“It is not about literally creating a black box, rather 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.”
Back to the topic at hand.
Here are some of the ideas from Black Box Thinking that I found interesting and want to explore further;
1. The importance of a system in organizing staff and team
A strong system closes the gaps between what we intend to have happen and what actually occurs. Of utmost importance in this system are mechanisms for communications. Particularly, a method for subordinates to be able to disrupt the thinking or errors of someone farther up the chain. This won’t happen by accident and needs to be thoughtfully and purposefully created.
Checklists also have value within a strong system. They prevent errors and facilitate communication. Quality communication and checklists go hand in hand. One reinforces the other.
Finally, the system needs a process for handling errors that do occur. The process should include: the importance of acknowledging mistakes, how to report them or discuss them, and how to incorporate the lessons into organizational growth.
2. An effective system leads to another crucial success factor, a shared mindset.
3. Be willing to investigate errors.
Don’t turn away. Sometimes you want to. For all kinds of reasons. He goes into some of these in different chapters, but what really resonates is the damage we do by turning away. We lose tremendous opportunity to learn in that moment and put new information to work.
I think of my own tendency to avoid film after a particularly galling loss. Either it’s too painful to watch or too threatening. I want to turn away or just move on. Neither is helpful to the team. I don’t necessarily need to show them the film–that is a different conversation–but the staff must watch and learn. We need to take the lesson in before we simply move on.
Syed makes the point that the further the event is from us the less power in the lesson.
The farther away the feedback is from the event the less effect it has on the practitioner. In addition, in some circumstances we never know we failed at something (i.e. the psychiatrist who never sees the patient again, or a radiologist who misreads a scan and it goes unnoticed for years, or a consultant who moves onto the next job without tracking the results) and therefore our opportunities for real growth are limited.
4. Recognize limits of attention
This is a relatively small point in the book but it stood out to me. Sometimes even as experts we get so focused on one factor to the detriment of other factors that matter. A great deal. Maybe the most. And nobody can get through to us.
A strong system and shared mindset helps to address this gap.
5. We reframe events to protect our self worth
Sometimes we just can’t face our own errors so we turn away from the mistake, refuse to investigate it or simply refuse to acknowledge that it was a mistake. Rather than lying to others we are lying to ourselves. Simple awareness that this is possible helps to overcome this, but so does having a system in place that allows others to push through our own barriers and limitations.
6. Many successes are the results of learning from past failures.
The paradox of success is that it is often 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 generation. We cannot have the moral failure of forgetting those lessons and have to relearn them.”
In other words, he had the skills and presence to succeed because he was building off someone’s failures from the past. Each man’s fate was not simply a reflection of skill, but also a result of timing.
The industry as a whole has the mindset and system in place to learn from mistakes.
There are other important ideas in this book that may stand out for others. These six resonate for me and are in fact entwined. I have long recognized the value of mistakes in the learning process, but this book helped me to look at it from more angles.
The key is to learn from mistakes. Create systems that reduce errors. Establish protocols that are always followed. Build into those systems a shared mindset that includes acknowledgement of error. By doing so we are able to build upon the painful lessons of ourselves and others and create something special.
The best book I have ever read on a coach creating a system (warning it is expensive!) Finding the Winning Edge by Bill Walsh. Filled with details on football, but yet filled with insights on systems, management and leadership.