Black Elephants in our Safety Systems

COVID-19 is a black elephant. A black elephant is a cross between a black swan and the proverbial elephant in the room. The black elephant is a problem that is actually visible to everyone, but no one wants to deal with it, and so they pretend it is not there. When it blows up as a problem, we all feign surprise and shock, behaving as if it were a black swan [1].

Nicholas Nassim Taleb popularized the black swan metaphor to describe an event that is rare, unexpected, and has a large negative, game-changing impact. COVID-19 is an infectious disease that waited for the right conditions to emerge. Like an accident just waiting to happen. It reminds me of Todd’s Conklin’s statement: “Workers don’t cause failures. Workers trigger latent conditions that lie dormant in organizations waiting for this specific moment in time.”

Taleb also noted that a black swan event is often inappropriately rationalized after the fact with the benefit of hindsight. This should ring a bell for those with accident investigation experience. It’s the counterfactual argument when work-as-imagined is compared to work-as-done. What’s ignored is the normal variability adjustments the victim had to make due to unexpected changes in the environment.

The emergence of COVID-19 is not a black swan. We shouldn’t have been surprised but we were. There have been 11 pandemics from the Plague of Justinian (541 – 750 AD) to Ebola (2014-2016).[2] In 2015, Bill Gates warned all nations that we have invested very little in a system to stop an epidemic.[3] In the October 2019 Event 201 global pandemic exercise, a call to action was outlined in seven recommendations.[4] Some countries have acted while others have chosen to ignore the peril for political-economic reasons deemed higher priority.

Those that acted installed seemingly robust fail-safe disaster response systems. Scarred by the SARS epidemic that erupted in 2002, China thought they had an airtight response process free from political meddling in place. However, Wuhan local health bureaucrats not wanting to raise an alarm and cause embarrassment suppressed automatic reporting. This fear kept Beijing in the dark and delayed the response. In our words, their fail-safe system failed. [5]

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The real surprise is finding out in a painful way how intricately connected we are globally. Our ground, air, water transportation systems made it easy for the COVID-19 disease to spread exponentially. “Going viral” has sickened and killed thousands, crumpled economies, and plunged societal life into a fearful limbo with no easily discernible end in sight. Tightly coupled supply chains we take for granted are disrupted. Westerners are feeling what “made in China” means when local store shelves remain empty. Everyone is having a firsthand excruciating experience of surviving in a complex adaptive system (CAS).

Every organization is a CAS. Every industry is a CAS. So is every state, country, nation.
Civilization is a CAS. We are many complex adaptive systems entangled to form one mega CAS called planet Earth. That idea was reinforced seeing Blue Marble, the image of the Earth from Apollo 17. Boomers felt that when Disney showcased It’s a Small World at the 1964 World’s Fair. (Now that we’ve mentioned it, is the tune streaming in your head too? Sorry about that.)

In the spirit of Safety Differently, let’s ask our 3 fundamental questions: Why? What? How? and pose different, non-traditional responses.

WHY… will we face more Black Elephants?

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The emphasis in a CAS is on relationships between agents. Besides humans, other agents are machines, events, and ideas. Relationships are typically non-linear, not if-then causal, strengthened or weakened by fast feedback interactions. The Butterfly effect means a small initial change can yield a huge impact if a tipping point is reached. Non-linear relationships are exponential like the COVID-19 spread. Many relationships in the real world follow a Pareto distribution, a logarithmic power law. Catastrophes like Black Elephants are rare in frequency but huge in severity. These are also called outliers, as they lie outside the realm of regular expectations of the Gaussian world. So it’s not if they will happen but a matter of when.

The level of complexity increases exponentially every time a new relationship is formed. For humans it could be the simple act of friending on Facebook or accepting a LinkedIn invitation. Or a person you don’t know choosing to follow you on Twitter. Annoying outcomes from new connections are more spam emails and unsolicited ads. More disconcerting is computer programmed machines interacting with other smart parts sometimes in hidden ways. When algorithms collide, no one really knows what will happen. Flash market crashes. Non-ethical AI. Boeing 737 Max 8. Or in one hypothesis, the cutting down of rain forests which allowed once-contained diseases like COVID-19 to infect wild animals. Hmm, workers trigger latent conditions that lie dormant

Realistically organizations are unable to develop emergency plans for every disaster identified. Even if they had unlimited time and money, there’s no guarantee that the recovery solutions will be successful. And by definition, we can’t plan for unknowables and unimaginables.

 WHAT…can we do Today?

The starting point is understanding the present situation of the CAS. The Cynefin Framework has been widely around the world in contexts as diverse as the boardrooms of international fashion houses, militaries, NGOs, and SWAT teams on city streets. For a brief explanation of the sense-making framework, check out Jennifer Garvey Berger’s YouTube video.

The adjacent graphic maps the type of safety decisions made and actions executed in each Cynefin domain. No domain is better than any other. The body of knowledge that Safety-I has provided is clearly in the Obvious and Complicated domains. Much of Safety-II advancements reside in the Complicated domain as experts wrestle with new processes and tools. Whether these can be made easy for anyone to use and thus moved into the Obvious domain remains to be seen. A major accomplishment would be shifting the front-line worker mindset to include what goes right when planning a job.

Now let’s apply sense-making in our battle with COVID-19. Be aware this is a dynamic exercise with relationships, events, and ideas constantly changing or emerging. Also note that the Cynefin Framework is a work-in-progress. The Obvious domain is being renamed as the Clear domain.

Self-isolation is in the Clear domain; you haven’t been tested so avoid others as a precautionary measure. Self-quarantine means you have tested positive; your act is to monitor your conditions and respond as you get better or worse.

Conspiracy theorists are in the far corner of the Clear domain. They believe their ordered life mindset has been deliberately disrupted. Strongly held beliefs range from political party subterfuge to willingness to risk death to save the economy to blaming 5G.

At the time of this writing, experts have not agreed if the mandatory wearing of masks will help or hinder the COVID-19 battle.
Two resistance movements are shown. Both reside in the Cynefin Complex domain near the Chaotic border. Not all Coronavirus challenges trying to go have been positive. Licking toilet seats may have garnered lots of social media attention for the challenge creator. But it has plunged one follower into the Chaotic domain with his testing positive.[6] Some who attended parties with a feeling of invincibility have also fallen into the Chaotic domain.[7]

The Disorder domain is associated with confusion and not knowing what to do. Many myths, hoaxes, and fake news include expert quotes and references. When eventually exposed as fiction and not fact, they can up the level of personal frustration and anxiety.

One fact is that your overarching safety strategy hasn’t changed: strengthen Robustness + build Resilience. As this article is about surviving change, let’s focus our attention on 3 capabilities of a resilient organization.

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With the COVID-19 battle still raging, the chances of doing a fast recovery and returning to the original operating point [A] are practically slim to none. If we know that we have black elephants, then we have an early detection system in place [C]. Being caught with our pants down simply means the messenger doesn’t have enough trust and respect or the organization bureaucracy is too dominant and overbearing. Path [B] is shaping the “new normalcy” for the organization. This entails asking key questions and exploring options. Change Management specialist Peter Hadas has posed a set of questions:

  • If we suddenly had to double our capacity, could we do it?”
  • Are our systems well connected to suddenly handle a spike in capacity?”
  • If I had to scale back to just 20% of my employees that I would absolutely need to rebuild my company from scratch, who would that be?”
  • Of the remaining 80% of your staff, who has mission-critical information in their heads that is not written down anywhere?

In his blog Peter cites case studies where a downturn was perceived not as a calamity but an opportunity. In terms of safety, let’s ask:

  • What black elephants will be unleashed when our organization changes to the new normalcy?
  • What existing latent conditions will enable safety or danger to emerge due to a new tipping point in the new normalcy?
  • When we return to work or if we need new recruits, what will be different in our safety induction and orientation programs in the new normalcy?

HOW…can we operationalize the What?

Top Management is under fire to demonstrate leadership and take charge in a time of crisis. Stop the bleeding to get out of the Cynefin Chaotic domain. Now what? Craft an idealistic vision of the new normalcy? Direct subordinates to “make it so”?  Well, this would be a Complicated domain approach. Since the future is uncertain and unpredictable, developing the new normalcy happens in the Cynefin Complex domain. Instead we manage the evolutionary potential of the Present and shape the new normalcy on a different scaffold.

One of the principles of Safety Differently is: Safety is not defined by the absence of accidents, but by the presence of capacity. Adaptive Safety means building adaptive capacity. When working in the Complex domain, one capacity is possessing useful heuristics to cope with uncertainty. Heuristics are simple, efficient rules we use to form judgments and made decisions. These are mental shortcuts developed on past successful experiences. The upside is they can be hard measures of performance if used correctly (i.e., not abstract and no gamification). The downside is that heuristics can blind us or may not work in novel situations. So don’t get locked into a trusty but rusty heuristic and be willing to adapt.

To operational the What, let’s apply 3 simple rules drilled into US soldiers to improve the chances of survival in war: Keep moving, stay in communication, and head to higher ground.

Keep moving

Okay, we’ve stopped the bleeding. We, however, can’t sit still hoping to wait until things settle out. Nor go into paralysis analysis looking at a multitude of options. We don’t want to be an easy target or prey for a competitive predator. Let’s speedily move into the Complex domain and head towards this new normalcy.

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Before we move, we need a couple of tools – a compass and a map to plot our path [B]. As shown by Palladio’s Amber Compass, a complexity thinking compass is different. In our backpack will be tools to probe the system (mine detector?), launch experiments (flares?), and that map not only to plot our direction but monitor our progress.

In the military world, each soldier on the battlefield is equipped with a GPS device. This capacity enables the Command centre to monitor the movement of troops in real-time on a visual screen. How might we build a similar map of movement towards a new normalcy?

Stay in Communication

In the battle against COVID-19 to stop the bleeding, numerous organizations immediately enacted an age-old heuristic: terminate, layoff, stand down. This action is akin to removing soldiers from the battlefield for financial reasons. The policy is based on the traditional reductionistic paradigm of treating people as replaceable parts of a mechanistic system. It reinforces a Classical Management theory of treating humans as expenses not assets. (Suggestion: Organizations that state Our people are our greatest resource should update to our greatest expendable resource.)

In novel times like today, perhaps it calls for a different heuristic. Denmark as a nation CAS leader decided to “Freeze the Economy.”[8] The Danish government told private companies hit by the effects of the pandemic that it would pay 75% of their employees’ salaries to avoid mass layoffs. The idea is to enable companies to preserve their relationship with their workers. It’s going to be harder to have a strong recovery if companies have to spend time hiring back workers that have been fired. Other countries like Canada [9] and the US [10] are following Denmark’s lead and launching modified experiments.  From a complexity perspective, this is a holistic paradigm where the whole is greater than the sum of its parts.

No matter what employee policy has been invoked, cutting payroll costs does not necessarily mean disengaging. Along the same lines, practicing social distancing does not mean social disconnecting. One can stay in communication. But let’s communicate differently.  Ron Gantt wrote that it’s time for an anthropological approach. We agree. Let’s become physically-distanced storytellers and ethnographers.

Cognitive Edge is offering the adaptive capacity of SenseMaker® for COVID-19 to collect real-life stories from employees working remotely plus temporarily removed from the battlefield. It’s an opportunity to show empathy, sense wellbeing, and build early detection capability [C].  Most of all, we can use stories to generate our map of movement towards a new normalcy.

Head to higher ground

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This is a story-generated 2D contour map from Safety Pulse. Each dot is a story that can be read by clicking on it. The red X marks a large cluster of undesirable stories – rules are being bent to get a low amount of work done. In our military analogy, we have soldiers on a hill but it’s the wrong high ground.

For illustrative purposes, the higher ground or new normalcy is the green checkmark where quality work is being completed on-time, on-budget, and within the safety rules. Thanks to the map, we now have our compass heading. The question is how do we make it easy to head to the higher ground? In other words, how might we get fewer stories at red X and more stories like green checkmark?

The challenge is the ground to be traversed is an entanglement of work-as-imagined safety policies, standards, rules, procedures and work-as-done practices. W-A-I is created by the Blunt end and W-A-D by the Sharp end of the safety spear. Another twisted layer is the formal vertical hierarchy and informal horizontal networks. Entanglement implies that any new normalcy thinking ought to include everyone and shines a different light on Diversity.

Heading in a Top-down only route to a new normalcy could cause inadvertent harm since it is clueless on how work really gets done in the organization. Read Peter’s firsthand experience of a company letting go of people with mission-critical tacit knowledge. Similarly a Bottom-up only route may fail to consider PESTLE tensions that impact the entire safety spear.

Shaping the new normalcy is not a change initiative with an authoritative few making a huge Ego bet. It’s the opposite. It’s Eco and empowering all in the CAS. The diverse learning orchestra assembled to lead would have the adaptive capacity to steer using a near real-time dashboard map generated by stories. Then run a portfolio of many small safe-to-fail experiments to evolve the organization as desirable aspects of a new normalcy emerge.

Act now. Act quickly. Act differently.


  1. The Black Elephant Challenge for Governments. Peter Ho, former head of civil service for the city of Singapore. 2017.
  2. Pandemics that Changed the Course of Human History. Business Insider. 2020-Mar-20.
  3. The next outbreak? We’re not ready.  Bill Gates. TED Talk. 2015-04-03.
  4. Public-private cooperation for pandemic preparedness and response. Event 201 recommendations. 2019-10.
  5. China Created a Fail-Safe System to Track Contagions. It Failed. The New York Times. 2020-03-29.
  6. ‘Corona Challenge’: Man Tests Positive For COVID-19 Days After Licking Toilet Bowl. 2020-03-26.
  7. Florida college students test positive for coronavirus after going on spring break. CBS News. 2020-03-23.
  8. Denmark’s Idea Could Help the World Avoid a Great Depression. The Atlantic. 2020-03-21.
  9. Trudeau promises 75% wage subsidy for businesses hit by coronavirus pandemic. Global News. 2020-03-27.
  10. The government will now pay businesses to keep workers on payrolls (and hire back ones they laid off). Fast Company. 2020-04-02.

Exploring an anthrocomplexity-based approach to Safety

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