Lessons from Kunduz: Prevent Disaster by Paying Attention to the Little Picture

Organizations that fail to heed their vulnerabilities are more likely to encounter catastrophes.

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In October 2015, an American AC-130 gunship rained devastating fire on a Doctors Without Borders hospital (Médecins Sans Frontières or “MSF”), killing 42. Last month, the Pentagon released a report detailing the chain of events that led to the catastrophic mistake. Immediately, debate began as to whether punishments meted out to 16 service members, including potentially career-ending suspensions, reprimands, and removals from command, were insufficient when compared with taking a route of criminal inquiry, or if, such tragedy has to be accepted as an inevitable consequence of the fog of war.

Debates about assigning responsibility and meting out punishment are expected consequences of any such event and its follow up, but they rarely address the bigger issue: how to prevent such catastrophes from happening in the first place. Indeed, when we focus primarily on punishment, without addressing the precipitating factors — both technological and organizational — we are inadvertently exposing ourselves to risk of recurrence.

In the moment, actors in chaos or crisis are overwhelmed, facing conditions that are, at worst, out of control and that, at best, present them with awful dilemmas, for which no choice or course of action is a satisfying one. That said, many catastrophes might have been avoided — but it would have required action far removed from the suffering in time and place, and that action would have had to focus on engagement and energetic problem solving, and not on discipline per se, either in the form of blind compliance with procedure or penalties for misbehavior. Prevention requires a considerably different set of organizational structures and dynamics than punishment, ones that may not come nearly as naturally to most leaders.

We’ll get to some specifics, but first some context. I’ve had the chance to work with many members of the uniformed military over several years. From what I’ve learned from the service members whom I’ve gotten to know, the delegation of authority to them — by the American people through the President and the chain of command — to use violence in pursuit of national interests is something taken seriously. Planning, training, drilling, and attention in the moment of action are aimed on ensuring that delegated authority is effected legally and effectively.

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Comment (1)
RALF LIPPOLD
It seems complex and complicated to decipher the emerging future as it evolves. 

During my economics studies, we had some hours on "weak signals" relevant for corporate planning. Back in the day, it was the mid-90s things seemed to be a rather steady state and focusing on some "weak signals" could get you ahead quite a bit. 

Nowadays we live in quite different times, with real-time communication, global interconnectivity and a crisscrossing the myriad of cultures (organizational, societal and occupational). Focusing on a few "weak signals" does not make much sense if you don't capture the "whole pattern" that is emerging and in which "weak signals" play a vital role. 

Missing either is missing the full consequences that you will say were not to be seen. 

h/t Steve for sharing something that is more relevant than ever in our time. Glad to be part of a huge crowd currently doing the MOOC #ulab, and seeing #LeanThinking and #SystemDynamics merging to understand the complexity around us better.