Draft teaching stories

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These are a series of stories that demonstrate some of the key ideas associated with Cynefin and anthro-complexity.

The Gorilla story

We have the problem that people don’t see what they don’t expect to see. On a lung nodule detection task, a picture of a gorilla 48 times larger than the average cancer nodule was inserted in plain sight on the last lung X-Ray. When radiologists were asked to perform a familiar lung nodule detection task, 83% of them did not see the gorilla.

What’s worse, is when the 17% that did see it talked to the 83%, they became convinced that they had been mistaken. This is a field with a body of knowledge built up over 4-5 generations. Pattern entrainment means we literally do not see what we do not expect to see. What we need to do, is try to find the 17% that think differently

Learning points

  • Inattentional blindness means we do not see what we don't expect to see.
  • Building on the above point, we see what we expect to see, which is another problem with setting explicit goals, we only see those things that match our goals.
  • You can’t train people not to do this, you just need to behave differently to accommodate for this reality. This is where the concept of weak signal detection is relevant and powerful.
  • Our perspective of the world is through the lens of the knowledge we already have. We don’t see the problems as they are, we see the world on the basis of the way we have already decided to act.
  • Three questions are prompted, will people see the data, will they pay attention to the data, will they act upon the data. These are 3 separate processes.
  • These three questions conflict with traditional Decision Theory which says: If you put the right information in front of the right people at the right time, and the have the right training and competencies, they will make the right decisions.


  • Drew, Vo & Wolfe (2013) Psychol Sci. 24(9) 1848-1853

9/11 and retrospective coherence

Audio source - Cynefin Online Foundations - Week 2.3 - See Attend Act.

After the 9/11 attacks there was a US home security review. One question asked was, ‘If there was an order to shoot down the passenger planes, would the order have been signed?’

The answer was probably not. After seeing the what unfolded on 9/11 everyone could see, in that context, it was probably the right thing to do. But before and during 9/11, the idea of a military aircraft interacting with a civilian aircraft was a recipe for disaster, so there was an inhibition.

Learning points

  • Sometimes, with the benefit of hindsight, an action can appear to have been obvious and should have been taken, but some actions are possible in certain situations, but not in others.
  • Retrospective coherence..
  • Behavioural constraints..

What's your crane story

Hansel and Gretel? I.e. fluffy bunny Jack and Jill, vs peril. We learn far more from failure.. as intro to..

A CEO of a major engineering company in Australia made a significant hire to the business, one of strategic importance. They were advised to recruit internally but rejected all the candidates put forward. They decided to recruit nationally instead and the accepted candidate was recruited from the centre of Australia. The new recruit was assigned their first project, which was on the Waterfront in Sydney. This required the use of a floating dock crane, these things are massive, we’re talking a multi-million dollar piece of equipment. So all is well, the first day goes fine and at the end of the day, the recruit makes sure the crane is securely docked overnight. The next morning, disaster, overnight the crane has tipped over and is destroyed - a complete write off.

Coming from inland the recruit had no idea about high and low tides, a spring tide in Australia can have a tidal range as high as 10 metres. The recruit is beside themselves as it’s obvious they’re going to get the sack, first day and such a major disaster. Obviously, the whole company knew about it in no time. The recruits phone rings and it’s the CEO, to invite them to lunch. This is it they thought, an example must be set. At lunch, the CEO remarks on it being a pretty bad first day, but doesn’t fire them. The recruit is astounded and asks why they haven’t been fired. Why would I do that the CEO remarks, I’ve invested a lot of money in you, the crane is written off now and nothing will undo that. You’ve learnt your lesson you’ll never make the same mistake again. And in that act, the CEO had ritualised the failure. A common subject of conversation around the business with new recruits is now, ‘What’s your crane story’. The failure had been ritualised and after a new hires first major error the CEO took them out to lunch. Stories of failure came to be shared widely and openly, everyone learns from them and no-one makes the same mistake again.

Learning points

  • We learn more from failure than we do from success
  • Ritualising failure can be valuable.

Deaths in Logistics

Cognitive Edge did some work with a logistics company, there had been a number of driver fatalities. The driver would be on the road for many hours, in what is largely a passive role. When the driver reached their destination, often late at night, they needed to quickly shift into a more active role to off-load the goods they had been transporting.

The fatalities had all been within the logistics part of the role which would typically be within a busy warehouse, where fork-lift trucks were operating. The solution applied was to get the drivers to put on a warming belt, a physical belt around their midriff, together with wearing a high vis jacket. Clothes form part of our identity and many will recognise that certain clothes we put on are associated or connected with a specific activity - a school uniform, a suit and tie to work, a Rugby kit. Putting on or changing out of clothes, is often accompanied by a change in our identity and aligning both identity and behaviours appropriate in school, work or on a rugby field. The ritual of putting on the warming belt and jacket, helped to shift the drivers into the more active role, the fatalities were reduced by half overnight.

Ritual makes behaviours possible that are not possible outside of this.

Learning points:

  • Roles, behaviours and identity are linked, ritual helps align identity with role and therefore makes different behaviours more possible.

Note! Connect to Surgeon and scrubbing up story.

Scrubbing up

Audio source - Cynefin Online Foundations - Week 2, Landscape of management.

Humans have become quite sophisticated at switching between roles and can take up, and move between, roles at will. We act differently and have different behaviours, even subtly, within different roles - a brother, son, parent, friend or team mate. Identities, roles and the behaviours associated with roles are woven together. Ritual helps align identity with the role being taken up and makes behaviours possible that would not otherwise be possible.

When surgeons and a surgical team scrub up before performing surgery this ritual act, is part of the cognitive activation of taking up their role as a surgeon. The scrubbing up process is a liminal space, a space in between one identity and another, much like when an actor preparing for a performance is putting on a mask - at that moment they are neither the actor themselves nor the role they are taking up. Within a theatre team there are distinct roles, they’re actually a crew, it’s possible to swap out one member with very little, if any, drop in effectiveness. A crew is therefore operationally highly resilient.

The behaviours and roles within a theatre team are highly codified, there is a high entrainment cost, the behaviours exist within the context of a medical profession with a body of knowledge built up over 5,000 years. So some things are possible in some contexts which would not be in others. Another example of a crew is airplane crews, the roles are well defined and you can swap out a Captain and the crew will still be effective, with little or no training or lead time.

Learning points:

Power Line Gang

Arriving at a site in the middle of a field somewhere, a Power Line gang/crew would stop for a coffee and a smoke before they started. They would talk and stories would be shared, afterwards the gang leader would talk through the job.

‘Right boys we all know the job we have to do, we're done this before, let's get on and do it.’

As part of a rationalising effort some management consultants were currently working with the company and were shadowing the gang for the day. After observing the process it was clear there was waste which could be saved, at the same time as making the process more robust and more scalable.

The informal chat could be formalised by converting it into a checklist, this would make the process more repeatable and reduce the dependency on the experience of the gang leader. Removing the coffee and cigarette break also saved time, so there was a double benefit of both process efficiencies and an operational resource savings to be claimed. In the new process the gang leader would now get to site, simply fill out the checklist and they could then get on with the job more quickly.

What was not anticipated, was that a consequence of this new, more efficient, process would be an increase in health and safety incidents.

The informal chat was actually part of a cognitive activation of patterns of behaviour, which had been removed and reduced to one person completing a checklist. The human judgement involved in the situational assessment had also been removed. Reducing the assessment to a checklist masked situations for which the checklist was not created for and the gang were therefore relying on something, which was operating outside of its intended parameters or purpose.

Learning points Over constraining. Mental rehearsal/Cognitive activation.

The Power of Disintermediation

This is the story of an early deployment of SenseMaker and its use by the Australian Army. The background to the story is that the Austrailian Army had been 'Leaned' to make it more effective and agile. During a training deployment, SenseMaker was used to capture stories and to help assess the effectiveness of the unit.

On review of the SenseMaker stories, a lot of them mentioned the need to dig a hole so the troops could relieve themselves. It turns out that as part of the Leaning it has been decided that the portable toilets were not critical to the functioning of fields units and they were not sent in along with the troops. On reading the stories the commander walked over to the phone and made a call. The toilets were dispatched to stop the wasting of time digging holes.

Learning points When leaders are presented with appropriate information they can act and leaning for the sake of leaning can be self-defeating

HR Expenses Fraud

Working for the head of HR in a geological survey company, early on in their career, [Dave/An Assistant] was keen to make a good impression.

There had been some abnormal expense claims and after some analysis and investigation, it was fairly clear that, the claims were fraudulent. Armed with the evidence the case was made to the the HR Director and the whole team were implicated, ‘What do we do, haul them all in here one by one to explain themselves?’

‘Come on’ said the Director and off they went to the team’s office. The Director pointed to a desk, ‘Have a root around in there’, meanwhile he calmly sat down on a stool and lit up his pipe.

A short time later, a large pile of blank receipts was found, conclusive evidence that the expenses were being fiddled. ‘This is great, now we have proof, so are we going to fire the whole lot of them to make an example of them?’

‘No’ said the Director,

‘Why not, it’s fraud?’

‘Compared to the expenses claims it would be far more expensive to rehire a whole new team, if we even could find people with the skills, if they’re willing to go to this extent it’s because they’re under paid. What we’ll do is give them a 10% pay rise and let them keep one piece of equipment after each trip.’

‘What! But now that’s theft?’

‘Put those receipts in here.’ the Director handed a large steel tray and with that, he tapped out his still burning pipe onto the receipts. After the fire had burnt out, the tray and pile of ashes were left for the team to find.

The Director didn’t say anything about it, and the team didn’t bring it up either. They knew that he knew, that they knew. After that, the expenses claims went down by 50%.

Dark Chocolate and Nicholas Cage

So then we have the problem of mistaking correlation with causation. Mistaking the fact that two things appear to have a correlation, with a belief that one thing caused another.

This leads us to the revelation that all you have to do if you want to win more Nobel Prizes as a country is increase the proportion of people eating dark chocolate. If you look at the data, where more people eat dark chocolate, the country also has more Nobel prize winners.

Or if you want to look at another side of things, you should ban all Nicholas Cage movies, because if you didn’t know these movies cause more instances of suicide by drowning.

Neither of these things are actual causes, although if you don’t like his movies, you may be happy to use correlation in the second one.

The pizza and coke story

As you go up management levels, whenever you speak to a customer, generally it’s because there’s a problem. In this instance your job is, again generally speaking, to keep the customer at bay whilst the team fix the problem.

A good technique is to get the customer involved in the investigation, anything that keep the customer occupied is a good idea really. They think they’re helping and that you’re waiting on them, but whilst they’re occupied, the team can get on and fix the issue.

In one such time, there was an unexpected major outage and it was going to take all night to fix. The idea was to buy pizza and coke for the team to keep them going all night, but pre-approval of the cost was required. The expenses department initially choked on hearing the request, but it was explained that the request was actually for food and fizzy drinks.

The department asked why the expense was being incurred, and it was further explained that they were pulling overtime all night due to a major P1 outage for a priority client. The next question was why they hadn’t been given notice of the unexpected outage, ‘We will approve it on this occasion, but expect 24 hours notice in future.’

Now the thing to do at this point was engage in a Socratic questioning technique, which is wonderfully irritating.

‘That’s a brilliant idea.’ ‘And what happens in the highly unusual case where we don’t have 24 hours notice of an unexpected outage.’

There was a brief silence on the end of the line. ‘You will need to get Vice-Principal approval.’

This was code for, ‘It’s never going to happen.’ If you did chase up the claim, you would get put on a list and it’s the wrong kind of list.

The result of this was, allegedly, to start a system which is apparently still used today, of over-tiping Taxi drivers to get blank receipts. These blank receipts could then be submitted as legitimate expenses to be used to pay for the pizza and coke.

The issue here is, if you over constrain the system, there may be unintended consequences and that unwanted behaviours are unlikely to change.

‘Make it smaller’


During development of the iPod, Steve Jobs was in a key meeting with his top engineers. They were presenting their work, the completed iPod prototype, for his approval so production could begin.

Jobs played with the device, scrutinised it, weighed it in his hands, and promptly rejected it. ‘It’s too big, make it smaller.’

The engineers explained all they had done, the lengths they had gone to and how advanced it was.

‘It’s too big, make it smaller.’ came the prompt reply.

The engineers continued to explain, that they had had to reinvent inventing just to get this far. That it was simply impossible to make it any smaller.

Jobs was quiet for a moment.

Finally he stood, walked over to an aquarium in the corner of the room and dropped the only working prototype in the tank. After it touched bottom, probably along with the engineers jaws, bubbles floated to the top.

"See those are air bubbles," Jobs snapped.

"That means there's space in there. It’s too big, make it smaller."

With that, Jobs had created a moment of chaos, the context and arguments by the experts had been undone.

Learning points

  • The complicated domain is the domain of experts, such as engineers.
  • Shifting to the Chaotic domain, relaxes all constraints and requires a shift in how we know what to do.

A Squash and a squeeze


If you haven’t heard it, there is a wonderfully simple fable called 'A Squash and a Squeeze' by Julia Donaldson.

The story stars a lady who lives in a house all by herself, with a table and chairs and a jug on a shelf.

The house is so small she explains very sadly, and advice she is given she follows most gladly.

Watched over and coached by the wise old man, she has doubts and confusion about his curious plan.

At the end of the plan there’s no room to sneeze, with all of her animals it really now is a very tight squeeze.

Then the man tells her take them all out, the lady, confused of the outcome, has doubts.

So at the end of the story what was the plan? The house now returned to how it began.

The actions now taken still remain - see, with her now always, stored in the memory..

..and that you now know was the real intention, to alter forever the ladies perception.

Learning points

  • Path dependence is when the decisions presented to people are dependent on previous decisions or experiences.
  • In human systems this means we are never guaranteed to get the same results twice.
  • The context we inhabit can sometimes be exactly the same, but at the same time be completely changed.
  • Our perception, the lens through which we view the world, can have major implications.

Keystone species and Matrons in NI

https://www.theatlantic.com/magazine/archive/1997/04/underground-rome/376836/ https://www.yellowstonepark.com/things-to-do/wolf-reintroduction-changes-ecosystem

Sometimes the organisations we work in reflect the wider world around around us. One such mirror is represented best using a metaphor of keystones, that is, the stones that stabilise and hold an archway together.

When we can see the archway and the keystone in context we understand that removing it will cause the whole archway to collapse. If however the archway becomes hidden, such as with the catacombs of Rome which can be up to 30 feet below todays ground level - we are unaware of the archway, much less the keystones that hold them together.

Another example of keystones are keystone species, such as Beavers in Yellowstone National Park. When the wolf was hunted to extinction here, the trophic cascade that resulted caused an Elk population explosion. Beavers also disappeared and it turned out they were a keystone species, ecosystem engineers who literally created an entire habitat for other species.

A last example, within organisations is Matrons in the NHS. In Northern Ireland during the troubles, Matrons were retained as it was clear the role they were playing in holding the whole thing together. Their role as a keystone was visible. In the rest of the UK they were removed as a review had concluded they were an entirely superfluous management tier.

Understanding the hidden keystones within an organisation, the dark constraints or enablers of positive behaviours is critical if you want to prevent the collapse of Rome, an ecosystem or the effectiveness of your organisation.

It’s unlikely most people would have a quick tinker about with a jet engine before they took their next flight, perhaps the dynamics of organisational interactions should be afforded the same consideration. Order in human systems is sometimes hard won and many times we squander this all too casually - many times at our peril.

Innovation and exaptation

Innovation is sometimes viewed as creating something entirely novel, a new thing, the like of which nothing has been seen before.

Reality is often not like this. If we view innovation through the lens of evolution, evolutionary leaps resulting in the creation of an eye, ear, or the process of Glycolysis - the critical stage of extracting energy from our food - are incredibly rare.

More often it is about radical repurposing of what we already have. This approach is perhaps best represented these days by Google X and the Moonshot factory. One example here being repurposing hot air balloons as a cheap and effective way of routing the internet to mountainous areas where physical infrastructure is economically unviable.

Other examples of radical repurposing, or exaptation are

  • Our opposable thumbs, the brain power required to use this exapting to handle the complexity of speech and grammar.
  • Dinosaurs and feathers which evolved for warmth, exapting into flight as one poor unfortunate fell from a tree, only to glide to safety.
  • Cassette tapes, for those who remember them, and a pencil to save your favourite mix tape when it came unwravelled, got caught in your Walkman mechanism, or simply to save your battery.
  • Hotel rooms late at night and you’re without a bottle opener - many things reveal themselves as a surrogate.
  • A Raytheon engineer working on a radar magnetron, on realising his peanut cluster bar had melted, invented the microwave.

Viewing innovation through this new lens, we need to find ways to repurpose what we already know.

One way of doing this in through entangled trios and an example of this is when combining three vastly different bodies of knowledge like the humanities, engineering and pure sciences.

This trio is then paired with crisis management teams to identify radical ways forward, by repurposing knowledge from one context to another. In the context of a crisis, the chaos means there is often far more tolerance for trying something new which would be too risky in more stable times.

Learning points

  • Innovation is rarely about creating something entirely novel, more likely it will be reusing what is already known in a novel way.


Other stories to be developed ...

  1. Unannounced office moves - probe to identify those resisting / causing issues, break it up.
  2. North Sea Oil rig story - re-remembering vs listening to the music
  3. Peru story - Crossing boundaries where there is no Adjacent possible.
  4. Napoleon, march to the sound of the drums - Heuristics
  5. US Marines, capture the high ground, keep moving, stay in touch.
  6. 24/7 development, 3 times zones - Radical repurposing, unarticulated needs.
  7. Cycling down Tan Hill after 3 pints of Theakstons at the Tan Hill Inn.
  8. Taxi Drivers or Map Readers
  9. Swallows and Amazons - Duffers.
  10. Kipling, The Butterfly that Stamped.
  11. Cobra Effect & language of power
  12. Hawthorne Effect and responding to novelty.
  13. IBM, OS3 Microsoft and Apple - Competence Induced failure
  14. Rathian Engineer Magneto Machine - Exaptation
  15. Nutrient Lattice - Scaffolding
  16. Kayaker and cognitive activation - Dark constraints
  17. The Regents Clock / The Longitude problem, Dog vs Harrison clock.
  18. Company joker - Able to attend any meeting (crossing boundaries)
  19. Listening to an expert in CX and undermining expertise
  20. 125th street in a Tuxedo late at night.
  21. Welsh government and disintermediation, organisational anti-bodies.
  22. CEO and papers vs disintermediation - systemic bias
  23. Driving on the left, even if a child runs in front of you - over constraining.
  24. Mrs x(?) from a community in South America(?), looking after local children to keep away from local drug cartel.
  25. Dishwasher stackers - stackers or dumpers. Endless arguments in his house, cutlery up... Anticipatory thinking.. Leaving options open for later.. Linked to Tupperware..
  26. Tom, Jason & Linda project - references in https://www.cognitive-edge.com/the-chef-the-recipe-book-user/