More on this book
Community
Kindle Notes & Highlights
by
Matthew Syed
Read between
August 28 - December 22, 2018
Today, however, things are very different. In 2013, there were 36.4 million commercial flights worldwide carrying more than 3 billion passengers, according to the International Air Transport Association. Only 210 people died. For every one million flights on western-built jets there were 0.41 accidents – a rate of one accident per 2.4 million flights.3
Jelena Vasiljević liked this
These figures place preventable medical error in hospitals as the third biggest killer in the United States – behind only heart disease and cancer.
When our professionalism is threatened, we are liable to put up defences. We don’t want to think of ourselves as incompetent or inept. We don’t want our credibility to be undermined in the eyes of our colleagues.
It is partly because we are so willing to blame others for their mistakes that we are so keen to conceal our own. We anticipate, with remarkable clarity, how people will react, how they will point the finger, how little time they will take to put themselves in the tough, high-pressure situation in which the error occurred. The net effect is simple: it obliterates openness and spawns cover-ups. It destroys the vital information we need in order to learn.
Studies have shown that we are often so worried about failure that we create vague goals, so that nobody can point the finger when we don’t achieve them.
We cover up mistakes, not only to protect ourselves from others, but to protect us from ourselves. Experiments have demonstrated that we all have a sophisticated ability to delete failures from memory, like editors cutting gaffes from a film reel – as we’ll see.
Only by redefining failure will we unleash progress, creativity and resilience.
success can only happen when we admit our mistakes, learn from them, and create a climate where it is, in a certain sense, ‘safe’ to fail.
‘Learn from the mistakes of others. You can’t live long enough to make them all yourself.’
In each case the investigators realised that crews were losing their perception of time. Attention, it turns out, is a scarce resource: if you focus on one thing, you will lose awareness of other things.
They lost track of time not because they didn’t have enough focus, but because they had too much focus.
The more we can fail in practice, the more we can learn, enabling us to succeed when it really matters.
In effect, the holes in the returning aircraft represented areas where a bomber could take damage and still return home safely. They had survived precisely because they had not been hit in the cockpit and tail.
This is the paradox of success: it is built upon failure.
When pilots make mistakes, it results in their own deaths. When a doctor makes a mistake, it results in the death of someone else. That is why pilots are better motivated than doctors to reduce mistakes.
Failure is inevitable in a complex world. This is precisely why learning from mistakes is so imperative.
When we are confronted with evidence that challenges our deeply held beliefs we are more likely to reframe the evidence than we are to alter our beliefs. We simply invent new reasons, new justifications, new explanations. Sometimes we ignore the evidence altogether.
‘Cognitive dissonance’ is the term Festinger coined to describe the inner tension we feel when, among other things, our beliefs are challenged by evidence. Most of us like to think of ourselves as rational and smart. We reckon we are pretty good at reaching sound judgements. We don’t like to think of ourselves as dupes. That is why when we mess up, particularly on big issues, our self-esteem is threatened. We feel uncomfortable, twitchy.
The more we have riding on our judgements, the more we are likely to manipulate any new evidence that calls them into question.
If we edit out failure, if we reframe our mistakes, we are effectively destroying one of the most precious learning opportunities that exists.
The idea here is that the learning advantage of adapting to a mistake is outweighed by the reputational disadvantage of admitting to it.
In other words, people were holding on to losing stocks too long, because they couldn’t bring themselves to admit they had made a mistake.
But avoiding failure in the short term has an inevitable outcome: we lose bigger in the longer term.
It provides another reason why the scientific mindset, with a healthy emphasis on falsification, is so vital. It acts as a corrective to our tendency to spend our time confirming what we think we already know, rather than seeking to discover what we don’t know.
Intelligence and seniority when allied to cognitive dissonance and ego is one of the most formidable barriers to progress in the world today.
We try to make the memory fit with what we now know rather than what we once saw.
But Danziger found something quite different: if the case was assessed by a judge just after he had eaten breakfast, the prisoner had a 65 per cent chance of getting parole. But as time passed through the morning, and the judges got hungry, the chances of parole gradually diminished to zero. Only after the judges had taken a break to eat did the odds shoot back up to 65 per cent, only to decrease back to 0 over the course of the afternoon.
Cognitive dissonance occurs when mistakes are too threatening to admit to, so they are reframed or ignored. This can be thought of as the internal fear of failure: how we struggle to admit mistakes to ourselves.
Evolution is a process that relies on a ‘failure test’ called natural selection. Organisms with greater ‘fitness’ survive and reproduce, with their offspring inheriting their genes subject to a random process known as mutation. It is a system, like the one that created the Unilever nozzle, of trial and error.
Indeed, many of the greatest thinkers of the last two centuries favoured free market systems because they mimic the process of biological change,3 as the author Tim Harford notes in his excellent book Adapt.4 Different companies competing with each other, with some failing and some surviving, facilitate the adaptation of the system. This is why markets – provided they are well regulated – are such efficient solvers of problems: they create an ongoing process of trial and error.
The failure of companies in a free market, then, is not a defect of the system, or an unfortunate by-product of competition; rather, it is an indispensable aspect of any evolutionary process.
In markets, on the other hand, it is the thousands of little failures that lubricate and, in a sense, guide the system. When companies go under, other entrepreneurs learn from these mistakes, the system creates new ideas, and consumers ultimately benefit.
Much real-world failure is not like this. Often, failure is clouded in ambiguity. What looks like success may really be failure and vice versa. And this, in turn, represents a serious obstacle to progress. After all, how can you learn from failure if you are not sure you have actually failed?
‘The approach comes from the idea that if you break down a big goal into small parts, and then improve on each of them, you will deliver a huge increase when you put them all together.’
This is the potency of marginal gains. By dividing a big challenge into small parts, you are able to create rigorous tests, and thus deliver incremental improvements.
the deepest and most overlooked truth is that innovation cannot happen without failure. Indeed, the aversion to failure is the single largest obstacle to creative change, not just in business but beyond.
The first is that the creative process started with a problem, what you might even call a failure, in the existing technology.
Had everything been going smoothly Dyson would have had no motivation to change things.
Creativity is, in many respects, a response.
Without a problem, without a failure, without a flaw, without a frustration, innovation has nothing to latch on to. It loses its pivot.
If failure sparks creativity into life, the moment of insight invariably emerges from the attempt to bridge the problem with previously unconnected ideas or technologies. It is about finding a hidden connection in order to solve a problem with meaning.
Today education is conceived as providing young people with a body of knowledge. Students are rewarded when they apply this knowledge correctly. Failures are punished.
But this is surely only one part of how we learn. We learn not just by being correct, but also by being wrong. It is when we fail that we learn new things, push the boundaries, and become more creative.
‘The problem with academia is that it is about being good at remembering things like chemical formulae and theories, because that is what you have to regurgitate. But children are not allowed to learn through experimenting and experience. This is a great pity. You need both.’
In short, we have to engage with the complexity of the world if we are to learn from it; we have to resist the hardwired tendency to blame instantly, and look deeper into the factors surrounding error if we are going to figure out what really happened and thus create a culture based upon openness and honesty rather than defensiveness and back-covering.
It was precisely because the nurses in low-blame teams were reporting so many errors that they were learning from them, and not making the same mistakes again. Nurses in the high-blame teams were not speaking up because they feared the consequences, and so learning was being squandered.
Managers were initially worried that reducing the penalties for error would lead to an increase in the number of errors. In fact, the opposite happened.
In a simple world, blame, as a management technique, made sense. When you are on a one-dimensional production line, for example, mistakes are obvious, transparent and are often caused by a lack of focus. Management can reduce them by increasing the penalties for non-compliance. They can also send a motivational message by getting heavy once in a while. People rarely lose concentration when their jobs are on the line. But in a complex world this analysis flips on its head. In the world of business, politics, aviation and healthcare, people often make mistakes for subtle, situational reasons.
...more
In management courses today, a contrast is often offered between a ‘blame culture’ and an ‘anything goes’ culture. In this conception, the cultural challenge is to find a sensible balance between these two, seemingly competing objectives. Blame too much and people will clam up. Blame too little and they will become sloppy.
But judged from a deeper level, these are not in conflict after all. The reconciliation of these seemingly contradictory objectives (discipline and openness) lies in black box thinking. A manager who takes the time to probe the data and who listens to the various perspectives has a crucial advantage. Not only does he figure out what really happened in the specific case, he also sends an empowering message to his staff: if you make an honest mistake we will not penalise you.
