Blame. Language. Sharing: Three Tips for...
summary
Argues that learning is blocked by three concrete inhibitors — blame, language, sharing — and shows practical fixes: use the framing hierarchy what > how > why > who, insist on timelines explained in foresight, run structured canvases (example: Trello) for timelines/actions, appoint anonymous devil’s advocates, and check confirmation and hindsight biases. Gives striking specifics: a 45-second outage during a peak that cost donations, two pulmonary embolisms from a port-a-cath, and a 12cm tubing fragment recovered by angiogram.
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chapters (24)
- 0:00Start
- 10:23Bimodal operations
- 11:23Connections not components
- 12:31Embracing complexity
- 14:38Advantages of learning orgs
- 15:56factors that inhibit learning
- 16:15Language hacks to minimise blame
- 18:08counterfactuals
- 18:53Fundamental Attribution Error
- 19:26how did the team react?
- 20:36what did you think was happening?
- 23:22what did the inside of the tunnel look like?
- 24:07Bad apples
- 26:14Mental shortcuts
- 28:06Pattern matching
- 29:33Ignore alternative explanations
- 32:27During incident
- 33:40Take opposing viewpoints.
- 36:03Hindsight bias
- 38:56Attribute failure to a person not a system
- 43:42Counter this bias
- 44:06Sense-making
- 46:02Psychologically safe environments
- 53:04Two factors
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