goes on to consider whether this is the fault of efforts to follow preset algorithms, like computers, instead of actually thinking, or on "evidence based" thinking that is linear and algorithmic, and incapable of going outside the box when the situation calls for it.

I have further thoughts, but those will wait for another post. At least I am in good company in thinking that something very important has just changed in our youth.

A good epidemiologist would next wonder how widespread is this? Is this also true in Europe? In Asia? In Africa? Only in North America? In Canada? Is this something we can go back and reanalyze existing data sets and trace an "epidemic curve" on to see when it began and if it has peaked or is still rising? And, of course, if real, is this a change in the students, or a change in the way the older generation perceives students?

And, finally, with the "Where?" and "When?" nailed down, we could look at "Why?" and "How?" and then work our way to "What to do to fix it."


Wade

Controlled by the Blue Gozinta

For those who are following this discussion of feedback loops, we're most of the way through the basic description of the insides of such a loop.

I showed how a microphone and speaker, or getting a glass of water represented kinds of feedback loops, and made a distinction between dumb feedback loops and smart - goal seeking - feedback loops, also known as control loops. And we showed how control loops are everywhere in nature, made up of almost any substance - animal, mineral, vegetable, light, chemicals -- and they don't care because the principles work regardless. Control is to the loop as a song is to the instrument - you can play the "same" song on almost any instrument, or sing it, and the "sameness" is there.

So, I need to give a name to the four parts that I had in the upper left in this picture I drew yesterday:



The basic diagram that Professor Gene Franklin uses in the book "Feedback Control of Dynamic Systems" is similar to that block diagram, except for pulling the "GOAL" out and lumping the three other boxes "comparer", "model", and "decider" into a single blue box that is labelled "?" in his diagram of a car's cruise-control system for maintaining a constant speed.


So, the diagram is from that book, as quoted by me in slide 16 of my Capstone presentation on patient team management of diabetes control. I think you may need to click on the picture to make it zoom up large enough to read the words.



In any case, the only box on that diagram that is blue is the one that the feedback "goes into", so I'm calling it a "blue gozinta" as just a funny name that rhymes and that no one else is using.

Besides, the word "controller" rings all sorts of bells I didn't want to ring, echoing back to parents and school and bosses, etc.

Well I guess I failed in that already, as I gave the example of "negative feedback " of a student getting "graded" by a teacher for performance on an "exam", and receiving a failing grade of zero percent, which could be quite discouraging and dampen enthusiasm for the subject.

Franklin's picture has two other minor differences from mine. First, he adds "sensor noise" to the bottom "speedometer" box, to emphasize that this loop is all built around a perception of reality, not reality, and the thing that does the perceiving may not be perfectly accurate. That's a pretty good model of human beings or any other regulatory agent or agency.

As John Gall would say in his book Systemantics -- inside a "system" the perception IS the reality. The medical chart IS the patient.

That effect is so strong that the patient can be dying in the bed but caregivers are so busy looking at the monitors showing something else that they don't see the problem -- which is part of what went on in the tragic Josie King case, where an 18 month child slowly died of thirst in the middle of one of the best hospitals in the world. So, yes, we better remember on our diagram that what our senses tell us is going on may be very wrong. We'll come back to that in a big way when discussing how human vision and perception get distorted by all sorts of invisible and insidious pressures - especially in groups with very strong beliefs.

The other difference between Franklin's diagram and mine is on the upper right, where he adds an incoming arrow labelled "road grade". This means the slope of the road, and how hilly it is, not what we think of the road. His point is that the behavior of a car and the speed it ends up going after we have set our end and put the gas pedal where we think it should be actually ALSO depends on factors that are outside the car - such as whether it's going up a steep hill.

That will also be a universal pattern. The results of our actions are mixed into the impact of outside actions, which makes it hard to disentangle the two from just looking at the end result. The good news is that there are software programs that can disentangle those two for us.

Anyway, the whole point of this post is to get the "blue gozinta" identified.

This little blue box is the heart of the problem, because "feedback" is really just information, and is not intrinsically "positive" or "negative". In this diagram, the "feedback" is the speed of the car, as measured by the speedometer. That's just a number.

The number becomes "positive" or "negative", leading to "more gas!" or "more brake!" actions, only because the blue box, the controller, the blue-gozinta, compared that number to the desired speed, and saw that it was less than desired. Then the controller had to check a mental model and use some rule like "if we're going too slow, push on the pedal on the right!"
"If we're going too fast, push on the pedal on the left!'

As anyone who has ever taught someone else to drive knows, that turns out NOT to be the actual rule that drivers use to control the gas pedal. The behavior those rules and that simplistic model of the world result in is holding down the gas until the car shoots past the correct speed, then slamming on the brake until the car passes the desired speed slowing down, then overshooting and slamming on the gas until the car passes the right speed on the way up, then slamming on the brake, etc. The car jerks back and forth in an unstable and very unpleasant oscillation forever if that's the only rule in use.

However, we can probably all think of organizational policies or laws that have exactly that behavior, and are either too harsh or too lenient, or something, and keep on going back and forth and never manage to get the right setting.

It has been hard to recognize those problems and go

• Hey, I've seen that behavior before!
• That's a "control loop" behavior.
• The way to fix it is to change what goes on in the blue gozinta box.
• What part of the process / law / policy I have corresponds to that box?
• That's where the problem can be fixed.

It's really important to see that there is nothing wrong with the car. The gas pedal works fine, and does not need to be replaced. The brake pedal works fine. The speedometer (in this case) works fine. What is wrong is inside the blue box, and is subtle - it's the "mental model" or rule that is used to decide what action to take depending on what information is coming into the box from outside.

And, the realization is that a very simple rule, a dumb rule, doesn't accomplish what we want, but a slightly better rule will make the very same parts behave correctly together.

The better rule requires a little more brains inside the box. We have to track more than just how fast we are going and how fast we want to go -- we have to figure out how fast we are converging on the goal, and start letting up on the gas as we get near the target speed, before we even get there.

The controller needs to "plan ahead" or "look ahead" and react to something that hasn't happened yet.

This seems to fly in the face of science and logic. How can a dumb box react to something that hasn't happened yet? We can't afford the "glimpse the future!" add on module, at $53 trillion.

Ahh, but here's another wonderful property of feedback loops. What goes around comes around. We've been here before. Nothing is new under the sun. The past is a guide to the future.

Either putting out the garbage can causes the garbage trucks to come, or we can learn the routine well enough that we can predict when the trucks will come based on past experience. It turns out, in a loop, the past and future become very blurred together.

Being able to recall the past IS being able to predict the future, in a control loop.

We don't just go around a control loop once or twice -- we go around a control loop thousands or millions of times. So, if we have any rudimentary learning capacity at all, we can start to notice certain patterns keep happening. We can detect what always seems to be happening JUST BEFORE the bad thing happens, and use THAT as the trigger event to react to instead.

So, we have a second rule that gets added by experience -- "When you get near the target goal, start easing up on the pressure to change and start increasing the pressure to stay right there and keep on doing exactly what you're doing."

This basic ability to learn from experience is the simplest definition of "intelligence" we can come up with. Do you recall the joke about Sven and Ollie that Garrison Keeler told?

Sven comes by Ollie's house and sees that Ollie has both ears bandaged.
"What happened?" he asks.
"Well", Ollie replies, "I was ironing and the phone rang and I picked up the iron by mistake and held it to my ear!"
"Oh.... So, what happened to your other ear?"
" Ahh.... once I was hurt, I tried to call an ambulance. "

So, the moral of all this post is that the key to the behavior of a system being managed by a feedback control loop is the blue box, the "blue gozinta."

Very simple changes to that box can change a horrible experience into a pleasant ride.

The heart of "Control System Engineering" is figuring out what to put in that box.

For human beings, a second major problem is that little tiny addition of "sensor noise", and figuring out how to prevent, reduce, or account for distortions in perception that can cause the system to be responding to a perception, not a reality.

And, for both, there's another very subtle but very well understood problem, and that is "lag time." I didn't draw "lag time" on the picture but I will in the future.

If we're trying to drive based on the speedometer reading from 5 minutes ago, things will not go well for us. In fact, the more we try to "control" things, the worse they can get.

This is a huge problem. A perfectly stable system that is perfectly controllable becomes a nightmare and unstable and can fly out of control just by there being too much of a lag between collecting the sensor data and presenting the picture to the controller.

Or, in hospitals and business, it's popular now to have a "dashboard" that shows indicators for everything, often exactly in "speedometer" type displays.

The problem is, the data shown may be two months old. We are trying to drive the car using yesterday's speedometer reading at this time of day. When I state it that way, the problem is obvious. But, I can't find any references at all in the Hospital Organization and Management literature about the risks caused by lag times in dashboard-based "control".

At this point, even with just this much understanding of control loops, you, dear reader, should be starting to realize how may places around you these loops are being managed incorrectly.

We're spending a huge amount of effort trying to improve the brakes and gas pedals, when the actual problem is a lag time in the messages to upper management, or that sort of problem.

None of these problems need to be in our face. These are all "Sven and Ollie" problems that we can fix with what we know today.

But that will only work if we're really sure about how control loops work, and how they fail, and can make that case to the right people in the right way at the right time.

Take home message -

Even a very basic understanding of control loops can help us ask the right questions, and realize where the problems may be lurking instead of where they appear to be at first glance, so we don't waste our time barking up the wrong tree.

Especially in complex organizations, the generator of failure is usually not that labor failed or management failed, or that any one person did something "wrong." What is killing us now is that we have a huge collection of "system problems" that are due to things like "lag time" and "feedback". Every piece of the system is correct, but the way they behave when connected is broken. There is a "second level" of existence, above the pieces, in the "emergent" world. Things can break THERE. Most of the systems humans built are broken there, or at least seriously in need of an engine mechanic, because we didn't even realize there WAS a THERE.

Worse, "management" still thinks that discussion of "higher level" problems means that someone is pointing the finger at THEM, and that leads to bad responses.

The problems are subtle. We won't see them unless we spend a little time studying how control systems work, and how they fail. Then, the patterns will be much more obvious, and our efforts will be much more likely to be successful. And, then we can stop blaming innocent people for problems that aren't their fault.

It is, however, in my mind, the fault of the whole enterprise of Public Health if this kind of insight is not taken advantage of when designing regulatory interventions or in helping individuals try to "control" behavior. That, in my mind, would be a clear failure of due diligence.

Or - it would be, if these concepts had been published in the peer-reviewed literature that's the only thing they read and pay attention to.

Which says, it's my fault for not publishing this and your fault, dear reader, if you don't get after me to do so.

After all - I depend on feedback from my readers to control my behavior. So, what I do depends on what you do.

Wow, doesn't that sound familiar?

Unity in diversity - the universal problem

If we're going to have a useful discussion on solving our most important common problems, we need to understand the concept of "unity in diversity" at more than a basic level.

I want to stress two features of this design problem of "unity in diversity" as I'm using that term:

• The design problem is very wide-spread. There are instances everywhere in space, time, and scale.
• The processes and principles behind this are not just a little similar, or even very similar - they are identical.

First - the problem is very wide spread, across space, time, and scale.

• Our bodies have muscle tissue, nerve tissue, bone, blood, etc. - each with different jobs to do.
• Companies may have marketing, engineering, and manufacturing departments, each with different orientations and vocabularies.
• Families may have very young, young, middle-age, older, and very old members, each with very different interests and needs and vocabularies.
• A university may have different departments - such as "engineering" and "literature" and "athletics", with very different orientations, priorities, needs, and vocabularies.
• A hospital may have departments, specialties, and sub-specialties - such as medicine versus surgery, emergency medicine, emergency pediatric medicine, emergency pediatric respiratory medicine, etc. -- each with different interests, needs, orientations, and vocabularies.
• Our cells, internally, are not uniform but have specialized subsections for energy production, protein production, effectively library services (DNA), etc. These are all specialized with different structures, orientations, and functions.
• Our planet is not uniform but is divided, somewhat contentiously and fluidly, into "nations" which don't line up exactly with "cultures" or "continents." These may very specifically speak different languages and have different values, needs, and aspirations.
• There are often "classes" of society with differnt values, needs, and use of language, even if it appears at first glance to be "the same language."
• There is, literally, "no end to this." If we look upwards and outwards, it seems that the visible universe is divided into solar-systems surrounding stars, and the stars are clumped in to galaxies, and the galaxies are clumped into clusers.
• If we look at the internet and the world of weblogs and interest groups (the "blogosphere") researchers have found that it too has differentiated and clumped into subgroups that mostly talk within themselves, not across groups. (See Lada Adamic's work.)
• If we look at a high-school cafeteria, sometimes the breakup into groups, cliques, etc. is obvious.
• If we look at our cities, there are "neighborhoods" with local flavors that may be very different from each other.
• Our very concepts of life and knowledge have somewhat dynamic boundaries put into them breaking one world into different "fields of knowledge" with specialized vocabularies and interests and persistent identities.
  

This tendency to break apart a homogeneous population and turn it into specialized sub-groups is everywhere. This is a very basic physical process that always tends to happen.

If you don't believe me, ask any Dean, Director, parent, school-principal, general manager, mayor, governor, president or king. As soon as you get a large group of people together they tend to break apart into "warring factions." over the smallest things. And these people will also confirm that this problem is not just wide-spread and one that absorbs a lot of their time and attention, but is one that has a dramatic, often fatal impact on the survival of the collective enterprise - from productivity to creativity to agility. Everything gets wrecked by this breaking up into silos. So, yes, there is a lot of interest in ways to counteract that tendency, and in design patterns that are "reusable" and can be plugged into your own problem situation.

What's not yet shared, however, is the realization that these problems don't just span space, but they span scale and time. These are all, mathematically, the same problem - and it is the central problem everyone on earth has a vested interest in getting solved right now, if just to "fix" their own little corner that has gone wrong and spends more time fighting itself than it does getting useful chores done.

Without destroying the benefits of specialization, and without homogenizing everyone into "the Borg", how do we overlay something else additional on top of those specialties so that they all also have a common identity, a shared component, and can, when we need to, act as one? That's the engineering design question. What works? What has ever worked?

Second, the processes and principles behind this are not just a little similar, or even very similar - they are identical.

The good news, then, is that anything we can learn about this process in one "field", say sociology, is immediately helpful in understanding another "field", such as "developmental biology", if (and only if) we can distinguish the universal aspects from the accidental local implementation details.

The physical laws and principles behind this tendency to break up into self-sustaining clusters come to us from "control system engineering", not physics or chemistry.

There are only a few stable and simple ways to make a self-sustaining control loop, with certain parts we will always find. More on this tomorrow. We know this can work because we're sitting here reading this, and our bodies are made of trillions of cells that are differentiated and yet integrated. There is a solution to this design problem. We need to understand it better.

If every level and instance of this problem has its own low-resolution sense and view and picture of this problem, limited by the very small size of their receiver, mathematically, we can still assemble all of those low-resolution pictures and process them using "image processing" techniques to come up with a single, high-resolution image of the design issue. That's where I'm going with this, phrased as an "image processing" problem. There are very powerful muscles to do that, if we can rotate this problem around and get it over to those muscles.
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Looking ahead , in the next few days I'll bring this back to the question of "immune systems" and the defenders of the faith, or at least, defenders of certain specialized substructures that life has rearranged itself into. There are some fascinating problems caused by the difference in scale between "members" and "the whole."

For example, in our own bodies, to function, we want our cells to be specialized into very specific functions and grouped into tissues and organs, and we want blood cells to be good blood cells, not sloppy blood cells. There are standards! Deviations must be rooted out!

But we also don't want "bone" cells to attack "blood cells" as if they were foreign invaders and enemies.

Now, this is a challenging problem, because we love our cells but, like loved birds like parakeets, they are still, well, to put it crudely, bird brains. PhD's have trouble understanding differences between cells - how are single-celled cells supposed to make a better job of it? (And, the astounding reality is that they do!)

Something really, really important is going on here. Somehow, a collection of dim-witted cells (relatively speaking) has managed, between them, to be collectively bright. This may be something some of us could use. How do they do that! Can we use the same principle to become collectively bright?

It's as if they don't have a brain cell between them. Actually, that's because they don't. They're too small to have "a brain". So, huh. How do we craft a design so that low-IQ cells, making only local observations, will correctly tell "good guys" from "bad guys" quickly and reliably - when the concept "good" and "bad" are actually not even meaningful at that level, but are concepts from a higher level of existence, at the organism level?

This kind of cross-level exchange of wisdom, and the relationship between the police of the immune system and the "immune system as a whole" is where we need to go to understand how things work, and therefore, how it can break, and therefore, if we have a broken one, how to fix it.

The Sixth Discipline of Learning Organizations - part B

Yesterday, in my post The Sixth Discipline of Learning Organizations, I reviewed a few of the lessons Peter Senge's book The Fifth Discipline teaches that we can learn from thinking in circles, not in lines.

There are other properties of loops that are critical, but as subtle as the difference between the behavior of a spinning bicycle wheel (a gyroscope) and a stationary one, or attempting to throw a plate or a playing card that is spinning rapidly versus one that is not spinning. At first glance you might say - it's just spinning, so what? But the behavior of trying to throw a plate and a "Frisbee" is quite different - the plate may go 20 feet and the Frisbee 100 yards.

Spinning rapidly in a circle matters. All feedback is not the same. The speed of feedback in a feedback loop also matters. The feedback rate matters ( loops per second or per day or per year).

But this morning I want to start looking at vertically oriented loops in hierarchically structured organizations - for which a triangle or pyramid shape is more helpful than a circle for discussion.
(Imagine the pyramid shown on the back of every US dollar bill.)

Say that the "boss" is the eye on the top of the pyramid, and that the boss's orders come down the right side, through the "chain of command" (which is actually a branching tree shape.)

At the bottom of the organizational pyramid, where it actually touches the reality and "ground truth", employees attempt to carry out those orders, and imagine that activity moving us from right to left across the bottom of the pyramid. Finally, status reports ("mission accomplished!") move back up the chain of command being consolidated at each level all the way back to the boss at the top. So, we have a vertically oriented loop, or cycle, because now new orders come down the chain and that loop pattern repeats.

So far, so good.

In a static, simple world, if all employees except one named "Joe" report success, and Joe keeps reporting failure, the classic model would say that the action management needs to take is to replace Joe. The model says all employees are interchangeable machine parts and if a part fails to do its job, the part is broken and should be replaced. This is a simplified version of McGreggor's "Theory X" of management, very popular in the machine age, from 1850 - 1950.
Another implicit assumption is that the boss completely understands the tasks to be performed, and is the resident expert. If people don't "perform" it must be because they are "lazy" and what is needed is a "bigger whip." Employees are told to "jump" and they don't need to understand why or agree -- they just need to ask "yes sir, how high sir?"

That model worked for early industrial models, such as workers in textile mills, or slaves picking cotton.

But, in a dynamic, complex world, that model breaks down and doesn't work. Actions and responses that worked yesterday suddenly no longer work. The "cheese has moved." The organization has to learn new responses to the same old inputs. The response of the outside world to an action is no longer predictable, and has to be judged based on rapid-feedback and a quick poke to see what happens and learning from that. We move into McGreggor's "Theory Y" of management where the expertise is now on the bottom of the pyramid, where front-line
troops are as likely to reply "What bridge? The bridge is gone!" as "OK, yes we crossed the bridge." Now an ever-changing set of facts or dots of information have to be aggregated upwards and "reporting" has to change into continuous "sense-making" of shifting patterns and images of the battlefield truth.

Again, this model is not that strange. It's the basic model we use when we have to move a bit of food from the table to our mouth on a very windy day - we move the hand a little, see where it is now, move it a little move, see where it is now, etc., in a very rapid sequence that automatically adjusts for the wind. If we don't adjust for the wind, the hand and food will miss the mouth on the downwind side. We don't "compute" wind velocity and use Newton's laws to figure out what to do - we just do it and watch while it's happening. It's no big deal. It's the basic "cybernetic loop" of tiny intent, tiny action, tiny perception, and repeat the loop rapidly over and over. It's a loop we can use to cross an unfamiliar room in the dark. Move slowly, stay alert and aware, and adjust as you run into things. It works. It doesn't require quantitative analysis or calculus or a computer or a PhD in robotics. It just requires using a very basic action and sensory loop over and over.

And, like any feedback loop, causality disappears in the normal sense. Motion alters perception and perception alters motion and the two become one, in a very real sense, a single motion-perception action and a loop as an actor.

Again, no big deal. So why is this important?

The big deal is that our society is in the middle of adjusting to this change from "Theory X", and a stable, static world with expertise at the top to "Theory Y" with a very dynamic, unknown world and the expertise at the bottom. In fact, because of the property of loops, there really is no longer much of a "top" and "bottom" in the classical Theory Y sense of the terms.

Just as the level of the water could be seen to control the hand on the faucet, the staff at the bottom of the chain of command can be seen to be controlling the General at the top of the pyramid -- and both those models are wrong, because it's actually the shape of the feedback loop that now has taken on a life of its own, on a whole different scale, and is controlling both of them.

Senge's point, and mine, is that most of the organizational problems we see around us are because we haven't managed to get that much right. In some health care organizations, an extreme case of the expertise being on the "bottom" of the pyramid, the top management still thinks in "Theory X" terms and tries to see itself as the expert in everything and "gives orders" to move in a certain way. The body reports back "No -- what bridge?" and the boss sees this as stubbornness, stupidity, or hostility and things just get worse from there.

Arguably one of the best "learning organizations" around is the US Army. I've mentioned many times before role of Doctrine in FM22-100, the US Army Leadership Field Manual. The pyramid model I just described is the theoretical basis for the doctrine, and every field action is supposed to be followed with a "lessons learned" session. News, particularly surprising news about a misfit between upper management's concept of where the battle or bridge should be and what actual boots on the ground see in front of them, is supposed to be free to travel upwards. Management, as it were, is supposed to listen to the staff and learn what's actually going on, not what management imagined yesterday was going on. It's not insubordination to say "Sir, What Bridge Sir?"

By simple trial and error experience, repeated millions of times, the Army has finally figured out what works and what doesn't and come to some conclusions that are startling to the Theory X old guard, but not at all surprising to the Theory Y thinkers. For one thing, listening has to go upwards, at every level. It's as important that superior officers listen to junior officers as vice versa. If new conditions at the bottom don't result in a new picture of what's going on at the top, the whole pyramid will simply drive off a cliff or otherwise carry out actions that bear no resemblance to reality.

And, because the picture of reality is not perceived directly, but has to come up the chain of command and be re-filtered and consolidated at a dozen different levels, that process has to be incredibly accurate, frank, honest, and unbiased. Even a 10% "adjustment" in facts, repeated over and over at each level of consolidation, can result in a reported "reality" at the top that is 180-degrees out of whack.

In a profound sense, the key word is integrity, and not just integrity when the going is easy, but integrity when the going is tough - not because of enemy action but because of "friendly fire from above". That kind of integrity is also part of the other key word in the doctrine - character.

If the information flows freely and rapidly and can spin up to a high rate of rotation, as with a bicycle wheel or gyroscope, this whole design pattern becomes very stable, agile, nimble, and capable of navigating the most bizarre terrain as events unfold in surprising and unexpected ways. BUT, if there are pockets of resistance to the flow of information, such as cover-ups, that model breaks down. Or, if there are superiors who think "superior" means they know everything and they don't need to learn from their men, the model breaks down. So, another few important words are honesty and humility.

See US Army Leadership Field Manual FM22-100
and What relates Public Health and the US Army?
and the whole posting from my Capstone slide 7 Theories are Changing which has twenty more references to the literature on high-reliability organizations in nuclear power plants and chemical plants and aircraft cockpits and hospital intensive care units, and what makes them actually work in practice. It just keeps coming back to the same thing and the same model that's right in front of us be we haven't finished mastering.

And, again we have a place where our religious heritage has been observing what makes society work for thousands of years and has more wisdom to offer on this than scientists, although the science is beginning to catch up at last. Our religions have been stressing virtues - integrity, honesty, compassion, humility, etc. - for centuries but we haven't really been listening or haven't thought that "mattered any more in the modern age." Actually, the basic cybernetic model is ageless, and true at any size and scale. It's going to be something we have in common with aliens from other worlds when we meet. It's a universal truth every bit as solid as other physical "laws" we rely on.

These are truths that are seen by Hindus, by Muslims, by Christians, by Jews, by atheists, and by learning organizations like the US Army. They can serve as a basis for unity among even such diverse groups and cultures. They can link science and religion without either side having to admit they were wrong about something and lose face.

Grasping and implementing that truth certainly looks like it could give us far more "bang per buck" than investing in new technology, new weapon systems, new gizmos and gadgets, and other ways to shift the detail complexity around.

Also, see my early post Virtue drives the bottom line with many links at the end to such literature. (excuse the formatting near the top of that post - I'm technically challenged by the html editor.)

Another author's take on this subject is "Spirituality in the Workplace - The Sixth Discipline of a learning organization, by Harish Midha at the University of Toronto.

Peter Senge's latest book is Presence: Human Purpose and the Field of the Future and readers interested in that book might also be interested in Stephen Covey's book The Eighth Habit. All these books teach the same gospel - that we are going to have to come to grips with the nature of community to "make it" through our social problems of this century, and that community requires us to realize the power and impact of "virtues" when amplified by the feedback properties of complex systems.

Another post I wrote exploring the role of community, virtues, and organizational learning and agility is The Importance of Social Relationships (short)

I also recommend: Pathways to Peace - beautiful slides and reflections to music on the value of virtues

A general summary of what I think are my best dozen posts on related subjects is here.

This is also relevant:

Spiritual solutions for technical problems

Enjoy, and please, for reasons this whole post embraces, send me feedback! A human can't sustain a thought without some measure of social support! Criticisms and objections are welcome. Use the comment box below, or send to my email in my "profile" box above.

Wade