From Silence to Screams: Feedback loops in the Simple Domain
I have come to think of the Simple domain as the Enabling domain. However, most of our clients enjoy the excitement of the Complex domain, and dismiss the Simple domain as necessary though dull, but this is too shortsighted.
If we manage them correctly, activities in the Simple domain enable us to spend more time and resource in the other domains, but if we get it wrong, there are huge negative consequences that can disable the resources allocated to growing and driving the business. Consequently, the greater the negative impact of failure of Simple systems, the greater should be our vigilance in ensuring that sensors are in place to pick up weak signals and hence avoid catastrophe.
We don’t often talk about weak signals in the Simple domain, but I believe they exist.
My family were miners in South West Wales, and to fund their son’s education, my grandparents also ran the village pub. At the end of each shift, the local bus would drop miners off outside the pub and, as a child, I was always amazed by these grown men who, pelican-like, were able to open their gullet and make their first pint of beer disappear in seconds.
Mining was hazardous and accidents were frequent. I was used to seeing men without limbs, and I don’t think many of my uncles had a full set of fingers. As the men tended their gardens shirtless in the summer, it was common to see tattoos of coal dust on their backs, etched in as they scraped the roof whilst working at the face. I often heard the expression, “the mine always gets you” (quickly through accidents or slowly through pneumoconiosis), but it never struck me how dangerous colliery work was until the loss of a relative in 1971.
The high calorific value at the Pentremawr colliery lead to the establishment in Llanelli of one of the largest tin-plate industries in the world, and production of the first canned beer in Britain. However, geological faults ran throughout the mining complex making coal extraction difficult, and roof collapse and firedamp explosion were constant dangers. In April 1971, a methane gas explosion took 6 lives, and injured a further 100.
As families gathered in the village square to provide mutual support, I remember ‘the men’ blaming the mine manager for putting production before safety, but they believed the biggest contributing factor was the replacement of wooden pit props by those made of steel; “you can hear the (wooden) props singing, but with steel, you just go from silence to screams.”
Placing this aspect of mine safety into the Simple, fail-safe domain, this example suggests the domain can have feedback loops, and hence allows the possibility for weak signal detection. Of course, this is not limited to mining, but many capital intensive industries (oil, rail, aerospace) where the neglect of robust procedures has significant consequences.
Having been exposed to the Cynefin framework, I can now put this memory into a new context. It struck me that detection of weak signals is just as important in the Simple domain as the Complex, but in my experience gets far less attention. Failure to detect weak signals in the Complex domain merely delays and increases the cost of response, but failure to detect weak signals in the Simple domain can have catastrophic even fatal consequences. But given that a lot of best practice processes are delegated or mechanised, and rarely get senior management attention, how can weak signal detection in the Simple domain be organised, particularly when new systems are introduced?
It would seem to me that the people who manage the system have to be listened to, and their input taken seriously. This should include supervisors and operators, or anyone who has day to day experience with the operation. Their feedback should not be dismissed by the ‘complicated’ experts responsible for the implementation of the new Simple system.
Even in the Simple domain, value the feedback and listen for the singing. The cost of the alternative is too high.
Acknowledgement to Mr David Jones, Pontyberem for the photograph