Oops! Why Things Go Wrong: Understanding and Controlling Error

by Niall Downey

Niall Downey brings you the go-to guide for error management for your business and every day life.

"I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails..."

So begins this pioneering book by Niall Downey – a cardio-thoracic surgeon who retrained to become a commercial airline pilot – where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organization can greatly reduce the incidence and impact of making serious mistakes.

While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring.

An acknowledged expert in error management, Niall Downey advises governments, major corporations and the health industry on how to develop a systemic approach to controlling for human imperfection. Arguing that prevention is far preferable to denying responsibility after the fact, he gave an influential TEDx talk outlining how healthcare could use aviation's experience to reduce tragic outcomes and improve patient safety.

Table of Contents

Chapter 1. Come Fly with Me!
Chapter 2. It’s Not Your Fault!
Chapter 3. A Good Sport
Chapter 4. Blues and Twos
Chapter 5. Where There’s Muck, There’s Money
Chapter 6. Your Good Health!
Chapter 7. Political Science..?
Chapter 8. “Move Fast and Break Things” – Will We Ever Learn?
Chapter 9. Are We Ready to Accept Error Yet or Is That Fake News..?
Chapter 10. Tripwires and Safety Nets

312 pages, Paperback

Published September 4, 2023

Reviews

[Jukka Niskala · Rating 5 out of 5]

Having read numerous books on aviation safety for some 40+ years I wish Capt. Downeys had come earlier, would have filled the void in time. What an inspirational, eye opening and down to earth piece of work! Safety and error management need, to a turn, the relative and insightful messages brought forward - in lieu of the often complicated and entangled lectures of others. A must read for all with an aspiration or longing to reduce errors and enhance safety.

[Tim · Rating 5 out of 5]

I have known Niall for the past 36 years and shared many of his early experiences during our mutual medical training. I have bumped into him a number of times since over the years and was aware more than a decade ago of his desire to bring learnings from the world of aviation to the world of healthcare and the difficulties he encountered in this effort.
With this book he has produced an excellent and an irrefutable argument for his position. Using examples from many different strands of life he brings the novice through the complex world of Human Factor management and Error reduction with an easy to read style and clear, concise information.
I wish I had this book 30 years ago and will be attempting to introduce these concepts into my work practice.
Bravo!

[Carol Garland · Rating 5 out of 5]

What an important and knowledgeable read. Author uses his years of expertise in both the medical and aviation sectors. Human error happens. This is a wonderful guide on how to manage situations and deal with them, with an understanding of how the two sectors differ in their approach to catastrophic emergency situations, and everyday difficult situations that require quick, yet calm decisions. The importance of using all our senses when error happens, recognising why it happened and what we can do to rectify. An insightful and interesting read on a lot of fronts. Highly recommend.

[Alec Short · Rating 4 out of 5]

An engaging and, at times, challenging read. However it underlines the importance of accepting that errors happen. But we must have acceptance to learn from them to prevent or reduce the chance of it happening again. There are several strategies that aviation has applied to plan for risk including a culture where you can challenge the approach of a colleague without fear of retribution or punishment. This again reduces the chance of errors occurring and is good for all. Many lessons to be reflected upon by the healthcare sector here. Flow is good with this book though snd hard to put down.

[Reader · Rating 5 out of 5]

Highly recommend this book to doctors and all health professionals - and anyone else working in a safety critical field. Excellently written, a brilliant read!

[Declan Hasson · Rating 5 out of 5]

Niall Downey, the cardio thoracic surgeon and qualified airline captain knows more than most about controlling error. His expert analyses and understanding of what causes error and what can result from it, is superbly demonstrated in this outstanding book.
He provides a fascinating insight into his areas of specialist knowledge, aviation and healthcare, where error can have profound consequences. He charts the great progress that has been achieved in reducing error in aviation and the huge improvements in air safety. The "check list" approach and the new teamwork ethic in the cockpit has been transformational in reducing fatalities. Today fatal air crashes are rare.
Downey also draws from his experience in healthcare and reveals the extent to which 'adverse events' (errors) in the hospital system have, until fairly recently, led to large numbers of avoidable deaths.
This book demonstrates how a systematic approach to controlling error with crystal clear guidelines can greatly reduce the incidence of serious and often catastrophic mistakes.
It is a must read for healthcare professionals as well as those teams working in industries where risk to life is high.
To err may be human, but controlling it, understanding it and learning from it is what this powerful book is all about.

Declan Hasson