Learning from Mistakes: Black Box thinking

Thursday, 12 November 2015 21:25 W R Tomlinson

Observe-Interpret-Intervene-CycleSince becoming Chief Minister, Allan Bell has regularly stated that government must be prepared to take risks. This sentiment has also been supported by Minister for Policy and Reform, John Shimmin and DED Minister, Laurence Skelly. In preparing the ground for the adoption of a £50 million Economic Development package, all three warned that there could well be some failures within the various projects supported under the scheme.

The converse of this argument is for those in power also need to recognise when they have goofed and what's more to learn from the experience. 

Times columnist Mathew Syed succinctly makes the case for a positive attitude to failure in the "Soap Box" feature on BBC 2's Daily Politicson 28.10.15:

The Comet was the world's first jet airliner. 

But British pride soon turned to horror when two de Havilland jets crashed crash within months of each other.

An extensive investigation showed that the accident was the result of metal fatigue caused by the repeated pressurisation of the cabin.

This information was shared with de Havilland rivals Boeing and a key lesson was learned.

In aviation lessons are learned all the time.

Each aircraft is equipped with two indestructible black boxes which record vital information.

If there is an accident the boxes are excavated, the data analysed and the system crucially is adapted. That means the same mistakes don't happen again and it has had astonishing results - last year the accident rate from major airlines was 1 crash for every 8.3 million take-offs.

Compare this with Healthcare, where clinicians often spin and conceal mistakes because of the fear of litigation and the threat to reputation. The consequence is simple - the same mistakes are repeated and that's why preventable medical error is one of the biggest killers in the UK.It kills way more people than traffic accidents!

Failure is inevitable in a complex world. Politicians, businessmen, even scientists, are going to get things wrong. But what are we going to do with these mistakes? Do we spin them? Do we shun them or do we harness them as precious learning opportunities?

After all if we don't know where we're going wrong how can we ever put things right?
*Mathew Syed - "Soap Box" on BBC 2 "Daily Politics" 28.10.15

Last Updated on Thursday, 12 November 2015 22:50