Matthew Syed, who is the keynote speaker on day one of the World of Learning Conference at the NEC on 19th and 20th October, gives anyone involved in learning, development and performance improvement some food for thought in his most recent book. In fact, he provides a tasting menu of well-crafted dishes and delicious morsels.
Whenever there is an aviation incident, the authorities will comb the area for the fabled Black Box (apparently they’re actually orange) or flight data recorder. By analysing the information about the actions of the cockpit crew, the recordings of interactions between crew members and between the plane and air traffic control, and the performance data of instruments and equipment, investigators are able to piece together the events leading up to any tragedy. Assuming the crew survive, the information is often much more reliable and detailed than the recollections of those involved. The data tells the real story – however it may have been remembered.
But the so-called Black Box is not just analysed in the event of a plane falling from the sky. Malfunctions, near-misses and errors of judgment may also result in an investigation. Again the data will be analysed. Importantly, neither to identify the guilty, to apportion blame or to seek redress. The point of these investigations is to learn.
Syed details a number of different lessons which have made aviation safer for all of us since the introduction of the Black Box. And because it is in the interests of pilots and crew members – who fly more than most of us and are most likely, therefore, to be harmed or killed in aviation incidents – there is a culture of reporting and asking for incidents to be investigated. It is not just the Black Box which provides safety information, it is the attitude of those who fly and navigate around the globe.
But this attitude is not simply fostered out of self-interest. It is not just a concern for their personal safety which prompts aviators to report incidents. It is that they are protected in law if they report all untoward occurrences in a timely manner. The presence of the means of discovering root causes and the clarity about how successful this investigative process has been in ensuring flying is the safest form of mechanised transport, means that the Black Box has given way to Black Box Thinking – a forensic pursuit of learning lessons from failure. It is one which is embraced by those at all levels in the aviation industry.
Syed contrasts this with the state of affairs within many of the world’s medical systems. This was a sobering part of the book for sure, and I recommend that none of you do what I did which was to read those chapters while sitting in a waiting room of a hospital. The failure of many health bodies to accept failure as a learning opportunity or to develop robust processes for openly investigating when things go wrong, sits in stark contrast to the transparency of the aviation industry.
This was particularly interesting for me as someone who spent several years working with the National Patient Safety Agency (NPSA) on tools which surrounded their National Recording and Learning System. Despite its clear and well developed systems, its commitment to openness and some very good people, the NPSA was unable to break through the defensiveness, the fear of litigation and the arrogance demonstrated in some areas of the medical professional in England. In 2012, the NPSA was closed down in an orgy of budget cutting and the lessons it had managed to learn lost in the drive for austerity at all costs.
From Syed’s analysis we learn that the UK is not alone and that, with a few exceptions, hospitals and health boards are still likely to spend more time on denying mistakes and silencing the survivors than they are on investigating reasons and learning from mistakes. It is a shocking read and one which should energise all of us concerned with people doing things better that we have a job to do and a damned important one at that.
There are other reasons why individuals and organisation do not learn from failure. Syed describes cognitive dissonance in accessible and memorable detail; the challenges of complexity and how blame stops key lessons being learned.
But this is not simply a catalogue of despair. In his section called Small Steps and Giant Leaps, he details the marginal gains culture originally introduced by Sir Dave Brailsford to the SKY and GB Cycling teams, he talks about rapid prototyping and ‘lean’ development processes. Most importantly, he makes the challenges of learning from mistakes and failure human, personal and addressable. His key message, we can all do this stuff better and we need to if we are to get better.
Matthew’s first book, Bounce, was an in depth look at how successful people become successful – dispelling the myth of the naturally talented in favour of a route to success modelled on risk taking, practice and determination.
I can’t wait to introduce him to the conference on Wednesday 19th October. I hope you’ll be able to join me.
Robin will be Chairing the World of Learning Conference at the NEC on 19th and 20th October, 2016. He is the author of Complete training: from recruitment to retirement and Informal Learning in Organizations; how to create a continuous learning culture, both of which are published by Kogan Page.
You can read more about Matthew’s session at World of Learning here.