Black Box Thinking: Why Some People Never Learn from Their Mistakes

21 " Learning from failure has the status of a cliché. But it turns out that, for reasons both prosaic and profound, a failure to learn from mistakes has been one of the single greatest obstacles to human progress "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

22 " The secret to modern F1 is not really to do with big ticket items; it is about hundreds of thousands of small items, optimized to the nth degree. People think that things like engines are based upon high-level strategic decisions, but they are not. What is an engine except many iterations of small components? You start with a sensible design, but it is the iterative process that guides you to the best solution. Success is about creating the most effective optimization loop. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

23 " The marginal gains approach is not just about mechanistic iteration. You need judgment and creativity to determine how to find solutions to what the data is telling you, but those judgments, in turn, are tested as part of the next optimization loop. Creativity not guided by a feedback mechanism is little more than white noise. Success is a complex interplay between creativity and measurement, the two operating together, the two sides of the optimization loop. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

24 " the most powerful engine of progress is to be found deep within the culture of the industry. It is an attitude that is easy to state, but whose wider application could revolutionize our attitude to progress: instead of denying failure, or spinning it, aviation learns from failure. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

25 " In a study in Scotland, members of the public were adamant that they could remember a nurse removing a skin sample from their little finger. But this never happened. A week earlier these volunteers had been asked by researchers to imagine a nurse removing the sample. But somehow, on recollection, it had morphed into a real event. They were four times as likely to recall it as real compared with those who had not been asked to imagine it. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

26 " These failures are inevitable because the world is complex and we will never fully understand its subtleties. The model, as social scientists often remind us, is not the system. Failure is thus a signpost. It reveals a feature of our world we hadn’t grasped fully and offers vital clues about how to update our models, strategies, and behaviors. From this perspective, the question often asked in the aftermath of an adverse event, namely, “Can we afford the time to investigate failure?,” seems the wrong way around. The real question is, “Can we afford not to? "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

27 " Proper investigation achieves two things: it reveals a crucial learning opportunity, which means that the systemic problem can be fixed, leading to meaningful evolution. But it has a cultural consequence too: professionals will feel empowered to be open about honest mistakes, along with other vital information, because they know that they will not be unfairly penalized—thus driving evolution still further. In short, we have to engage with the complexity of the world if we are to learn from it; we have to resist the hardwired tendency to blame instantly, and look deeper into the factors surrounding error if we are going to figure out what really happened and thus create a culture based upon openness and honesty rather than defensiveness and back-covering. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

28 " When a culture is unfair and opaque, it creates multiple perverse incentives. When a culture is fair and transparent, on the other hand, it bolsters the adaptive process. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

29 " trying to increase discipline and accountability in the absence of a just culture has precisely the opposite effect. It destroys morale, increases defensiveness and drives vital information deep underground. It "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

30 " Psychologists often make a distinction between mistakes where we already know the right answer and mistakes where we don’t. A medication error, for example, is a mistake of the former kind: the nurse knew she should have administered Medicine A but inadvertently administered Medicine B, perhaps because of confusing labeling combined with pressure of time. But sometimes mistakes are consciously made as part of a process of discovery. Drug companies test lots of different combinations of chemicals to see which have efficacy and which don’t. Nobody knows in advance which will work and which won’t, but this is precisely why they test extensively, and fail often. It is integral to progress. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

31 " These witnesses were not necessarily lying. They were not making it up. But then neither was Neil Tyson when he talked about Bush’s stars speech. When the witnesses said they remembered seeing the suspect at the scene of the crime, they were telling the truth. They did remember seeing him there, but they didn’t actually see him there. These are two quite different things. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

32 " A pre-mortem typically starts with the leader asking everyone in the team to imagine that the project has gone horribly wrong and to write down the reasons why on a piece of paper. He or she then asks everyone to read a single reason from the list, starting with the project manager, before going around the table again. Klein cites examples where issues have surfaced that would otherwise have remained buried. ‘In a session held at one Fortune 50-size company, an executive suggested that a billion-dollar environmental sustainability project had “failed” because interest waned when the CEO retired,’ he writes. ‘Another pinned the failure on a dilution of the business case after a government agency revised its policies.’15 The purpose of the pre-mortem is not to kill off plans, but to strengthen them. It is also very easy to conduct. ‘My guess is that, in general, doing a pre-mortem on a plan that is about to be adopted won’t cause it to be abandoned,’ Kahneman has said. ‘But it will probably be tweaked in ways that everybody will recognize as beneficial. So the pre-mortem is a low-cost, high-pay-off kind of thing. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

33 " It sounds simple, doesn’t it? Learning from failure has the status of a cliché. But it turns out that, for reasons both prosaic and profound, a failure to learn from mistakes has been one of the single greatest obstacles to human progress. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

34 " And we will see that beneath the inspirational stories told about these shifts, the deepest and most overlooked truth is that innovation cannot happen without failure. Indeed, the aversion to failure is the single largest obstacle to creative change, not just in business but beyond. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

35 " As Galileo said in a letter to the German mathematician Johannes Kepler: My dear Kepler, I wish that we might laugh at the remarkable stupidity of the common herd. What do you have to say about the principal philosophers of this academy who are filled with the stubbornness of an asp and do not want to look at either the planets, the moon or the telescope, even though I have freely and deliberately offered them the opportunity a thousand times? Truly, just as the asp stops its ears, so do these philosophers shut their eyes to the light of truth. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

36 " It was only when professionals believed that reports on errors and near misses would be treated as learning opportunities rather than a pretext to blame that this crucial information started to flow. Managers were initially worried that reducing the penalties for error would lead to an increase in the number of errors. In fact, the opposite happened. Insurance claims fell by a dramatic 74 percent. Similar results have been found elsewhere. Claims and lawsuits made against the University of Michigan Health System, for example, dropped from 262 in August 2001 to 83 following the introduction of an open disclosure policy in 2007. The number of lawsuits against the University of Illinois Medical Center fell by half in two years after creating a system of open reporting. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

37 " 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. We simply invent new reasons, new justifications, new explanations. Sometimes we ignore the evidence altogether. "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

38 " Creativity is so delicate a flower that praise tends to make it bloom, while discouragement often nips it in the bud.’3 "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

39 " All airplanes must carry two black boxes, one of which records instructions sent to all on-board electronic systems. The other is a cockpit voice recorder, enabling investigators to get into the minds of the pilots in the moments leading up to an accident. Instead of concealing failure, or skirting around it, aviation has a system where failure is data rich. In the event of an accident, investigators, who are independent of the airlines, the pilots’ union, and the regulators, are given full rein to explore the wreckage and to interrogate all other evidence. Mistakes are not stigmatized, but regarded as learning opportunities. The interested parties are given every reason to cooperate, since the evidence compiled by the accident investigation branch is inadmissible in court proceedings. This increases the likelihood of full disclosure. In the aftermath of the investigation the report is made available to everyone. Airlines have a legal responsibility to implement the recommendations. Every pilot in the world has free access to the data. This practice enables everyone—rather than just a single crew, or a single airline, or a single nation—to learn from the mistake. This turbocharges the power of learning. As Eleanor Roosevelt put it: “Learn from the mistakes of others. You can’t live long enough to make them all yourself.” And it is not just accidents that drive learning; so, too, do “small” errors. When pilots experience a near miss with another aircraft, or have been flying at the wrong altitude, they file a report. Providing that it is submitted within ten days, pilots enjoy immunity. Many planes are also fitted with data systems that automatically send reports when parameters have been exceeded. Once again, these reports are de-identified by the time they proceed through the report sequence.* "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

40 " This approach is now the focus of a crusading group of economists who have transformed international development over the last decade. They do not come up with grand designs; rather, they look for small advantages. As Esther Duflo, the French-born economist who is at the forefront of this approach, put it: “If we don’t know if we are doing any good, we are not any better than the medieval doctors and their leeches. Sometimes the patient gets better; sometimes the patient dies. Is it the leeches or something else? We don’t know.”6 "

― Matthew Syed , Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do

Black Box Thinking: Why Some People Never Learn from Their Mistakes - But Some Do QUOTES