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Be aware, be prepared
How did this happen? Often accompanied by a level of surprise and disbelief, this is the question always asked when negative events occur. Regardless of the scale, leaders will seek the cause. With regret, many desire an easy to understand and simple cause - the mid-level sacrificial lamb employee, a flawed process/procedure, or even better contracted support staff. This simple cause allows the organization to quickly ‘solve’ the problem through a firing, solution outsourcing via a consultant, or shifting of blame to outside the organization in the case of temporary/contracted support (see SolarWinds response). A good leader will not accept this, and will dedicate the time and effort to truly understand.
To truly understand is not simple. One way is to find the root cause, via a Root Cause Analysis (RCA). Depending on the industry or system there are differing definitions and methods (Kaizen Five Whys, Ishikawa Diagrams, etc.), essentially RCA is a process that outlines the cause and effect relationships: situation-problem-cause. Hint, there may be more than one root cause. Regardless of how you go about finding out how and why a problem occurred, it will require time and expertise - resources in limited supply prior to the event, which afterwards places an additional strain on the organization.
Resourcing after an event tends to surge, however it shifts focus away from daily tasks and creates stress on a potentially already stressed system. The ideal then, is prevention. Again not simple. Are you able to detect and make sense of weak signals of impending events? How do you know if you are on the wrong path which will lead to an event or increase vulnerability (see path dependence)? Or if a flaw exists in your organization/system, which has not made itself known yet? One way is to have a framework for understanding: I find Cynefin and its related SenseMaker very helpful. Regardless, prevention is elusive, as Robert Black writes,”We are all seeking the unobtainable. Until we find it, we settle for life.”
So, we must resign ourselves to ‘life’ with its certainty that things will happen. Some events you may be able to prevent, others you will not. Regardless, prevention must be sought and remain the focus. For me, prevention starts with being aware - aware that bad things happen, aware that there are blind spots, aware that you will be surprised. Being aware is coupled with being prepared. Being aware and being prepared is a cycle into which we must introduce resources.
We arrive back to the beginning, how did this happen? Luck, chance, kismet, etc. on occasion will be the cause, however, in most cases it will be because there was a lack of awareness and/or preparedness, i.e. a lack of resourcing. You must resource now, prior to change occurring and events happening. Being aware will give you the ability to prevent an event happening. And for those events which can not be prevented, being prepared may make them a non or limited event for you. Be aware. Be prepared.