Index
A
AARs, 168
ABRY Partners, 41
acceptable versus unacceptable failures, 125-131
advocacy and information filtering, 34-35
after-action reviews, 131, 166-172
Ager, David, 3
Alessi, Alberto, 120-121
Allgaier, Larry, 21
Ametek Corporation, 40
analogies, misuse of, 77-84
Cocoa Pete’s Chocolate Adventures, 82
Enron, 83-84
1976 “swine flu” incident, 77-80
Zoots, 80-81
analyzing competitors, 173-176
Argyr, Chris, 62
Arm & Hammer, 54
Army after-action reviews, 166
assessing failures, 125-131
assumptions, examining, 84-87
B
Bacon, Francis, 103
Baker, James, 14
Baltimore Colts, 161-163
Baumard, Philippe, 124
Bay of Pigs fiasco, xvi, 130-131
Beaudoin, Taryn, xxi
behavior
gap between statements and behavior, reasons for
group dynamics, 59-60
leading questions, 58-59
unconscious mind, 61-62
observer’s influence on, 66-69
Belichick, Bill, 180-181
Berlin, Isaiah, 73
Berra, Yogi, 53
Berry, Raymond, 161-163
Beth Israel Deaconess Medical Center, 43
bias, confirmation bias, 33-34
Bird, Larry, 177
Bishop, Todd, 151
Blackburn, Donald, 28-30
Blinkoff, Robert, 61
Bolt, 134
Bower, Joseph, 44
Braden, Vic, 178
Bragg, Robert, 142
Breashears, David, 149
briefings, 147-149
Build-a-Bear Workshop, 9-11
Burt, Ronald, 110
business school, weaknesses of, 90-91
C
Capital One, 123
Casciaro, Tiziano, 110
case method, xvii
Chesterton, G. K., 1
Children’s Hospital in Boston, 150
Children’s Hospital in Minneapolis, 122
Christensen, Clayton, 45
Churchill, Winston, 46-48, 155
circumventing gatekeepers
Churchill, Winston (case study), 46-48
connecting with young people, 41-43
going to the periphery, 43-44
listening with your own ears, 36-39
seeking different voices, 39-41
Son Tay incident (case study), 27-31
table of strategies, 35
talking to noncustomers/nonsuppliers, 45-46
Citicorp building case study, 186-189
Clark, Maxine, 9-11
Cocoa Pete’s Chocolate Adventures, 82
Colts, 161-163
Coming of Age in Samoa (Mead), 55
communication
briefings, 147-149
Crew Resource Management (CRM) training, 143-145
errors, 145-147
handoffs, 149-151
listening, 155-156
speaking up effectively, 151-154
team training, 156-158
Tenerife airline disaster (case study), 139-143
competitor intelligence, 173-176
complex organizational structure, tendency to mask problems, 11-12
Concorde jet, 129
confirmation bias, 33-34
conformity, 32-33
connecting with young people, 41-43
Connors, Jack, 193
Crew Resource Management (CRM), 16, 143-145
Crovitz, Gordon, 111
cultures of fear, 9-11
Cummings, Arthur, 112
curiosity, 189-191
CVS, 38-39
D
Darwin, Charles, 66
Davidi, Inbar, 171
Deal, Duane, 191
deliberate practice
after-action reviews, 131, 166-172
in business environments, 176-180
case studies
Bill Parcells and Bill Belichick, 180-181
Raymond Berry and Johnny Unitas, 161-163
Tony Gwynn, 163-165
competitor intelligence, 173-176
Department of Homeland Security (DHS), 109
Disney studios, 132
DNI (Office of the Director of National Intelligence), 109
Drycleaning & Laundry Institute, 81
Dyson vacuum cleaners, 119-120
Dyson, James, 119-120
E
Edmondson, Amy, xx, 3, 107, 122
efficiency and information filtering, 31-32
Eli Lilly, 131
Ellis, Schmuel, 171
embracing problems as opportunities to learn and improve, 6-9
encouraging useful failures
acceptable versus unacceptable failures, 125-131
Alessi case study, 120-121
Dyson vaccuums case study, 119-120
Pixar case study, 132-134
Engle, Dave, 164
Enron, 83-84
Ericsson, K. Anders, 176
errors, communication errors, 145-147
ethnographic research
Arm & Hammer example, 54
gap between statements and behavior, reasons for
group dynamics, 59-60
leading questions, 58-59
unconscious mind, 61-62
General Mills example, 54
Huggies example, 53
observer’s influence on behavior, 66-69
principles of effective observation, 62-66
Proctor & Gamble example, 54-57
evaluating failures, 125-131
Evista, 131
examining assumptions, 84-87
F
Facebook, 43
facilitating information sharing, 106-111
failure
definition of, 5
tolerating
acceptable versus unacceptable failures, 125-131
advantages of, 121-124
Alessi case study, 120-121
Dyson vaccuums case study, 119-120
Pixar case study, 132-134
Fairbank, Richard, 123
fear, culture of, 9-11
Feldstein, Martin, 146
filtering information, 31
finding problems, xvii
FISA (Foreign Intelligence and Surveillance Act), 100
Fisher, Bill, 81
focus groups, problems with, 55
group dynamics, 59-60
leading questions, 58-59
Foreign Intelligence and Surveillance Act (FISA), 100
Foulkes, Helena, 39
Foushee, Clayton, 144
Fuld, Leonard, 173-174
fundamental attribution errors, 124
G
Garber, Peni, 41
gatekeepers, 13-14
circumventing
Churchill, Winston (case study), 46-48
connecting with young people, 41-43
going to the periphery, 43-44
listening with your own ears, 36-39
seeking different voices, 39-41
Son Tay incident (case study), 27-31
table of strategies, 35
talking to noncustomers/nonsuppliers, 45-46
reasons for information filtering
advocacy, 34-35
confirmation bias, 33-34
efficiency concerns, 31-32
pressures for conformity, 32-33
Gavetti, Giovanni, 80
GE (General Electric), 42, 157
General Mills, 54
Gilkey, Roderick, 190
Ginnett, Robert, 144
Glago’s Guest, 134
Glocer, Tom, 43
groups
focus groups, 104
group dynamics, 59-60
sharing information in, 104-106
Guillain-Barr syndrome, 79
Gunther, Robert, 123
Gwynn, Tony, 163-165
H
Hamel, Gary, 41
handoffs, 149-151
Hayward, Larry, 40
Hazmi, Nawaf al, 97
healthy paranoia, 192-193
Helmreich, Robert, 144
Hewlett-Packard, 42
hidden problems, reasons problems remain hidden
cultures of fear, 9-11
dismissing intuition, 14-15
gatekeepers, 13-14
isolation trap, 20-21
lack of training, 15-17
organizational complexity, 11-12
overview, 9
Hill Holliday, 192
Hilton Garden Inn, 179
Hoang, Ha, 129
Huggies, 53
hunting for patterns, 73
Hyatt Regency Hotel case study, 185-186
I
IAFC (International Association of Fire Chiefs), 145
identifying problems, xvii
IDEO, 122
Immelt, Jeffrey, 157
improving interpersonal communication
briefings, 147-149
handoffs, 149-151
listening, 155-156
speaking up effectively, 151-154
team training, 156-158
information filtering
circumventing filters
Churchill, Winston (case study), 46-48
connecting with young people, 41-43
going to the periphery, 43-44
listening with your own ears, 36-39
seeking different voices, 39-41
table of strategies, 35
talking to noncustomers/nonsuppliers, 45-46
reasons for
advocacy, 34-35
confirmation bias, 33-34
efficiency concerns, 31-32
pressures for conformity, 32-33
Son Tay incident (case study), 27-31
information sharing
facilitating, 106-111
9/11 terrorist attacks (case study), 95-101
CIA in Kuala Lumpur, 97-98
lack of information sharing, 100-101
Minneapolis field office investigation, 99-100
Phoenix memo, 98-99
“prevent first” mindset, 112-114
reasons for inadequate information sharing, 102-104
in small groups, 104-106
intellectual curiosity, 189-191
International Association of Fire Chiefs (IAFC), 145
interpersonal communication
briefings, 147-149
communication errors, 145-147
Crew Resource Management (CRM) training, 143-145
handoffs, 149-151
listening, 155-156
speaking up effectively, 151-154
team training, 156-158
Tenerife airline disaster (case study), 139-143
isolation trap, 20-21
Ison, Kelly, 147
J
JetBlue, 63
Jobs, Steve, 132
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 167
K
Kansas City’s Hyatt Regency Hotel case study, 185-186
Kelleher, Herb, 174
Kennedy, John F., 130
Kilts, Clint, 190
Kimberly Clark, 53
Kinder, Thomas, 57
Kissinger, Henry, 28
Kleenex tissues, 68
Klein, Gary, 75
KLM Flight 4805, 139-143
Krasnow, Todd, 80
Kuala Lumpur, terrorist meeting in, 97
Kurre, Adrian, 179
Kwan, Julianne, 153
L
lack of training, 15-17
Lafley, A. G., 54-56
Laird, Melvin, 28-30
Landry, Tom, 163
Larson, James, 106
Lasseter, John, 132
Lawrence, Paul, 102
leading questions, 58-59
LeMessurier, William, 186-189
Levy, Paul, 43
listening, 145
listening with your own ears, 36-39
Livin’ It initiative (Proctor & Gamble), 54
Lobo, Miguel Sousa, 110
Loftus, Elizabeth, 58
Lorsch, Jay, 102
LTX Corporation, 39
M
making tradeoffs, 17-18
Martin, Roger, 113
McNamara, Robert, xvi-xvii, 91, 130
Mead, Margaret, 55
mentoring, 87-88
Meurs, Klaus, 141
Microsoft, 54
Mihdhar, Khalid al, 97
mindset of problem-finders
Citicorp building case study, 186-189
healthy paranoia, 192-193
intellectual curiosity, 189-191
Kansas City’s Hyatt Regency Hotel case study, 185-186
systemic thinking, 191-192
mining data for patterns, 89-90
Mohammed, Khalid Sheikh, 97
Moorer, Thomas, 28-30
Morath, Julie, 122
Moussaoui, Zacarias, 99
Mueller, Robert, 112
Mulcahy, Anne, 36-38
Murphy, James, 148
MySpace, 43
N
NBA (National Basketball Association) draft picks, 129
Neeleman, David, 63
Nelson, Randy, 132
Nemeth, Charlan, 153
Nichols, Ralph, 155
9/11 Commission, 12
9/11 terrorist attacks, prior information about, 95-101
CIA in Kuala Lumpur, 97-98
lack of information sharing, 100-101
Minneapolis field office investigation, 99-100
Phoenix memo, 98-99
1976 “swine flu” incident, 77-79
Nixon, Richard, 27
noncustomers, talking to, 45-46
nonsuppliers, talking to, 45-46
Novartis, 21
novel experiences, seeking, 190
O
observation
observer’s influence on behavior, 66-69
principles of effective observation, 62-66
Office Depot, 69
Office of the Director of National Intelligence (DNI), 109
Only the Paranoid Survive (Grove), 192
organizational complexity, tendency to mask problems, 11-12
P
Padres, 164
Pan Am Flight 1736, 139-143
paranoia, healthy paranoia, 192-193
Parcells, Bill, 180-181
pattern recognition
examining assumptions, 84-87
intuition, 75-77
mentoring, 87-88
mining data, 89-90
misuse of analogies, 77-84
Cocoa Pete’s Chocolate Adventures, 82
Enron, 83-84
1976 “swine flu” incident, 77-80
Zoots, 80-81
Rapid Response Team case study, 73-74
PayPal, 90
Pentagram, 176
periphery of organization, seeking information from, 43-44
Pete’s Wicked Ale, 82
Phoenix memo, 98-99
Pixar, 132-134
Plomer, William, 95
Polaroid, 175
postmortems, 168
Powell, Colin, 27
practice, 165
“prevent first” mindset, 112-114
principles of effective observation, 62-66
process interventions, 107
Proctor & Gamble, 54-57
Q-R
questions, leading questions, 58-59
Rapid Response Team (RRT) case study, 1-5, 73-74
Red Pencil Award (Build-a-Bear Workshop), 10
Reed, Americus II, 55
Reed, John, 188
Ricchetti, Carlo, 121
Robinson, Chris, 167
Rowley, Coleen, 101
RRT (Rapid Response Team) case study, 1-5, 73-74
S
SALT (Satisfaction and Loyalty Tracking) score, 179
San Diego Padres, 164
SBAR (Situation-Background-Assessment-Recommendation), 16
Schon, Donald, 62
Schreuder, William, 141
seeking different voices, 39-41
Senge, Peter, 168
sharing information
facilitating, 106-111
9/11 terrorist attacks (case study), 95-101
CIA in Kuala Lumpur, 97-98
lack of information sharing, 100-101
Minneapolis field office investigation, 99-100
Phoenix memo, 98-99
“prevent first” mindset, 112-114
reasons for inadequate information sharing, 102-104
in small groups, 104-106
Shelby, Richard, 95
Shiliashki, Mario, 90
Shoemaker, Paul, 123
Situation-Background-Assessment-Recommendation (SBAR), 16
Skilling, Jeffrey, 83
Slosberg, Pete, 81
small groups, sharing information in, 104-106
Son Tay incident (case study), 27-31
Soubra, Zackaria, 98
speaking up effectively, 151-154
Starbuck, William, 124
Stasser, Garold, 104-106
statements, understanding gaps between statements and behavior
group dynamics, 59-60
leading questions, 58-59
unconscious mind, 61-62
Staw, Barry, 128-129
sunk-cost effect, 128-129
Surowiecki, James, 111
Sutcliffe, Kathleen, 7
Suzuki, Shunryu, 185
“swine flu” incident of 1976, 77-79
systemic thinking, 191-192
T
Tacelli, David, 39-40
talking, 145
Tapscott, Dan, 111
team communication, 156-158
Tenerife airline disaster, 139-143
Tenet, George, 96
Thomson Reuters, 43
Titus, William, 104
Toy Story, 132
Toyota, willingness to embrace problems, 7-9
Toyota’s “Andon cord” system example, 17
tradeoffs, making, 17-18
training, lack of, 15-17
triangulation, 65
Tucker, Anita, xx
Truman, Harry, 86
U
Ultimate Team Play, 179
unconscious mind, 61-62
United Airlines Flight 232, 17, 145
UPS, 179-180
useful failures, encouraging
acceptable versus unacceptable failures, 125-131
advantages of, 121-124
Alessi case study, 120-121
Dyson vaccuums case study, 119-120
Pixar case study, 132-134
V-W
van Zanten, Jacob Veldhuyzen, 139-143
Wal-Mart, 69
Walcott, Charles, 14
Walsh, Kevin, 192
Walt Disney studios, 132
Walton, Sam, 69
Warns, George, 142
Warshaw, Shirley, 14
Watanabe, Katsuaki, 8
WaterCooler technology, 42
Wayne, Stephen, 14
Welch, Jack, 42
Who Wants to Be a Millionaire?, 111
Wikinomics: How Mass Collaboration Changes Everything (Tapscott and Williams), 111
Williams, Anthony, 111
Williams, Chris, 134
Williams, Chuck, 133
Williams, Kenneth, 98
Wohlstetter, Roberta, 189
Workin’ It initiative (Proctor & Gamble), 54
Wriston, Walter, 188
X-Y-Z
Xerox, 36
young people, connecting with, 41-43
Zildjian, 192
Zoots, 80-81