The substrate of safety
Dave Snowden,
The Cynefin Co,
Sept 04, 2025
It is almost unthinkable in a large organization or institution to say this, but: "Our current paradigm, with its manuals, compliance checklists, and 'best practices,' is engineered for the Gaussian centre. It is predictably - and tragically - useless in the Pareto tails where the real problems live. This is why we must stop trying to write better rules and start building better processes for rapid decision-making in each unique context" (my emphasis). It is a form of management by observing and nudging, not grand visions, principles, and rules. I think there's a lot more to be said on this. Via Chris Corrigan.
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