How solving little problems can alert us to big ones
Or conversely, how ignoring little problems might lead to big ones.
I read an interesting article a while ago, by Matthew Parris in the Times (subscription only, I am afraid).
Matthew based his article on the observation that a squeaking door at Derby railway station has remained unfixed for months. He suggests that this sort of persistent low-level problem is seldom the subject of review, even though that fact that it persists is probably symptomatic of some major cultural or systematic flaws within the station-management organisation. If small problems don’t get fixed, what does this tell us about the large problems?
Matthew notes that official reviews of public sector delivery, such as the railways, tend to be either very theoretical and high-level, or a reaction to a major disaster, often accompanied by blame-seeking. He proposes that review of “a real, small, unsensational fault whose folly no one would dispute” such as a squeaky door that remains unoiled, is a powerful way to unravel the fundamental problems in an organisation.
Why is this important? Because if an organisation can fail to notice, or fail to fix, a squeaky door, then maybe something else has remained unnoticed or unfixed. Something with far bigger consequences. If you ignore a squeaky door, maybe you ignore a loose handrail, and maybe you end up with an unsafe facility.
This is part of something called the “normalisation of deviance“, which is how people within an organization get used to things being “not right”, and because nothing happens, the “not right” becomes the new normal. People grow more and more accustomed to this deviant behavior, until it spirals into something really bad, or until disaster strikes.
The implication for Knowledge Management
The implication for Knowledge Management is that reviewing the large things – the programs, the major deliveries, the “Top 3 lessons” – should be accompanied by reviewing the small things as well. The major learning reviews, Retrospects and Learning Histories should be accompanied, at a much smaller scale, by team-level After Action Reviews, for example.
The After Action Review, held on a regular basis (daily, weekly, monthly, or at set performance milestones), can not only help the team improve their own performance, they can (through use of the 5 Whys) can uncover systemic root causes which need to be fixed.
Why is the door squeaking?
– Because nobody oiled it
Why did nobody oil it?
– Because they did not feel it was their job
Why did they not feel it was their job?
– Because a) it was not in their job description, or b) they had no job description, and c) nobody does anything that is not in their job description, or (etc etc etc)
Why does nobody do things that aren’t in their job description?
– Because (and, by now we might be getting into more fundamental issues such as positive and negative incentives, fear of transgression, lack of vision, lack of ownership; I dont know what they would be in the case of Derby Railway station)
How do we fix this?
– (and then they start to determine the actions to fix the systemic problems that lie behind the symptom of the squeaking door).
Local actions can be taken to fix the squeak, but higher level actions will need to be taken to fix the problems that allowed the squeak to continue unfixed. The learning system therefore needs a mechanism by which lessons and actions can be escalated to a level of someone with power to take action. And that person needs to be willing to learn; willing to be informed by small symptoms that large systems need to be addressed, and willing to fix small deviance before it becomes the new norm
The squeaking doors are the early warning system, provided we have the ability to learn from them.