Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

by Matthew Syed

In aviation there is a profound respect for complexity. Pilots and system experts are deeply aware that they are dealing with a world they do not fully understand, and never will. They regard failures as an inevitable consequence of the mismatch between the complexity of the system and their capacity to understand it. This reduces the dissonance of mistakes, increases the motivation to test assumptions in simulators and elsewhere, and makes it “safe” for people to speak up when they spot issues of concern. The entire system is about preventing failure, about doing everything possible to stop mistakes happening, but this runs alongside the sense that failures are, in a sense, “normal.” In health care, the assumptions are very different. Failures are seen not as an inevitable consequence of complexity, but as indictments of those who make them, particularly among senior doctors whose self-esteem is bound up with the notion of their infallibility. It is difficult to speak up about concerns, because powerful egos come into play. The consequence is simple: the system doesn’t evolve.