A little book of not even 70 pages. It tells the story of an ICT failure and its aftermath, including a superficial hunt for ‘the’ root cause, the blaming and punishment of someone at the sharp end and the realisation among managers that this is not the right way forward and their search for better alternatives.
The story gives us a very accessible way to discover and discuss new ways of learning and looking at success and failure (most at failure though). Mostly the message (you will find stuff from people like Woods, Hollnagel, Kahneman, Dekker and others hidden in there) is crafted very well in the narrative, only the discussion of the Cynefin framework, fascinating as it is, doesn’t work entirely and has a bit pasted-on feeling, like the author wanted to cram in too much. Well, no harm done because the lesson is delivered and if you hop over it you will not miss a thing from the story.
One of the take-away lessons for me, by the way, was the way the team members start alerting each other when they notice biases in action. A technique one should try out, I think.
The book concludes with a brief (3 pages) discussion of what a learning review should be like.
I read it in a very short time - around one hour well spent.
O'Reilly Media; ISBN 978-149190641-5. I have the second edition from 2016.