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

by Matthew Syed

And we will find that in all these instances the explanation for success hinges, in powerful and often counterintuitive ways, on how we react to failure.

It sounds simple, doesn’t it? Learning from failure has the status of a cliché. But it turns out that, for reasons both prosaic and profound, a failure to learn from mistakes has been one of the single greatest obstacles to human progress.

A progressive attitude to failure turns out to be a cornerstone of success for any institution.

Only by redefining failure will we unleash progress, creativity, and resilience.

a closed loop is where failure doesn’t lead to progress because information on errors and weaknesses is misinterpreted or ignored; an open loop does lead to progress because the feedback is rationally acted upon.)

Attention, it turns out, is a scarce resource: if you focus on one thing, you will lose awareness of other things.

procedures. The mnemonic that has been used to improve the assertiveness of junior members of the crew in aviation is called P.A.C.E. (Probe, Alert, Challenge, Emergency).* Captains, who for years had been regarded as big chiefs, were taught to listen, acknowledge instructions, and clarify ambiguity. The time perception problem was tackled through a more structured division of responsibilities.

it is about the willingness and tenacity to investigate the lessons that often exist when we fail, but which we rarely exploit. It is about creating systems and cultures that enable organizations to learn from errors, rather than being threatened by them.

The first is that you have to take into account all the data, including the data you cannot immediately see, if you are going to learn from adverse incidents. But it also emphasizes that learning from failure is not always easy, even in conceptual terms, let alone emotional terms. It takes careful thought and a willingness to pierce through the surface assumptions. Often, it means looking beyond the obvious data to glimpse the underlying lessons.

This is the paradox of success: it is built upon failure.

Everything we know in aviation, every rule in the rule book, every procedure we have, we know because someone somewhere died . . . We have purchased at great cost, lessons literally bought with blood that we have to preserve as institutional knowledge and pass on to succeeding generations. We cannot have the moral failure of forgetting these lessons and have to relearn them.