THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net
S U M M A R Y
DIARY: September 21, 2004 04:18 PM Tuesday;
Rod Welch
Morris analyzes root cause analysis based on links.
1...Summary/Objective
2...Beyond Reach Socretes Skepticism Gave Up on Literacy without Trying
3...Giving Up on Communications Perfect Truth Beyond Reach Cycinism Despair
4...Cynicism Despair Sacraficing Good Because Perfection Beyond Reach
5...Morris Giving Up on Better Tools Because Perfection Beyond Reach
..............
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CONTACTS
0201 - Intel Corporation O-00000704 0201
020101 - Mr. Morris E. Jones;
SUBJECTS
Analysis Difficult Frustrating Bad Luck Using Conventional Methods R
Referent Email Omitted Poor Communication Causes Confusion Difficult
False Positive Requiring All Information in Record to Perform Effect
Legal Problems Need SDS for Organizational Memory
Write Everything Down Unnecessary Capture Information Important to O
Good Management Lot of Hard Work Knowledge Management Using Conventi
Peer Review Root Cause Analysis NWO Intelligence Support Scope Repor
POIMS Difficult Understand Explanation KM Cannot Comment
Communication Metrics Peer Review
3411 -
3411 - ..
3412 - Summary/Objective
3413 -
341301 - Follow up ref SDS 31 0000, ref SDS 30 0000.
341302 -
341303 -
341304 -
341305 -
341307 - ..
3414 -
3415 -
3416 - Progress
3417 -
341701 - Received ref DRT 1 0001 from Morris responding to the letter
341702 - yesterday, ref DIP 3 0001 that urged not giving up on good analysis,
341703 - simply because analysis can never be perfect. ref SDS 31 5X8X
341705 - ..
341706 - Morris says today...
341707 -
341708 - 1. You only find the root cause if it is linked. Otherwise, it
341709 - will be an item that is missing from the system. It is often
341710 - the case that the person creating the record doesn't have
341711 - control over the million parts in a complex system. Let alone
341712 - a technical understanding of what they do. This necessary
341713 - division of labor, expertise, and understanding makes having a
341714 - "record" a monumental challenge. ref DRT 1 0001
341716 - ..
341717 - "Links" are only one several ways SDS supports "root cause" analysis,
341718 - as shown in the scope for intelligence support in NWO. ref OF 10 QP5I
341719 - Moreover, even when one thing is not directly linked to another, it is
341720 - possible to find closely related context with connections to root
341721 - causes. On 960406 Morris mentioned that finding relevant context is
341722 - hard with conventional tools. ref SDS 13 4249 Intelligence support
341723 - context management makes finding relevant details fast and easy.
341724 - ref OF 10 HH5L
341726 - ..
341727 - POIMS describes SDS design for using "context" to find information
341728 - based on remembering only the gist of the story. ref OF 6 KH8J
341730 - ..
341731 - Morris continues...
341732 -
341733 - 2. Experience has shown that electricians and plumbers often have
341734 - a different view of what must/should be done on a job site
341735 - reading the same blueprints. The old running joke is that the
341736 - electrical code requires connecting the plumbing together to
341737 - provide a ground, and the plumbing code requires disconnecting
341738 - the ground jumpers to prevent electrolysis in the pipes.
341739 - ref DRT 1 EG6G
341741 - ..
341742 - SDS supports multiple views of context, as set out in NWO defining the
341743 - scope for "intelligence support." There are many dimensions of
341744 - effective context management, as Morris noted in a meeting on 970116.
341745 - ref SDS 15 1732 SDS solves this problem with a robust tool set.
341746 - ref OF 10 QR6J On 010425 Morris described SDS advantages of Knowledge
341747 - Space that positions everything in the right place at the right time.
341748 - ref SDS 25 EP7F A few months later, Morris commented on 010924 that
341749 - SDS improves management better than other methods, ref SDS 27 NK4J,
341750 - because nobody can use conventional tools the way SDS is used.
341751 - ref SDS 27 XT5F
341753 - ..
341754 - Morris continues...
341755 -
341756 - 3. If the root cause of a problem is that a latent bug was in a
341757 - complex software system, or the programmer didn't consider a
341758 - condition, then it is unlikely it will be in the record. It
341759 - often takes a lot of work to determine the cause of the problem
341760 - was even software. A system can work correctly 10 million
341761 - times, and then fail due to slightly different conditions in
341762 - the environment. Many systems have memory. Either computer
341763 - type memories, or mechanical ones. (Stress, rust, etc.) The
341764 - farther separated in time the failure is from the casual event,
341765 - the harder it is to see. (Stress placed on a bolt due to
341766 - excessive assembly torque that fails after 10 years of service
341767 - and 500 reassemblies of the components). ref DRT 1 RG6O
341769 - ..
341770 - We are getting dangerously close to aruging that because perfection is
341771 - not possible, we should give up on improvement and ignore good
341772 - management practices that greatly reduce mistakes, save lives, time,
341773 - and money.
341775 - ..
341776 - The fact that an engineer, lawyer, doctor, contractor, subcontractor,
341777 - executive, bureaucrat, etc., does not consider an issue in performing
341778 - work is precisely the goal of Communication Metrics using traceability
341779 - to original sources, as called out in management standards reviewed on
341780 - 950721. ref SDS 9 1740 Root cause analysis is one dimension of
341781 - working intelligently.
341783 - ..
341784 - The issue may have been raised in various forums where the agent
341785 - participated, but forgot about it, or forgot to write it down, or
341786 - wrote it down incorrectly, or wrote it down correctly, but lost the
341787 - document, or maintained the document, but forgot to examine it when
341788 - performing the work, because he lacked tools to manage details, or it
341789 - may have presented when the programmer was not present. His boss, a
341790 - colleague, subordinate, or subcontractor was tasked to notify the
341791 - programmer about consideration, but forgot to do so. The issue may
341792 - have been set out in documentation that was not distributed to the
341793 - programmer, or if distributed, was not read, or, if read, was not
341794 - understood, or if understood, was captured put into a schedule for
341795 - consideration in performing software programming.
341797 - ..
341798 - NWO makes the same point about "meaning drift" in communications. The
341799 - more distant in time from original communications the more likely
341800 - people will lack understanding of context and misapply instructions.
341801 - ref OF 9 14FG This makes tools for maintaining alignment useful for
341802 - maintaining alignment.
341803 -
341804 -
341805 -
341806 -
3419 -
SUBJECTS
Giving Up on Better Tools Because Perfection Not Attainable Beyond R
5803 -
580401 - ..
580402 - Beyond Reach Socretes Skepticism Gave Up on Literacy without Trying
580403 - Giving Up on Communications Perfect Truth Beyond Reach Cycinism Despair
580404 - Cynicism Despair Sacraficing Good Because Perfection Beyond Reach
580405 - Morris Giving Up on Better Tools Because Perfection Beyond Reach
580406 -
580407 - Morris continues...
580408 -
580409 - 4. My comment is that multiple records create multiple
580410 - "realities". Each reality is valid from the record keepers
580411 - prospective. If you allow for even a modicum of advocacy on
580412 - the part of the record keeper, then you have a bias in the
580413 - record. While constant feedback can correct a "record", it
580414 - probably correct entire departments, or companies. Imagine a
580415 - record of the political world. One kept by a republican, and
580416 - one kept by a democrat. No amount of feedback and comment will
580417 - convince the democrat to change to a republican, and agree with
580418 - his "record". There is always descent in any organization.
580419 - How can the record maintain all of it in an objective way that
580420 - allows one to after the fact find the "root" cause. Perhaps
580421 - the root cause is the bias and advocacy of the record keeper.
580422 - ref DRT 1 TG8H
580424 - ..
580425 - Morris cites the challenge of communication to build "shared meaning"
580426 - set out in NWO. ref OF 9 IH7L This is another way of saying that
580427 - "truth is a moving target," noted in NWO. ref OF 8 019R Judges and
580428 - juries do this work everyday, as discussed on 950204. ref SDS 7 WT5J
580429 - Executives, farmers, mechanics, teachers, bureaucrats, scientists,
580430 - engineers, and everyone struggle to find truth on the information
580431 - highway of evolving reality. SDS offers tools to aid that struggle.
580432 - Previously, on 951103 Morris made the same argument giving up on
580433 - improving accuracy of communication. ref SDS 11 9066
580435 - ..
580436 - Morris' worry about bias in the record, ref SDS 0 PG6T, pales in
580437 - comparison with the corrollary problem of errors in human memory when
580438 - no record is created. Vannevar Bush emphasized the importance of
580439 - accurate records in his famous article "As We May Think" published in
580440 - 1945, and reviewed on 960304. ref SDS 12 L47F
580442 - ..
580443 - Pointing out challenges seeking, discovering and acting on objective
580444 - truth is helpful, so long as faith striving for improvement does not
580445 - yield to cynicism and despair, and people continue the journey without
580446 - giving up, as Peter Drucker worried, reviewed on 931130. ref SDS 5
580447 - 3851 Life is a struggle; we can give up or do the best we can,
580448 - including using better tools, even though perfection cannot be
580449 - attained, as Charles Peirce noted, reviewed on 000515. ref SDS 24 7380
580451 - ..
580452 - Morris' expression in this part of his letter sounds a lot like
580453 - Socratic skepticism reported in Plato's Phaedra explaining people give
580454 - up on literacy because perfect memory is not attainable, i.e., beyond
580455 - reach, reported on 991209. ref SDS 20 5658
580457 - ..
580458 - Under Morris' formulation following Socrates' advice nothing should be
580459 - written down, because it is all false opinion that is not useful for
580460 - root cause analysis.
580461 -
580462 -
580463 -
580464 -
580465 -
580466 -
580467 -
580468 -
580469 -
580470 -
5805 -
Distribution. . . . See "CONTACTS"