Bij de crisis bij Fortis e.a. vragen velen zich af hoe het zo ver is kunnen komen. De verleiding om de schuld (enkel) bij de topmannen te leggen is groot. Welk licht werpt Kennismanagement op rampen? Patric Lambe, in de KM wereld gekend van zijn blog Green Chameleon, schrijft in zijn boek "Organising Knowledge: Taxonomies, Knowledge and Organisational Effectiveness" de volgende interessante gedachten.
[...] It is a consistent feature of major disasters and tragic failures that multiple small causes conspire to bring about the tragedy. Despite our desire to identify simple causes — preferably people we can blame — terrible things most frequently come about because of complex combinations of failures: personal, cultural and systemic. [...]
To a knowledge management eye, these issues go beyond information systems and information management. Individuals and agencies knew what was happening [...] but were unable to transfer that knowledge to where it could be actioned or to act on it themselves. This was a knowledge management problem, not simply an information management problem.
The symptoms of this problem turn up all too frequently in other disastrous mistakes, from the Challenger space shuttle disaster in 1986 (Vaughan, 1996) to the goor emergency services coordination during the World Trade Center collapse after the 9/11 attacks (Dwyer, 2002), to the shambles of the crisis response to Hurricane Katrina in New Orleans in 2005. Typical symptoms include:
- a culture of not caring about the implications of knowledge held beyond a narrow task-fulfilment role;
- different ways of describing and naming the same problem;
- inability to integrate multiple perspectives on the same problem;
- lack of opportunity for routine information exchange between parties involved;
- incompatible information systems;
- lack of access to other parties' information systems;
- few shared attentional cues among the parties involved — warnings from external parties are not taken seriously because there are no mechanisms for recognising their authority or the experience upon which the warnings are based;
- few informal socialisation opportunities to build ,up a common language, shared categories, or trust mechanisms that underpin a group's shared attentional cues and sense of authoritative knowledge-based experience.
Wat zijn jullie inspirerende gedachten?