Cynefin Framework Reflection
The Cynefin
model has 5 domains or contexts: simple, complicated, complex, chaotic, and
disorder. Disorder is where you are when
you do not know what space you are in.
The normal response is to act according to your preferred method of
action. There is no decision model in
this context, but the danger if you react to a situation based on your
preferred method and it does not match the context of your action, you will
most likely fail or even cause more harm (Snowden, 2010).
In the simple
domain there is an obvious cause and effect that is understood by everyone and
there is one right answer. The model to
facilitate decision-making is sense, categorize, respond. Applying best practice is appropriate (Snowden,
2010).
Up until
recently, water leaks at my sister’s house were a very common occurrence. The piping that was originally installed
overtime became brittle and weak. The
first leak flooded the place because the shut off at the house would not
close. That time I repaired five
different leaks and replaced the shut off valve at the house. I showed my sister and her daughter where the
valve was and how to close it. After the
first repair I was under that house repairing leaks nearly once a week. But, I never had to work under it in flood
conditions again. Unlike me, my sister’s
hearing is excellent. She would call and
tell me she heard a leak and ask me if I would fix it. She was right every time.
When I
installed the shutoff valve and took the time to show them where the valve is,
how to use it, and when to use it, I created a task for them that falls
perfectly in the simple domain. She
hears water running (senses) she checks in the house to see if there is water
running. If she does not find water running inside the house, she determines
that it is a leak (categorize). And
immediately closes the shut off valve which stops the leak until I can get
there to fix it (respond). There is no
ambiguity, cause equals effect, and repeating the pattern consistently produced
the same result. I replaced all of the
lines a few weeks later and she has not had a leak, but if one does spring up,
she will still know exactly what to do and it will produce the same results
(Snowden, 2010).
In the
complicated domain, there is a relationship between cause and effect, but it is
not easy for everyone to identify and it is possible that more than one right
answer exists. These issues require
expert analysis. It may be necessary to
bring in experts. The model to
facilitate decision-making is sense, analyze, respond. The use of good practice is appropriate (Snowden,
2010).
Not too long ago, I experienced an outage on my home
phone. I had seen telephone repairmen in
the neighborhood all day, so I assumed they were working on the system and they
would restore service by the end of the day.
When that did not happen, I checked with my neighbors. They all had service and had not been without
all day (sensed). Then I assumed that I
had somehow damaged the lines or an animal had chewed through the line. I found that the line was buried over two feet
deep and it was encased all the way to their side of the box. I opened my side of the box, but did not see
anything out of the ordinary. At this
point I had gathered up enough information to call the issue complicated. I also knew that I still had the problem, but
I had no idea what was causing it or how to fix it. The extent of my analysis told me that I
needed the experts to make any further progress (analyze). Having exhausted my resources and capability,
I called the phone company and put in a service request (respond) (Snowden,
2010). They were at my house the next
day. I told them what I had done and
found. I also mentioned seeing one of
their repair vehicles in the neighborhood the day I lost service. They were certain that it was on my side and
spent a few hours trying to find my problem.
Finally, they did what I could not do.
They opened their side of the box and found their line dead. There is a panel box (not sure what it is
called) just down the street. On the day
I lost service, a technician was removing service to a different house. In doing so, he cut one of my lines. He either cut the wrong line and forgot to
reinstall it or broke it without realizing it when he was locating the one he
needed to remove. It does not matter, those
things happen and I am certain it was not done purposely. However as a technician, you always look at
the last place people worked before the problem occurred. It would have saved the phone company a half
day of labor. They found the problem
within minutes and had it repaired in less than an hour.
The cause and effect relationship became clear when they found
the problem. I feel that when I turned
the problem over to the experts, my complicated problem should have become
their simple problem. They should have
been able to use best practice from the simple domain. That, of course, is just my opinion.
The complex domain is unpredictable and there is no apparent cause. There are no apparent right answers. Creative and innovative approaches are necessary;
dissent and diversity are helpful (Snowden, 2010). The decision model is probe, sense, respond
(Snowden, 2010)..
I had just upgraded to the 5-skill level…and to be perfectly
honest I had been signed off on a number of things I had not done yet. Being a 5-level meant I could work on the
system on my own. I was a little nervous,
but I had a safety net of qualified people I could question when
necessary. Two weeks later I was in a
C-141 on my way to Saudi Arabia where I would be one of two Radar
technicians. There would be a 7-level on
day shift and me on night shift. My
safety net was gone. But I went in with
my head up and a positive attitude.
Things went well for the first week.
Then an aircraft had to abort its mission because the main Radar
computer called the RDC would simply turn off about every ten minutes or so,
but it was very intermittent. Without
the RDC, nothing works. The entire time
it failed, it only generated a failure message one time. The message indicated a power transient
occurred. So this issue started in the
complicated domain because I had an idea what was causing the problem and I
thought I knew how I would fix it. On
the aircraft I began taking power measurements.
The input to the cabinet goes through a filter on top of the
cabinet. I measured input and output of
the filter and voltage and frequency were perfect and they were stable (probe). The system failed but the readings did not
fluctuate at all. The same was true for
every other power supply internal to the cabinet. I continued for a few hours without finding a
single problem from the front of the cabinet (probe). It was time to access the backplane. At that time, I had only been in the
backplane once, in a class. There are about
40,000 pins and 60 to 75,000 thirty gauge wires connecting all of the signals in
the RDC to their location. The way it is
laid out, there is a real danger of shorting wires and/or breaking wires. I really did not want to go in that night,
but I had no choice. When I opened the
backplane, the failure went away, completely.
When I closed the door, it started failing again (probe). In the cabinet there is a riser plate. When I closed the door, the riser lifted the
RDC chassis about a half an inch. It dropped
it by that much when I opened it. It was
consistent. I had not repaired anything,
in fact, I made it a little more confusing (sense). But I could make the problem go away. I spoke with the production superintendent
and explained that if I got into the backplane the problem would probably get
worse before it got better. We had three
aircraft and were responsible for airborne coverage 24 hours a day, 7 days a
week. Taking it down to two aircraft is
not sustainable. He understood and was
good with the creative fix even if temporary.
The next morning we got approval to modify the cabinet (respond). Removing the riser worked. It did not fail again.
When the aircraft returned, the maintenance commander sat the
aircraft down for maintenance. I and
another military Radar technician and two Westinghouse engineers were picked to
work the problem. We were to split up
and work the aircraft around the clock until we fixed it. That took three weeks. After putting the riser back in the cabinet
the failure returned. We searched signal
by signal for over two weeks and got nowhere. We borrowed a piece of equipment from the
mission computing shop. It allowed us to
probe 24 signals at the same time (probe).
Then we finally saw it. The
signal that protects the equipment for over current/voltage conditions changed
state very quickly and very slightly, but it was enough to shut the RDC
down. Every input to that signal looked
perfect except from the input filter. It
did not look bad it just was not as crisp as the others. When we looked at it with a spectrum analyzer
it was clear (sense). The signal was
noisy, but every few minutes the noise level spiked and the protective signal
saw it as out of tolerance and shut the system down (sense). Replacing the filter on top of the cabinet
corrected the problem (respond). I had
never replaced one of those filters before and I never did again.
This context of this problem was complex we probed for weeks
hoping to see anything emerge that we could follow. It finally happened, but not until we
employed the logic analyzer which allowed us to see relationships it was a
first for radar and as a result we added it to our required equipment documents
and added technical order procedures to use it.
Once we saw the protect signal change, we began to sense the problem was
not a power problem, but noise on the riding on the power signal. This was also the first time I had ever used
a spectrum analyzer on power signals, but it worked and we responded by
replacing the filter.
The chaotic domain poses unique problems. There is no clear cause and effect
relationship. There is no time to think
and many decisions have to be made immediately. The situation is highly stressful and
turbulent. It is pointless to look for
the right answer instead you must act immediately to establish order. The model to facilitate decision-making is
act, sense, respond (Snowden, 2010).
This example affected me profoundly, but I was not there. I will share the actions a friend of mine
took to establish order in a chaotic situation.
My friends name is Craig, He was a Senior Master Sergeant at the
time.
On Elmendorf Air Force Base, Alaska at 0745 on September 22,
1995, Aircraft 77-0354 ingested several Canada geese into the number 1 and 2
engines on the left wing just after rotation.
The number 2 engine was completely destroyed and the number 1 engine was
badly damaged and operating at 50 percent or less and was experiencing repeated
compressor stalls. The aircraft reached
250 feet, but it could not produce enough lift on the left side and was right
wing high. Approximately 2 minutes after
take-off roll the aircraft crashed into a heavily wooded area nose first and
right-wing high. The aircraft came
apart, exploded, and burned. All twenty
four crew members including two Canadian nationals perished. All were brothers, three were good
friends. Maintenance personnel watched
helplessly as the aircraft they just launched exploded into a fireball less
than a mile away (FSF, 1996).
My friend Craig was on duty, but he was not the production
superintendent that morning. He of
course heard the radio traffic and the explosion. He took immediate control. He grabbed two Master Sergeants (act). One he directed to collect all of the aircraft
records and bring them to his office then have the planners lock down all maintenance
software and automated systems (act). The
other Master Sergeant was to get the training records for every person and lock
them in his office. Then Craig went
outside and directed the production superintendent to shut down all flight line
maintenance and bring everyone inside the building (act). Back inside Craig initiated a full recall of
all personnel (act). He also called the
hospital and requested urinalysis support for the entire maintenance squadron
(act). He then called and requested Chaplain
Support (act). . He found the Crew Chief for the aircraft and
had a short, private conversation with him (act). Then he talked to the entire group. He explained all of his actions and why each
one was necessary. (sense). He told everyone not to talk about the
accident to anyone except Chaplains and spouses. Until the investigation is complete
everything is speculation. He encouraged
them to talk to each other and discouraged anyone from blaming themselves
(respond). The commander came in with a
chaplain and Craig retired to his office where I assume he had to let things
soak in (Brian, Eric, & Craig, 1995).(respond)
This topic is still difficult to discuss. Twenty four Airmen died that day. They were doing something they genuinely believed
in. Many lessons were learned that day, lessons
that changed people forever. I am one of
those people. The situation immediately
after the crash was chaotic. People were
in shock, disbelief, and denial. Some
were angry. The Dedicated Crew Chief was sobbing. Craig took action. He said he did because he did not know what else to
do. He was upset that he did not know
where to find the emergency action checklist.
I never saw their checklist, but I do not think he missed too much. Craig’s actions from the beginning helped
ensure the crash investigation team had current information when they needed it.
He also snapped his Airmen out of it so to speak. He had established order by the time the
commander came in. I believe he got them
into the complex domain by the time the commander arrived.
Brian, Eric, and Craig were asked and agreed
to go out to the crash site to search for aircraft pieces and debris…none of
them will discuss that experience.
References:
Snowden, D.
J., (2010). The Cynefin
Framework. YouTube.
Accessed 2017 February 28. Retrieved from:https://www.youtube.com/watch?v=N7oz366X0-8 (Links to an external site.)
Flight
Safety Foundation (FSF) Accident Prevention, Volume 53, Number11,
November 1996. Retrieved from: https://flightsafety.org/ap/ap_nov96.pdf
Conversations with Brian, Eric, & Craig, (1995). True to the best of my memory.
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