Confronting Mistakes

Lessons from the Aviation Industry when Dealing with Error

J. Hagen

• Publisher: Palgrave Macmillan
• Year: 2013
• Print ISBN: 9781349446551, 9781137276179
• eBook ISBN: 9781137276186
• Topic: Business
• Subtopic: Business Strategy
• Index: Business

In most organizations, errors - although common and unavoidable - are rarely mentioned bottom-up. Using this example of the high risk aviation industry this book assess how active error management can work and lead to success. Using academic research and 10 actual aviation accidents cases, this book will provide compelling and informative reading.

Part I Pre Crew Resource Management

The crisis on the financial markets began to unfold with increasing severity starting in 2007. Many were left dumbfounded that big-name banks had taken such disproportionately high risks with their structured securities. People saw the remuneration system in the investment banking sector, enormous bonus payouts, and the associated asymmetric risk distribution as the main causes of the crisis. They started asking how things could have spiraled so far out of control. Yet even before the crisis, some parties within the banks had urged caution. The question is why these warnings went unheard. Were they overlooked? Underestimated? What mistakes were made, how did they come about, who failed to pick up on them, and how were they allowed to trigger a series of further errors that ultimately culminated in such dramatic consequences?

The bankers’ behavior, however, is by no means an exception. Indeed, it is not even confined to the banking industry. Take Enron, for example, where for a long time no one moved to curb the company’s actions even though its management policy breached legislation.¹ Or take BP: in the period before the accident at the Deepwater Horizon oil-drilling rig, it has been reported that there were warnings about inadequate cementing around the drill hole. The same applies to the jamming gas pedals fitted in a range of passenger cars made by Toyota. The faulty models entered the market almost as if designers, automotive engineers, or quality control processes for suppliers were not in place. There have been mistakes, errors, poor decisions, infringements, affairs, and scandals in any organization you care to mention. None of them, though, appears to have had any effective controls in place to intervene in time to prevent things going awry. Instead, those involved could only watch as fate ran its course.

Let us take a look at normal day-to-day operations in a company. What happens if someone makes a mistake or takes the wrong decision? The issue here is not intentional misconduct, fraudulent behavior, gross negligence, or large-scale mismanagement. I am simply referring to the little mistakes, errors, and poor decisions that occur every single day. We are not necessarily even aware of these blunders while making them. In fact, according to a 1979 study by the National Aeronautics and Space Administration (NASA), we make a minor error every four minutes.² The original study focused on pilots – a group that, given the risks inherent in their chosen profession, makes every effort to avoid errors. But for them, as for us, errors are the result of momentary blackouts, a temporary short circuit in the brain, false impressions, deceptive memories, dots wrongly combined, fragments of conversation that we interpret incorrectly, prejudices – be they sexual, social, or ideological – momentary feelings of mental imbalance, disorientation, stress, and other disturbances. Or, as Charles Perrow described it in his brilliant work titled Normal Accidents, we “zig, when we should have zagged, even when we are attentive and can see.”³ At best, we may have a hunch that what we do or believe or say is not 100 percent solid. Perrow suggests that one of the reasons for this kind of behavior is “that we construct an expected world because we can’t handle the complexity of the present one, and then process the information that fits the expected world, and find reasons to exclude the information that might contradict it.”⁴ The fact is that we draw conclusions, derive knowledge, and make judgments based on mere assumptions. We see connections and relationships where there are only tenuous links. We misunderstand contexts and take stories and information as objective facts when they are actually hearsay. Basically, our problem is that we believe we can and should be “right,” when in reality we start out with “quasi-right” at best and ideally adjust our decisions and actions as we proceed. The alternative – that is, believing that we are right and later realizing that we were wrong – creates a state of confusion leading to uncomfortable questions as to the validity of our convictions per se. If I say, “I know my car keys are in the upper drawer of the little table in the entrance hall. No question about it. I have been putting them there every day for ages,” it will not sit nicely with me if I suddenly realize I have put them into the bedside locker. Actually, it will be so upsetting that I will force myself to repeatedly reconstruct how the keys ended up in the bedside locker, just to reclaim the sense that I am living in an ordered, plausible world.

In the daily business environment, these apparently rock-solid perceptions are all too often generated under pressure – namely, the pressure of deadlines, of getting a job done, and the pressure to succeed. This, too, renders their validity as being no more than relative. In concrete terms, this can result in incorrect figures that feed into decision-making processes. This in turn can lead to skewed interest rates, market shares, and growth rates. Alternatively, we might encounter causalities that – although derived from statistical analyses that are only partially complete – nevertheless mutate into the foundations used for key business decisions.⁵ Of course, there are actions that fail even though all the necessary conditions were apparently in place. It does not mean that the people involved were stupid or thought it would be fun to be reckless for a change. To quote Charles Perrow again, “in fact, very few people in any walk of life deserve that appellation [of being stupid]. Nor does the attribute ‘risk taker’ help us much [ … ] As drivers, we all would probably admit that at times we took unnecessary risks; but what we say to ourselves and others is, ‘I don’t know why; it was silly, stupid of me.’ We generally do not do it because it was exciting.”⁶

Yet, all these examples deal with errors that – if we took the time to analyze them properly – we could learn from, or at least use to make us more aware. We might want to find out why they occurred and work out how to prevent them from happening again. Managers in particular should surely be interested in doing just that.

A year ago, my ESMT colleagues and I wanted to know whether this is the case: do managers discuss errors made by their employees? Do they step in if a member of staff makes a mistake when calculating a rival company’s market share in a competitor analysis? Yes, we found out, most of them do. But do employees also say something if their superior gets his or her figures wrong or looks set to make a questionable decision? Here, as we learned, people are far more reluctant to speak up.⁷

One problem is that errors are often associated with shoddy work, failure, and personal weakness. That is why we find it unpleasant to discuss them openly. However, mistakes are not necessarily a result of carelessness or a lack of skill and ability. A person may be distracted, tired, or overburdened. Personal issues are by no means the only possible reasons for this. The problem may, in fact, lie in the work environment.

To get to the bottom of things, we asked 360 managers from different sectors about how they deal with errors. We looked at their willingness to discuss mistakes made by others: top-down, bottom-up, and among direct colleagues. We also asked them to evaluate to what extent errors are accepted within their own corporate culture. Some 41 percent of those questioned worked in companies with more than 10,000 employees. The managers’ average age was 43, and they were in charge of an average of 150 employees with a minimum of eight. Of those questioned, 83 percent were middle management and 11 percent were owners, CEOs, or managing directors. Women accounted for 12 percent.

How do managers address errors made by employees, colleagues, and superiors? Our survey revealed that if they discovered an error made by an employee or colleague, 88 percent of managers would raise the issue privately behind closed doors, 11 percent would discuss it openly, and just 1 percent would ignore the error. When it comes to pointing out a mistake made by someone higher up the ranks, 86 percent would do so in private. Only 4 percent would be prepared to broach the issue openly, whereas 10 percent would rather keep any knowledge of an error made by their superior to themselves.

How do employees, colleagues, and superiors report errors? We asked managers how their own employees, colleagues, and superiors speak to them about errors. Just 54 percent said they would mainly do so in private; 18 percent said mistakes were addressed in a more open forum. A further 28 percent assumed they were never actually made aware of their mistakes. However, these figures do not tally with the previous results. Of those questioned, 88 percent claimed that they themselves would generally address errors made by others in private. Yet only 54 percent believed they are being informed of errors in this way. In contrast with the 11 percent quoted earlier, 18 percent said their own errors are discussed in front of people. That could be because this experience has stuck in their minds more than those occasions in which they addressed others’ mistakes in a public forum.

In this context Kathryn Schulz reminds us of one of Freud’s spectacular errors. “Once, while settling his monthly accounts, Freud came upon a name of a patient whose case history he couldn’t recall, even though he could see that he had visited her every day for many weeks, scarcely six months previously. He tried for a long time to bring the patient to mind, but for the life of him was unable to do so. When the memory finally came back to him, Freud was astonished by his ‘almost incredible instance of forgetting.’ The patient in question was a young woman whose parents brought her in because she complained incessantly of stomach pains. Freud diagnosed her with hysteria.” A few months later, she died of cancer.

“On the whole,” Schulz concluded, “our ability to forget our mistakes seems keener than our ability to remember them.”⁸ Intuitively we might see this differently and feel that mistakes are so embarrassing that we will never be able to forget them, particularly if they were large. The answer to that is that both reactions coexist. We are able to either suppress the memory of our mistakes or remember them painfully.

Quite fittingly, 28 percent of the managers in our survey fear that discussions about their mistakes take place behind their backs. Alternatively, they hope – quite unrealistically – that no one will ever notice their mistakes. Given that we may be unaware while erring, we can be sure that others are not, as we usually notice other people’s errancies quite early on. The notion that we can successfully hide our errors or mistakes is one of our managers’ –and everybody else’s – many instances of wishful thinking and hoping against hope. “What with our error-blindness,” Schulz writes, “our amnesia for our mistakes, the lack of a category called ‘error,’ [ … ] it’s no wonder we have so much trouble accepting that wrongness is a part of who we are. Because we don’t experience, remember, track, or retain mistakes as a feature of our inner landscape, wrongness always seems to come at us from left field – that is, from outside ourselves. But the reality could hardly be more different. Error is the ultimate inside job.”⁹

Male and female managers. When it comes to the error management of male and female managers, both sexes prefer to speak to their superiors about an error in private. However, this tendency was slightly less pronounced among the female managers (78 percent compared to 87 percent of male managers). In contrast, female managers were almost three times more willing than their male colleagues to discuss errors openly; only 10 percent of those questioned admitted that they would never openly address errors made by their superiors. Sixt...

Table of contents

• Cover
• Title
• Part I  Pre Crew Resource Management
• Part II  Crew Resource Management
• Part III  Post Crew Resource Management
• Part IV  Error Management
• Sources for Figures
• Glossary and Abbreviations
• Bibliography