The recent Boeing 737 Max-8 crashes have brought the airline industry into sharp focus again. Whilst the aviation industry embraces failure and learns from it and has, since the early days of the Wright brothers to today, undertaken deep analysis of failure to establish what the causes are and then made adjustments to problematic processes, systems or people to avoid a similar occurrence in the future, there remain serious question marks against the Boeing company in the Max-8 tragedies.
Did Boeing break from the industry practice of radical truthfulness to open failure to scrutiny and ensure that above all, safety is at the core of every decision? Or, did they suffer from cognitive dissonance in their decision making, causing them to reframe the evidence to match their beliefs? Either way, their decisions cost lives and have negatively impacted the company’s image and value. If you think of airplane crashes and the procedure followed after each one, one of the first priorities after saving lives and recovering the dead, is the retrieval of the two black (now orange) boxes which hold all the data of voice recordings and system performance up to the time of the failure. This data forms the basis of all investigations going forward.
In his book, Black Box Thinking, Mathew Syed explores the concept that success is born from failure in detail and holds up the aviation and healthcare industries as two organisations that have divergent views on the concept of failure.
The aviation industry, he says, embraces failure, learns from it and adjusts according to the results of the investigations following accidents and incidents; healthcare, on the other hand does not. It tends to cover them up, reframe them and ascribe patient deaths to “pre-existing conditions” or “complications we could not have foreseen”.
Syed holds that more people die of medical negligence in the USA each year than in traffic accidents, yet the focus of attention is far more on how we can improve road safety than what can be done to avoid medical error. At the heart of the problem argues Syed is mindset and culture.
The five big ideas of Black Box Thinking are:
- The single greatest obstacle to progress is failing to learn from mistakes.
- A cornerstone to success is a progressive attitude to failure.
- “Only by redefining failure will we unleash progress, creativity, and resilience.”
- “When we are confronted with evidence that challenges our deeply held beliefs, we are more likely to reframe the evidence than we are to alter our beliefs.”
- “Marginal gains is not about making small changes and hoping they fly. Rather, it is about breaking down a big problem into small parts in order to rigorously establish what works and what doesn’t.”
Syed goes on to say that Black Box Thinking is “about the willingness and tenacity to investigate the lessons that often exist when we fail, but which we rarely exploit.” Furthermore, “It is about creating systems and cultures that enable organizations to learn from errors, rather than being threatened by them.”
We have long practiced in our business the idea of lifting the rocks to look at the squiggly things, as learnt from Good to Great by Jim Collins, but the work of Syed has given it much more meaning and framed it with deeper insights.
One of my favourite insights is the concept of cognitive dissonance, described in short in point 4 above and defined by Leon Festinger, who first proposed the theory as being centred around how people strive to reach internal consistency. He suggested that people have an inner need to ensure that their beliefs and behaviours are consistent. Syed develops this,“Cognitive dissonance occurs when mistakes are too threatening to admit to, so they are reframed or ignored. This can be thought of as the internal fear of failure: how we struggle to admit mistakes to ourselves.”
If we think of the Max-8 situation, Boeing evidently knew that there were issues with the control systems of the plane, admittedly they did make adjustments and installed a control mechanism, Maneuvering Characteristics Augmentation System, MCAS, but then did not follow through and train pilots who flew the more than 200 Max-8 planes in service on how to use the system.
This failure and lack of follow through most certainly added to the disasters and loss of lives. Could it have been that the strongly held belief that the system they had implemented would work, no matter what, given their successes of the past and as such they did not need further training of pilots? Or was it that the inconvenient truth was reframed to fit their belief that they were right and that the accidents were pilot error or as a result of other causes, not a failure of their systems?
To their credit though and in line with the industry norm they have embraced the failure and are subjecting themselves to critical scrutiny and I have little doubt that further system changes will be made, pilots will be trained on how to use them and we will see the Max-8, perhaps under another name, in our skies again, as this is the culture of the industry, that failure is not shied away from but part of their culture – it’s the way we do things here! They have created a system that “learns from failure, rather than hiding from it”, says Syed.
The ability to lift the rocks of failure and look deeply at what happened is ingrained in our culture too and we do this whenever there is a ball dropped, no matter how ugly the things are that we may find under the rocks. Whilst this has been a practice long held, I believe that with new learning coming from this work and others (The Obstacle is the Way, by Ryan Holiday and more) we will continue to learn to get better, embrace failure as the way to learn, improve and become great.
What is your view on failure, do you embrace it or shy away from it, too scared to go there because your image may be tarnished? What if you don’t, and you repeat the failure?
Senior Partner & Managing Executive
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