Edmondson

No passion so effectively robs the mind of all its powers of acting and reasoning as fear.” —Edmund Burke, 1756.

Psychological safety is not immunity from consequences, nor is it a state of high self-regard. In psychologically safe workplaces, people know they might fail, they might receive performance feedback that says they're not meeting expectations, and they might lose their jobs due to changes in the industry environment or even to a lack of competence in their role. These attributes of the modern workplace are unlikely to disappear anytime soon. But in a psychologically safe workplace, people are not hindered by interpersonal fear. They feel willing and able to take the inherent interpersonal risks of candor. They fear holding back their full participation more than they fear sharing a potentially sensitive, threatening, or wrong idea. The fearless organization is one in which interpersonal fear is minimized so that team and organizational performance can be maximized in a knowledge intensive world. It is not one devoid of anxiety about the future!

Yet a 2017 Gallup poll found that only 3 in 10 employees strongly agree with the statement that their opinions count at work. Gallup calculated that by “moving that ratio to six in 10 employees, organizations could realize a 27 percent reduction in turnover, a 40 percent reduction in safety incidents and a 12 percent increase in productivity.” That's why it's not enough for organizations to simply hire talent. If leaders want to unleash individual and collective talent, they must foster a psychologically safe climate where employees feel free to contribute ideas, share information, and report mistakes.

The study [on what made the best teams] examined several possibilities: Did it matter if teammates have similar educational backgrounds? Was gender balance important? What about socializing outside of work? No clear set of parameters emerged. Project Aristotle, as the initiative was codenamed, then turned to studying norms; that is, the behaviors and unwritten rules to which a group adheres often without much conscious attention. Eventually, as Duhigg wrote, the researchers “encountered the concept of psychological safety in academic papers [and] everything suddenly fell into place.

In hesitating and then choosing not to speak up, Christina was making a quick, not entirely conscious, risk calculation – the kind of micro-assessment most of us make numerous times a day.

Like most people, Christina was spontaneously managing her image at work. As noted sociologist Erving Goffman argued in his seminal 1957 book, The Presentation of the Self in Everyday Life, as humans, we are constantly attempting to influence others' perceptions of us by regulating and controlling information in social interactions. We do this both consciously and subconsciously.

I have defined psychological safety as the belief that the work environment is safe for interpersonal risk taking. 6 The concept refers to the experience of feeling able to speak up with relevant ideas, questions, or concerns. Psychological safety is present when colleagues trust and respect each other and feel able – even obligated – to be candid.

We now know that psychological safety emerges as a property of a group, and that groups in organizations tend to have very interpersonal climates. Even in a company with a strong corporate culture, you will find pockets of both high and low psychological safety.

I immediately saw that there was a significant correlation between the independently collected error rates and the measures of team effectiveness from my survey. But then I looked closely and noticed something wrong. The direction of the correlation was exactly the opposite of what I had predicted. Better teams were apparently making more – not fewer – mistakes than less strong teams. Worse, the correlation was statistically significant. I briefly wondered how I could tell my dissertation chair the bad news. This was a problem.

No, it was a puzzle.

The data are consistent in this simple but interesting finding: psychological safety seems to “live” at the level of the group. In other words, in the organization where you work, it’s likely that different groups have different interpersonal experiences; in some, it may be easy to speak up and bring your full self to work. In others, speaking up might be experienced as a last resort - as it did in some of the patient-care teams I studied. That’s because psychological safety is very much shaped by local leaders.

Fear inhibits learning. Research in neuroscience shows that fear consumes physiological resources, diverting them from parts of the brain that manage working memory and process new information. This impairs analytical thinking, creative insight and problem solving.

Working in a psychologically safe environment does not mean that people always agree with one another for the sake of being nice. It also does not mean that people offer unequivocal praise or unconditional support for everything you have to say. In fact, you could say it’s the opposite. Psychological safety is about candor, about making it possible for productive disagreement and free exchange of ideas. It goes without saying that these are vital to learning and innovation. Conflict inevitably arises in any workplace. Psychological safety enables people on different sides of a conflict to speak candidly about what’s bothering them.

In contrast, psychological safety is about candor and willingness to engage in productive conflict so as to learn from different points of view.

Psychological safety and performance standards are two separate, equally important dimensions - both of which affect team and organizational performance in a complex interdependent environment.

I like to say that psychological safety takes off the brakes that keep people from achieving what’s possible. But it’s not the fuel that powers the car.

...making the environment safe for open communication about challenges, concerns, and opportunities is one of the most important leadership responsibilities in the twenty-first century.

But the two most frequently mentioned reasons for keeping silent were one, fear of being viewed or labeled negatively, and two, fear of damaging work relationships. These fears, which are definitionally the opposite of psychological safety, have no place in the fearless organization.

Silence is instinctive and safe; it offers self-protection benefits, and these are both immediate and certain.

No one is fired for silence.’ The instinct to play it safe is powerful.

The workaround bypasses the problem, thereby silencing the signal by getting the immediate job done - but getting it done in a way that is inefficient over the long term.

Workarounds can occur when workers do not feel safe enough to speak up and make suggestions to improve the system.

Their work shows that psychological safety makes it easier for people to speak up about problems and to alter and improve work processes rather than engaging in the counterproductive workarounds.

They found that even when employing a highly-structured process improvement technique, interpersonal climate matters for success.

...more and more of the tasks that people do require judgement, coping with uncertainty, suggesting new ideas, and coordinating and communicating with others. This means that voice is mission critical.

But process innovation efforts only led to higher performance when the organization had psychological safety. In short, process innovation can be a good way to boost firm performance, but a psychologically safe environment helps the investment pay off.

The team also found four other factors that helped explain team performance – clear goals, dependable colleagues, personally meaningful work, and a belief that the work has impact.

...a study in a Midwestern insurance company found that psychological safety predicted worker engagement. In turn, psychological safety was fostered by supportive relationships with coworkers.

...the authors showed that trust in top management led to psychological safety, which in turn promoted work engagement.

In these studies, psychological safety acts (using statistical language) as a moderator that makes other relationships weaker or stronger. Psychological safety has been found to help teams overcome the challenges of geographic dispersion, put conflict to good use, and leverage diversity.

When I studied top management teams with action scientist Diana Smith, we analyzed detailed transcripts of their conversations to show how a psychologically safe climate for candid discussion of strategic disagreement can be created, even in high-level teams confronting strategic challenges, and how this can enable productive decision-making.

One of the most important things to keep in mind, wherever you work, is that the failure of an employee to speak up in a crucial moment cannot be seen. This is true whether that employee is on the front lines of customer service or sitting next to you in the executive board room. And because not offering an idea is an invisible act, it's hard to engage in real-time course correction. This means that psychologically safe workplaces have a powerful advantage in competitive industries.

What many people do not realize is that motivation by fear is indeed highly effective – effective at creating the illusion that goals are being achieved. It is not effective in ensuring that people bring the creativity, good process, and passion needed to accomplish challenging goals in knowledge-intensive workplaces.

The same script – unreachable target goals, a command-and-control hierarchy that motivates by fear, and people afraid to lose their jobs if they fail – has been repeated again and again. In part that's because it's a script that was useful in the past, when goals were reachable, progress directly observable, and tasks largely individually executed. Under those conditions, people could be compelled to reach them simply by fear and intimidation. The problem is that, in today's volatile, uncertain, complex, and ambiguous (VUCA) world, this is no longer a script that's good for business. Rather than success, it's a playbook that invites avoidable, and often painfully public, failure.

A former employee reported that members of his Los Angeles branch opened accounts or credit cards for customers without their consent, saying a computer glitch had occurred if customers complained. He also reported that employees lied to customers-saying that certain products could only be purchased together-to hit their numbers. Other tactics to meet sales goals included encouraging customers to open unnecessary multiple checking accounts – one for groceries, one for travel, one for emergencies, and so on – and creating fake email addressees to enroll customers in online banking.

Like Volkswagen, Wells Fargo's avoidable failure was not the result of one bad apple but of a system that demanded hitting targets so ambitious they could only be met by deceit. Employees operated in a culture of fear that brooked no dissent. Rather than manifesting interest in salespeople's experiences while executing the cross-selling strategy and using what was being learned in the field to shift or sharpen the company's strategy, managers sent a clear message: produce – or else.

For instance, an in-depth investigation of Nokia's rise and fall in the smartphone industry between 2005 and 2010, which included interviews with 76 managers and engineers at Nokia, concluded that the company lost the smartphone battle not as a result of poor vision or a few bad managers but at least partly due to a “fearful emotional climate” that created company-wide inertia, especially in response to threats from powerful competitors.

The regulators were, in a sense, disabled from effectively carrying out their regulatory duties by a culture of fear and deference.

When asked why she thought the regulators chose deference even though they possessed this power, her answer was succinct: “they are coming from a place of fear.

In many organizations, like those discussed in this chapter, countless small problems routinely occur, presenting early warning signs that the company's strategy may be falling short and needs to be revisited. Yet these signals are often squandered. Preventing avoidable failure thus starts with encouraging people throughout a company to push back, share data, and actively report on what is really happening in the lab or in the market so as to create a continuous loop of learning and agile execution.

That they found it easier to fabricate false accounts than to report what they were learning in the field is as powerful a signal of low psychological safety as you can find.

Yet to view the customer-accounts fraud as the result of individually-corrupt salespeople does not square with the widespread nature of the behavior in the company, which points to a system set up to fail. Set up to fail by the pernicious combination of a top-down strategy and insufficient psychological safety to encourage sharing bad news up the hierarchy.

When strategy is seen as a hypothesis to be continually tested, encounters with customers provide valuable data of ongoing interest to senior executives.

Early signs of gaps between results and plans must be viewed first as data – triggering analysis – before concluding that the gaps are clear and obvious evidence of employee underperformance.

Chapter 3 Takeaways:

• Leaders who welcome only good news create fear that blocks them from hearing the truth.

• Many managers confuse setting high standards with good management.

• A lack of psychological safety can create an illusion of success that eventually turns into serious business failures.

• Early information about shortcomings can nearly always mitigate the size and impact of future, large-scale failure.

Regret for the things we did can be tempered by time; it is regret for the things we did not do that is inconsolable.” —Sydney Harris

Rocha's statement captures a subtle but crucial aspect of the psychology of speaking up at work. Consider his words carefully. He did not say, “I chose not to speak,” or “I felt it was not right to speak.” He said that he “couldn't” speak. Oddly, this description is apt. The psychological experience of having something to say yet feeling literally unable to do so is painfully real for many employees and very common in organizational hierarchies, like that of NASA in 2003. We can all recognize this phenomenon. We understand why his hands spontaneously depicted that poignant vertical ladder. When probed, as Rocha was by Gibson, many people report a similar experience of feeling unable to speak up when hierarchy is made salient. Meanwhile, the higher ups in a position to listen and learn are often blind to the silencing effects of their presence.

Many who analyze events leading up to tragic accidents such as this one-which could have been avoided had the junior officer spoken up-cannot help pointing out that people should demonstrate a bit more backbone. Courage. It is impossible to disagree with this assertion. Nonetheless, agreeing doesn't make it effective. Exhorting people to speak up because it's the right thing to do relies on an ethical argument but is not a strategy for ensuring good outcomes. Insisting on acts of courage puts the onus on individuals without creating the conditions where the expectation is likely to be met.

The absence of a Director of Nursing at the time of Lehman's admittance, a post that had been vacant for over a year, also signals that the medical and clinical teams did not adequately appreciate the interdependence and complexity of their work.

Raising concerns that turn out to be unfounded presents a learning opportunity for the person speaking up and for those listening who thereby glean crucial information about what others understand or don't understand about the situation or the task.

A culture of silence is thus not only one that inhibits speaking up but one in which people fail to listen thoughtfully to those who do speak up – especially when they are bringing unpleasant news.

...the assembled group could have readily resolved the ambiguity with some simple analyses and experiments had they listened intensely and respectfully. In short, for voice to be effective requires a culture of listening.

The operative word here is “listening.” In the Chapters 5 and 6, you will read about eight flourishing organizations where leaders have created the conditions to make listening and speaking up the norm, not the exception. In these fearless workplaces, it's far less likely that employees will refrain from sharing valuable information, insights, or questions and far more likely that leaders will listen to rather than dismiss bad news or early warnings.

...most notably, in what Pixar calls its “Braintrust.”

A small group that meets every few months or so to assess a movie in process, provide candid feedback to the director, and help solve creative problems, the Braintrust was launched in 1999, when Pixar was rushing to save Toy Story 2, which had gone off the rails. The Braintrust's recipe is fairly simple: a group of directors and storytellers watches an early run of the movie together, eats lunch together, and then provides feedback to the director about what they think worked and what did not. But the recipe's key ingredient is candor. And candor, though simple, is never easy.

Pixar's Braintrust has rules. First, feedback must be constructive – and about the project, not the person. Similarly, the filmmaker cannot be defensive or take criticism personally and must be ready to hear the truth. Second, the comments are suggestions, not prescriptions. There are no mandates, top-down or otherwise; the director is ultimately the one responsible for the movie and can take or leave solutions offered. Third, candid feedback is not a “gotcha” but must come from a place of empathy. It helps that the directors have often already gone through the process themselves. Praise and appreciation, especially for the director's vision and ambition, are doled out in heaping measures.

Braintrusts – groups of people with a shared agenda who offer candid feedback to their peers – are subject to individual personalities and chemistries. In other words, they can easily go off the rails if the process isn't well led. To be effective, managers have to monitor dynamics continually over time. It helps enormously if people respect each other's expertise and trust each other's opinions. Pixar director Andrew Stanton offers advice for how to choose people for an effective feedback group. They must, he says, “make you think smarter and put lots of solutions on the table in a short amount of time.” Stanton's point about having people around who make us “think smarter” gets to the heart of why psychological safety is essential to innovation and progress. We can only think smarter if others in the room speak their minds.

Catmull is honest and human in acknowledging that failure hurts. Embracing failure is far easier to say than to actually put into practice! “To disentangle the good and bad parts of failure,” he says, “we have to recognize both the reality of the pain and the benefit of the resulting growth.” He points out that it's not enough to simply accept failure when it happens and move on, more or less hoping to avoid it going forward. We need to understand failure not as something to fear or try to avoid, but as a natural part of learning and exploration. Just as learning to ride a bike entails the physical discomfort of skinned knees or bruised elbows, creating a stunningly original movie requires the psychological pain of failure. Moreover, trying to avoid the pain of failure in learning will lead to far worse pain. Catmull: “for leaders especially, this strategy – trying to avoid failure by outthinking it – dooms you to fail.

Radical transparency and extreme candor go hand in hand at Bridgewater. There's even a prohibition on talking about people who are not present and thus cannot learn from what's being said. Managers are not supposed to talk about their supervisees if the person is not in the room.

Today, Eileen Fisher, the company, operates nearly 70 retail stores, which generated between $400 and $500 million in revenue in 2016. 31 It's a supplier to many other clothing retailers and has consistently been recognized as one of the best companies to work for. Unlike the businesses featured in Chapter 3 that faced enormous failures, the company has enjoyed continuous growth and thoughtful, productive change, unblemished by financial, legal, or safety failures. Its management practices and governance structures have created a showcase for psychological safety.

Fisher calls herself a natural listener, which helps to make “not knowing” a positive trait. When first setting up her company, she found the combination of these two traits to be an advantage. As she says, “when you don't know and you're really listening intently, people want to help you. They want to share.” Evidently, she's managed to maintain the vulnerability and receptivity of her original “I don't know,” even as she's become a seasoned leader of an enduring brand in the fashion industry. One of the outcomes of managing by not knowing is, as Fisher says, that “people feel safe to explore their own ideas instead of feeling like they just need to do what you tell them to do.”

Eileen Fisher clothing is structured along simple lines and fluid designs. The same could be said for the way the company conducts its meetings. People sit in a circle, with the intention of de-emphasizing hierarchies and instead encouraging what's called “a leader in every chair.” To create the mindfulness and focus conducive to an environment where everyone collaborates and contributes, meetings begin with a minute of silence. Sometimes an object, such as a gourd, is passed from person to person; the idea is the person is allowed and expected to speak when the object is in hand. The point is that Fisher, like the other leaders discussed in this chapter, has institutionalized very specific processes that help create psychological safety.

When Fisher describes how projects and initiatives come about in her organization, she emphasizes encouraging employees to be passionate and giving them “permission to care.” For example, an assistant, Amy Hall, rose in the company to become Director of Social Consciousness by following her passion for how the company was running its factories and treating its factory workers, eventually becoming involved in setting standards for how factories operate worldwide. In 2013, at a four-day off-site company sustainability conference, the staff made a commitment to produce only environmentally sustainable clothing by the year 2020. Although the idea had not originally come from Fisher, she wanted to lend her support and realized the importance of simply saying, “yes.” Although she doesn't call herself a CEO, she realized that “saying yes gives people permission” to go forward.

In 2015, CEO Bob Chapman and co-author Raj Sisodia published Everybody Matters: The Extraordinary Power of Caring for Your People Like Family, a book whose title concisely declares the company's mission to “measure success by the way we touch the lives of people.

Barry-Wehmiller rallied from the economic downturn relatively easily and by 2010 reported record financial results. In other words, by continuing to make its team members feel safe and cared for during a crisis, the company created a win-win situation for everyone.

He learned that trust – employees feeling trusted by management – was key, and that time clocks, break bells, and locking inventory in cages inhibited that trust. Chapman describes immediately getting rid of what he calls “trust-destroying and demeaning practices” inappropriate for responsible adults. Listening sessions, as they are called, have since become institutionalized times where team members are asked to speak their minds.

I don't mean to imply that working in a fearless organization takes more effort or a tremendously difficult undertaking. It doesn't. But initially, when we've been entrenched in fear and its attendant mental frameworks, it's not always obvious.

Catmull, E. & Wallace, A. Creativity, Inc.: Overcoming the Unseen Forces That Stand in the Way of True Inspiration. New York: Random House, 2013. Print.

Malcolm, J. “Nobody’s Looking At You: Eileen Fisher and the art of understatement.” The New Yorker. September 23, 2013. https://www.newyorker.com/magazine/2013/09/23/nobodys-looking-at-you Accessed June 12, 2018.

It is not death that a man should fear, but he should fear never beginning to live.” —Marcus Aurelius

Equally important, they were trained in threat and error management (TEM) and CRM (also sometimes called Crew Resource Management). Both programs teach ways of thinking and decision-making. CRM – a program that, among other skills, instructs aviation crews to speak up to their captain when they feel something is wrong and likewise instructs captains to listen to crew concerns – is especially well suited to creating environments of psychological safety.

In other words, clinic staff who themselves feel supported by high levels of psychological safety are able to support and bond with patients, which contributes to positive clinical outcomes.

Having begun his career at Daini in 1982, when it was still under construction, Masuda was intimately acquainted with the plant. That knowledge allowed him to give each group detailed instructions about where to go and what to do. to give each group detailed instructions about where to go and what to do. Concerned that fear might interfere with workers' ability to remember his instructions, he made the groups repeat the instructions back to him before they left. The point was not to command action but to assist them in acting quickly should the situation change, and their safety be compromised.

Masuda influenced the workers to act, even as the ground shook beneath their feet. Through his calmness, openness, and willingness to admit his own fallibility as a leader, Masuda created the conditions for the team to make sense of their surroundings, overcome fear, and solve problems on the fly. Although their physical safety was in constant danger, they felt psychologically safe, and this allowed them to come together, try things, fail, and regroup. In the many moments of fear for their lives over the course of those days, interpersonal fear within the group was nearly nil. Masuda's words and actions set the tone and reassured workers that they could – and must – save the plant.

…if thou shalt be afraid not because thou must some time cease to live, but if thou shalt fear never to have begun to live according to nature- then thou wilt be a man worthy of the universe which has produced thee.” - Marcus Aurelius.

Gulati, R., Casto, C., & Krontiris, C. “How the Other Fukushima Plant Survived.” Harvard Business Review, 2015. https://hbr.org/2014/07/how-the-other-fukushima-plant-survived Accessed June 13, 2018.

You can tell whether a man is clever by his answers. You can tell whether a man is wise by his questions. —Naguib Mahfouz

She introduced new terminology (“words to work by”) that altered the meaning of events and actions in important ways; for instance, instead of an “investigation” into an adverse event, the hospital would use the term “study;” instead of “error” she suggested people use “accident” or “failure.” In subtle but important ways, Morath was trying to help people think differently about the work – and especially about what it means when things go wrong. These leadership actions comprise what I refer to as framing the work.

All of us frame objects and situations automatically. Our focus is on the situation itself, and we are typically blind to the effects of our frames. Our prior experiences affect how we think and feel about what's presently around us in subtle ways. We believe we're seeing reality – seeing what is there.

She asked a question. “Was everything as safe as you would like it to have been this week with your patients?

In his book The Game-Changer, published while he was still CEO of Proctor and Gamble, A.G. Lafley celebrates his 11 most expensive product failures, describing why each was valuable and what the company learned from each.

Some failures are genuinely good news; some are not, but no matter what type they are, our primary goal is to learn from them.

Framing the work is not something that leaders do once, and then it's done. Framing is ongoing. Frequently calling attention to levels of uncertainty or interdependence helps people remember that they must be alert and candid to perform well.

Others perhaps took it for granted that people knew to speak up. Our survey measure rated three behavioral attributes of leadership inclusiveness: one, leaders were approachable and accessible; two, leaders acknowledged their fallibility; and three, leaders proactively invited input from other staff, physicians, and nurses. The concept of leadership inclusiveness thus captures situational humility coupled with proactive inquiry (discussed in the next section).

In sum, leaders who are approachable and accessible, acknowledge their fallibility, and proactively invite input from others can do much to establish and enhance psychological safety in their organizations. Powerful tools, indeed.

For more cases and detail on the power of inquiry as a fundamental leadership skill, I recommend Ed Schein's thoughtful book, Humble Inquiry.

To reinforce a climate of psychological safety, it's imperative that leaders – at all levels – respond productively to the risks people take. Productive responses are characterized by three elements: expressions of appreciation, destigmatizing failure, and sanctioning clear violations.

In short, psychological safety is reinforced rather than harmed by fair, thoughtful responses to potentially dangerous, harmful, or sloppy behavior.

Leadership at its core is about harnessing others' efforts to achieve something no one can achieve alone. It's about helping people go as far as they can with the talents and skills they have.

For instance, I've studied senior management teams in which a lack of psychological safety contributed to long-winded conversations (indirect statements, with veiled criticisms and personal innuendo, take longer than candid ones), elongated meetings, and an inability to come to a resolution about crucial strategic issues. Decisions that could have been resolved in hours stretched over months.

Questions cry out for answers; they create a vacuum that serves as a voice opportunity for someone. Especially when a question is directed at an individual (and expressed in a way that conveys curiosity), a small safe zone is automatically created.

The personal challenge for all of us lies in remembering, in the moment, to be vulnerable, as well as to be interested and available. To do this you will have to take on the small interpersonal risk that your attempts may be ignored or, worse, rebuffed. But in my experience, the odds are low. Assuming a modest level of good will in your organization, most of the time your colleagues will respond well to genuine expressions of vulnerability and interest. So, give it a try. Pause; look around. Whom can you invite into the safe space for learning and contributing to the shared goal? See what happens.

To the extent that you feel you fall into that category – a rare genius who has perfect pitch in terms of what the market wants – you may be able to specify the work that needs to be done clearly enough for others to merely execute. In that case, go for it! You will be able to forfeit seeking or listening to the input of those who work below you in the organization. Henry Ford, after all, was said to have complained, “why is it every time I ask for a pair of hands, they come with a brain attached?” But for the rest of us, I wouldn't recommend that approach. Few business leaders today can afford to squander the brainpower available in their companies. At the very least most of us need an honest sounding board. But better yet, we need people to bring their ideas to work to help us create better products and a better organization.

Psychological safety doesn't guarantee effectiveness. It just makes it easier to find out what people have to offer. Sometimes, that's a happy surprise. But when people feel able to express themselves, and you find that what they say is not adding value, then you have a responsibility to help. To coach. And even though it's not fun to give people that kind of feedback, it's better to know that someone is in need of it than to remain in the dark. Moreover, it's only fair to let your colleagues know that the impact they're having is not what they're hoping it is.

Right Kind of Wrong: How the Best Teams Use Failure to Succeed - Amy Edmondson

Introduction:

“Intelligent failures provide valuable new knowledge. They bring discovery. They occur when experimentation is necessary simply because answers are not knowable in advance.

My eureka moment was this: better teams probably don't make more mistakes, but they are able to discuss mistakes

Today, over a thousand research papers in fields ranging from education to business to medicine, have shown that teams and organizations with higher psychological safety have better performance, lower burnout, and, in medicine even lower patient mortality. Why might this be the case? Because physiological safety helps people take the interpersonal risks that are necessary for achieving excellence in a fast-changing, interdependent world. When people work in psychologically safe contexts, they know that questions are appreciated, ideas are welcome, and errors and failure are discussable. In these environments, people can focus on the work without being tied up in knots about what others might think of them. They know that being wrong won’t be a fatal blow to their reputation. Psychological safety plays a powerful role in the science of failing well. It allows people to ask for help when they're in over their heads, which helps eliminate preventable failures. It helps them report -and hence catch and correct- errors to avoid worse outcomes, and it makes it possible to experiment in thoughtful ways to generate new discoveries. Think about the teams that you’ve been a part of at work, or at school, in sports, or in your community.

When a group is higher in psychological safety, it’s likely to be more innovative, do higher-quality work, and enjoy better performance, compared to a group that is low in psychological safety. One of the most important reasons for these different outcomes is that people in psychologically safe teams can admit their mistakes. These are teams where candor is expected. It’s not always fun, and certainly it’s not always comfortable, to work in such a team because of the difficult conversations you will sometimes experience. Psychological safety a team is virtually synonymous with a learning environment in a team. Everyone makes mistakes (we are all fallible), but not everyone is in a group where people feel comfortable speaking up about them. And it’s hard for teams to learn and perform well without psychological safety.

Good failures are those that bring us valuable new information that simply could not have been gained any other way.

But before we go any further, a few definitions are in order. I define failure as an outcome that deviates from desired results, whether that be failing to win a hoped-for gold medal, an oil tanker spilling thousands of tons of raw oil into the ocean instead of arriving safely in a harbor, a start-up that dives downward, or overcooking the fish meant for dinner. In short, failure is a lack of success.

Next, I define errors (synonymous with mistakes) as unintended deviations from prespecified standards, such as procedures, rules, or policies.

Finally, violations occur when an individual intentionally deviates from the rules. If you deliberately pour flammable oil on a rag, light a match to it, and throw it into an open doorway, you are an arsonist and have violated the law. If you forget to properly store an oil-soaked rag and it spontaneously combusts, you have made a mistake. All of these terms can be so emotionally loaded that we may be tempted to simply turn and flee. But in so doing, we miss out on the intellectually (and emotionally) satisfying journey of learning to dance with failure.

I felt embarrassed and afraid that my colleagues wouldn’t keep me on the research team. My thoughts spiraled out to what I would do next, after dropping out of graduate school. This unhelpful reaction points to why each of us must learn how to take a deep breath, think again, and hypothesize anew. That simple self-management task is part of the science of failing well.

As pernicious as basic failures can be, complex failures, described in chapter 4, are the real monsters that loom large in our work, lives, organizations, and societies. Complex failures have not one but multiple causes and often include a pinch of bad luck, too. These unfortunate breakdowns will always be with us due to the inherent uncertainty and interdependence we face in our day-to-day lives. This is why catching small problems before they spiral out of control to cause a more substantial complex failure becomes a crucial capability in the modern world.

Part One: The Failure Landscape

Chapter 1: Chasing the Right Kind of Wrong

“Failing well is hard for three reasons: aversion, confusion, and fear. Aversion refers to an instinctive emotional response to failure. Confusion arises when we lack access to a simple, practical framework for distinguishing failure types. Fear comes from the social stigma of failure.

Numerous studies show that we process negative and positive information differently. You might say we’re saddled with a “negativity bias.” We take in “bad” information, including small mistakes and failures, more readily than “good” information. We have more trouble letting go of bad compared to good thoughts. We remember the negative things that happen to us more vividly and for longer than we do the positive ones. We pay more attention to negative than positive feedback. People interpret negative facial expressions more quickly than positive ones. Bad, simply put, is stronger than good. This is not to say we agree with or value it more but rather that we notice it more.

We also suffer from what celebrated psychologist Daniel Kahneman called “loss aversion”—a tendency to overweigh losses (of money, possessions, or even

social status) compared to equivalent wins.

Sydney Finkelstein, a Dartmouth professor who studied major failures at over fifty companies, found that those higher in the management hierarchy were more likely to blame factors other than themselves compared to those with less power. Oddly, those with the most power seem to feel they have the least control. So much for the “buck stops here” thinking popularized by U.S. president Harry Truman.

One of the most important strategies for avoiding complex failures is emphasizing a preference for speaking up openly and quickly in your family, team, or organization. In other words, make it psychologically safe to be honest about a small thing before it snowballs into a larger failure. Too many of the large organizational failures I’ve studied could have been prevented if people had felt able to speak up earlier with their tentative concerns.

Athletes in general possess a relatively enlightened understanding of failure’s relationship to success. As Canadian ice hockey superstar Wayne Gretzky famously said, “You miss one hundred percent of the shots you don’t take.

As you will learn in this book, how we frame or reframe failure has a great deal to do with our capacity to fail well. Reframing failure is the life-enhancing skill that helps us overcome our spontaneous aversion to failure. It starts with the willingness to look at yourself—not to engage in extensive self-criticism or to enumerate your personal flaws, but to become more aware of universal tendencies that stem from how we’re wired and are compounded by how we’re socialized. This is not about rumination—a repetitive negative thought process that isn’t productive—or self-flagellation. But it may mean taking a look at some of your idiosyncratic habits. Without this, it’s hard to experiment with practices that help us think and act differently.

Yet, some people are more resilient than others. What makes them different? First, they are less prone to perfectionism, less likely to hold themselves to unrealistic standards. If you expect to do everything perfectly or to win every contest, you will be disappointed or even distressed when it doesn’t happen.

Second, resilient people make more positive attributions about events than those who become anxious or depressed. How they explain failures to themselves is balanced and realistic, rather than exaggerated and colored by shame.

Note that healthy attributions about failure not only stay balanced and rational, they also take account of the ways—small or large—that you may have contributed to what happened. Maybe you didn’t prepare sufficiently for the interview. This is not to beat yourself up or wallow in shame. Quite the contrary; it’s about developing the self-awareness and confidence to keep learning, making whatever changes you need so as to do better next time. Each of us is a fallible human being, living and working with other fallible human beings. Even if we work to overcome our emotional aversion to failure, failing effectively isn’t automatic. We also need help to reduce the confusion created by the glib talk about failure that is especially rampant in conversations on entrepreneurship.

Implications of Context for Failure:

Context

Consistent

Variable

Novel

Example

Vehicle assembly line

Surgical operating room

Scientific laboratory

The state of knowledge

Well-developed

Well-developed knowledge, vulnerable to unexpected events

Limited

Uncertainty

Low

Medium

High

Most common failure type

Basic failure

Complex failure

Intelligent failure

For example, meeting with senior executives in a large financial services firm in April

2020, I listened as they explained that the current business environment made failure temporarily “off-limits.” Understandably concerned about an economic climate increasingly challenged by a global pandemic, these business leaders wanted everything to go as well as possible. Generally speaking, they were sincere in their desire to learn from failure. But enthusiasm about failing was acceptable when times were good, they told me; now that the future looked uncertain, pursuing unerring success was more imperative than ever. These smart, well-intentioned people needed to rethink failure. First, they needed to appreciate the context. The need for fast learning from failure is most critical in times of uncertainty and upheaval, in part because failures are more likely! Second, while encouraging people to minimize basic and complex failures may help them focus, welcoming intelligent failures remains essential to progress in any industry. Third, they needed to recognize that the most likely outcome of their prohibition on failure wasn’t perfection but rather not hearing about the failures that do occur. When people don’t speak up about small failures—say, an accounting error—these can spiral into larger failures, such as massive banking losses.

The instinct to exhort people to do their best work in challenging times is understandable. It’s tempting to believe that if we just hunker down, we can avoid failure altogether. It’s also wrong. The relationship between effort and success is imperfect. The world around us changes constantly and keeps presenting us with new situations. The best-laid plans encounter problems in an uncertain context. Even when people work hard and are committed to doing the right thing, failure is always possible in a new situation. Sure, sometimes failures are caused by people who are careless or don’t work hard, but even hard work can end in failure when a situation is new and different or some unexpected event happens. Finally, and most perversely, sometimes sheer luck allows you to mail it in and succeed anyway.

Now consider what happens when senior executives, or parents, for that matter, state unequivocally that failure is off-limits, that only good results are acceptable. Failures don’t stop. They simply go underground. Unwittingly, the financial services executives I spoke with were at risk of inhibiting the transmission of bad news. That wasn’t their goal. Their goal was to encourage excellence. But it’s human nature to hide the truth when it’s clear that sharing it will bring punishment—or even just disapproval. Our fear of rejection presents the third barrier to practicing the science of failing well.

First, fear inhibits learning. Research shows that fear consumes physiologic resources, diverting them from parts of the brain that manage working memory and process new information. In a word, learning. And that includes learning from failure. It is hard for people to do their best work when they’re afraid. It’s especially hard to learn from failure because doing so is a cognitively demanding task. Second, fear impedes talking about our failures. Today’s never-ending chore of self-presentation has exacerbated this ancient human tendency. The pressure to look successful has never been greater than in this age of social media. Studies find today’s teens, in particular, are obsessed with putting forward a sanitized version of their lives, endlessly checking for “likes” and suffering emotionally from comparisons and slights, real or perceived. Our emotional reaction to a perceived rejection is the same as to an actual one, because it’s how we interpret a situation that shapes our emotional response. And it’s not just the kids who worry. Whether in professional accomplishment, attractiveness, or social inclusion, keeping up appearances can feel as necessary as breathing to full-grown adults. The real failure, I’ve found, is believing that others will like us more if we are failure-free. In reality, we appreciate and like people who are genuine and interested in us, not those who present a flawless exterior.

I’d go so far as to say that insisting on high standards without psychological safety is a recipe for failure—and not the good kind. People are more likely to mess up (even for things they know how to do well) when they’re stressed. Similarly, when you have a question about how to do something but don’t feel able to ask someone, you’re at risk of running headlong into a basic failure. Also, when people encounter intelligent failures, they need to feel safe enough to tell other people about them. These useful failures are no longer “intelligent” when they happen a second time.

Of the sixteen cardiac surgery departments my colleagues and I studied, only seven stuck with the new technology. The other nine departments tried it out for a handful of operations, then abandoned it. The most important difference in the groups that succeeded was surgeon leadership—not surgeon skill, experience level, or seniority. When we started the study, we expected that the more elite academic medical centers would be more likely to succeed than the less well-known community hospitals. But we were wrong. Hospital type and status made no difference at all. The challenge all these teams faced was more interpersonal than technical. The innovation challenged the traditionally hierarchical structure of operating rooms, where the surgeon typically issued orders that others carried out. Surgeons practicing the new technique were newly dependent on the rest of the operating-room team to coordinate aspects of the procedure and keep a “balloon clamp” in place inside the patient’s artery as a way of restricting blood flow to the heart. The balloon’s tendency to shift meant that the team had to monitor its location through ultrasound imagery to make adjustments. But unless people felt psychologically safe enough to speak up, these activities were hard to carry out. For instance, asking the surgeon to pause while the balloon was

repositioned was both new and difficult for most nurses. Surgeons had to listen to other members of the team more often, and more intensely, than in traditional surgeries, where they had done most of the talking. The successful innovators in our study recognized that they needed to lead differently. They had to make sure that everyone in the operating room could talk openly and immediately about what was needed from one another to make the procedure work. When my colleagues and I analyzed the teams that persisted in mastering the new approach, we found that all of them engaged in a few special activities that reflect core practices in the science of failing well.

Chapter Two: Eureka!

“Mistakes are deviations from known practices. Mistakes happen when knowledge about how to achieve a certain result already exists but isn’t used.

What makes a failure qualify as intelligent? Here are four key attributes: it takes place in new territory; the context presents a credible opportunity to advance toward a desired goal (whether that be scientific discovery or a new friendship); it is informed by available knowledge (one might say “hypothesis driven”); and finally the failure is as small as it can be to still provide valuable insights. Size is a judgment call, and context matters. What a large company can afford to risk on a pilot project may be greater than what you can afford to risk on a new endeavor in your personal life. The point is to use time and resources wisely. A bonus attribute is that the failure’s lessons are learned and used to guide next steps.

My Harvard colleague Thomas “Tom” Eisenmann, an entrepreneurship expert, finds that many start-up failures are caused by the skipping of basic homework. For example, Triangulate, an online dating start-up, rushed to launch fully functional offerings that didn’t fit any market needs. Eager to launch fast, founders skipped the research— customer interviews to probe for unmet needs. Giving short shrift to that crucial preparation, the company paid the price. Tom attributes this common failure, in part, to “the ‘fail fast’ mantra,” which overemphasizes action, shortchanging preparation. Moreover, while this might seem self-evident, once you’ve done the homework, you must heed what it’s telling you.

Because failures consume time and resources, you’re smart to use both judiciously. Failures can also threaten reputations. One way to mitigate the reputational cost of failure is to experiment behind closed doors. If you’ve ever tried on a bold new style of clothing to see if it suits you, you probably did it behind the curtain of a store’s changing area. Similarly, most innovation departments and scientific labs are private, with scientists and product designers trying all sorts of crazy things without an audience.

By not doing the work to discover the vulnerabilities that needed to be fixed before a full-scale launch, the pilot failed the company and its customers. The solution is to create incentives that motivate pilots not to succeed but rather to fail well. An effective pilot is littered with the right kind of wrong-numerous intelligent failures, each generating valuable information. To design a smart pilot in your organization, you should be able to answer yes to the following questions:

1. Is the pilot being tested under typical (or better yet, challenging) circumstances (rather than optimal ones)?

1. Is the goal of the pilot to learn as much as possible (not to prove the success of the innovation to senior executives)?

1. Is it clear that compensation and performance reviews are not based on a successful outcome for the pilot?

1. Were explicit changes made as a result of the pilot?

Practices for Learning from Failure

To Avoid

Don’t Say

Try

Skipping the analysis

I'll try harder next time.

Thinking carefully about what went wrong and what factors might have caused it.

Superficial analysis

It didn’t work. I'll just try something else

Analyzing what the different causes of the failure suggest about what to try next.

Self-serving analysis

I was right, but someone or something else messed it up.

Digging in to understand—

and accept—your own

contribution (small or large)

to the failure.

When we experiment, we hope our hypotheses are right. But we must act to know for sure.

It starts with curiosity. Elite failure practitioners seem to be driven by a desire to understand the world around them—not through philosophic contemplation, but by interacting with it. Testing things out. Experimenting. They’re willing to act! This makes them vulnerable to failure along the way—about which they seem unusually tolerant.

Chapter Three: To Err Is Human

“Many slips occur due to inattention. Did you offend the friend because you didn’t think carefully before you spoke? Making assumptions is another source of error. As for the job you’d expected to land—hadn’t you impressed the interviewer? Your rapport, experience, and qualifications seemed perfect. Maybe you were overconfident, which can result in mistakes. Meanwhile, the clogged gutters on your roof that led to leaks into your basement and damaged the foundation? You were going to get those gutters cleaned as soon as

you had a spare moment. Neglect is yet another common cause of failure.

Like many theoretically preventable failures, the basic failure at the Emergent BioSolutions plant was not an isolated incident but reflected a problematic safety culture, as suggested by the following reported events: Earlier vaccine lots had also been thrown out for contamination. Mold was a persistent problem in areas that were supposed to be kept immaculately clean. Supervision and training were scant for the many new hires needed to handle the mammoth vaccine production. Although vaccine manufacturing is known as a “fickle” business and some error is inevitable, the reports suggested a pattern of lapses had led to the high-profile contamination of millions of doses. When inattention becomes a cultural feature in an organization, you have a breeding ground for producing basic and complex failures alike. Fatigue plays a role in slips due to inattention. The U.S. Centers for Disease Control and Prevention (CDC) reports that a third of adult Americans do not get enough sleep. Such alarming sleep deprivation not only leads to an array of health concerns, but also to accidents and injuries. To cite one example, investigators found that 40 percent of highway accidents identified human fatigue as a “probable cause, a contributing factor, or a finding,” despite the fact that the National Transportation Safety Board (NTSB) has made 205 fatigue-specific recommendations since the early 1970s.

Whether tragic (a lost life) or silly (spilled milk), waste can be reduced through the diligent application of good failure practices. Basic failures are the most preventable of the three types. Excellent companies strive to prevent as many basic failures as they can. The chances are that you wish to do so as well. This is why we cannot afford to ignore mistakes. Basic failure’s ubiquity. serves as an invitation to strive to minimize it. My goal is to make basic failures fewer and further between. (It’s the opposite of how we think about intelligent failures, which I believe we should strive to increase, to accelerate innovation, learning, and personal growth.) But behaviors and systems that prevent basic failure can save lives, create immense economic value, and bring personal satisfaction.

When presented with the choice between admitting our mistakes or protecting our self-image, the decision is easy. We want to believe we are not at fault, so we find every reason to justify what we did as correct. That makes it hard to learn! A psychological bias known as the fundamental attribution error exacerbates the problem. Stanford psychologist Lee Ross identified this fascinating asymmetry: when we see others fail, we spontaneously view their character or ability as the cause. It’s almost amusing to realize that we do exactly the opposite in explaining our own failures—spontaneously seeing external factors as the cause. For example, if we show up late for a meeting, we blame traffic. If a colleague is late for a meeting, we may conclude he is uncommitted or lazy.

Owning our errors becomes easier when we accept human fallibility as a fact and put that acceptance to use in learning and improving. In the most successful teams in my research, people, especially team leaders, talk about the ever-present chance that things will go wrong. They are honest and good-humored about mistakes, which nurtures the psychological safety you need for people to speak up quickly about them. This is a best practice—in families, too, not just work teams—if you want to reduce basic failures.

Mastery in any field requires a willingness to actually learn something from the many mistakes you will necessarily make. When Tanitoluwa Adewumi, a ten-year-old in New York, became the United States’ newest national chess master, the boy’s words, like his title, were well beyond his age: “I say to myself that I never lose, that I only learn. Because when you lose, you have to make a mistake to lose that game. So, you learn from that mistake, and so you learn [overall]. So losing is the way of winning for yourself.

Recall that the most effective hospital teams in my medical-error study could report errors without fear of being blamed. Compared to those who were reluctant to report errors, these teams were better able to learn from errors and take measures to prevent them.

Chapter Four: The Perfect Storm

“It’s this familiarity that makes complex failures so pernicious. In familiar situations you feel more in control than you actually are—say, driving home (familiar) despite consuming alcohol at a party—making it easy to be lulled into a false sense of confidence.

More generally, when you find yourself thinking, “I can do this in my sleep,” watch out! Overconfidence is a precursor to complex failure, just as it is to basic failure.

Idiosyncratic failures in complex technology. But as before, look more closely and you will see some of the usual culprits defining complex failure: multiple causes in a reasonably familiar setting, with its false sense of security; missed signals; and interactive complexity in a shifting business environment. At times I simply cannot bear the frequency of this recurring story. My research has shed light on why it happens—on the cognitive, interpersonal, and organizational causes that make complex failures so thorny. This multiplicity of factors also means you have many levers with which to interrupt the otherwise inexorable flow toward failure. It means that any one of us can become a complex-failure preventer.

My friends Chris Clearfield and András Tilcsik literally wrote the book on complex failure and why it’s on the rise. Meltdown, their engaging, and at times terrifying, book explains the “shared DNA of nuclear accidents, Twitter disasters, oil spills, Wall Street failures, and even wrongdoing.” Like me, Chris and András were influenced by sociologist Charles Perrow, who identified risk factors that make certain kinds of systems vulnerable to breakdowns.

My engineering background had made me a fan of Perrow’s groundbreaking book Normal Accidents, first published in 1984, which had a lasting influence on experts’ thinking about safety and risk. Perrow focused on how systems, rather than individuals, produce consequential failures. The importance of that distinction cannot be underestimated. Understanding how systems produce failures—and especially which kinds of systems are especially failure-prone—helps take blame out of the equation. It also helps us to focus on reducing failure by changing the system rather than by changing or replacing an individual who works in a faulty system.

I turned to Perrow’s work to help me figure out the persistence of medical accidents. Perrow described a normal accident—a term intended to provoke—as a predictable (that is, normal) consequence of a system with interactive complexity and tight coupling. Interactive complexity means multiple parts interact in ways that make the consequences of actions difficult to predict. For instance, slightly altering his ship’s course put Captain Rugiati on a path where the sudden appearance of two lobster boats required a subsequent sudden and difficult-to-execute turn, culminating in a fatal accident. Tight coupling, a term borrowed from engineering, means that an action in one part of the system leads inexorably to a reaction in another part; it’s not possible to interrupt the chain of events.

For Perrow, calling an accident normal meant that certain systems function as accidents waiting to happen. Their design makes them dangerous. It is simply a matter of time before such systems fail. In contrast, a system with low interactive complexity and loose coupling—say, an elementary school—would not be prone to normal accidents. If a system had high complexity but lacked tight coupling (say, a large university with many academic departments that operate relatively independently), things could go wrong in one part without automatically triggering a major failure in the whole system.

To aim for zero harm in complex systems such as hospitals is not the same as aiming to erase human error. To err is human. Error will always be with us. But we can design social systems that make everyone aware of the inevitability of error and poised to catch and correct it before it causes harm. That means understanding that Swiss cheese holes sometimes line up—despite being separated by time or distance—to create a tunnel through which complex failure flows unimpeded.

The problem with Perrow’s idea that organizations could not safely function with interactive complexity and tight coupling was that so many such organizations did in fact function without mishap for years, even decades. Nuclear power plants operated without incident nearly all the time. So did air traffic control systems, nuclear aircraft carriers, and a host of other inherently risky operations. A small group of researchers led by Karlene Roberts at the University of California, Berkeley, set out to study how they did it. What they discovered was more behavioral than technical. The term high reliability organization, or HRO, captures the essence of the theory. HROs are reliably safe because of how they make everyone in them feel accountable to one another for practices that consistently catch and correct

deviations to prevent major harm. Vigilance is one word for it. But it’s more than that. To me the most interesting part of HRO research is the observation that rather than downplaying failure, people in HROs are obsessed with failure. My colleagues Karl Weick, Kathie Sutcliffe, and David Obstfeld wrote a seminal paper highlighting the culture of HROs as preoccupied with failure, reluctant to simplify, acutely sensitive to ongoing operations (quick to detect subtle unexpected changes), committed to resilience (catching and correcting error,

rather than expecting error-free operations), and valuing expertise over rank. In other words, HROs are weird places. Rather than holding back to see what the boss is thinking, people there don’t hesitate to speak up immediately. A frontline associate, to avert a crisis, can tell the CEO what to do. Failure is clearly seen as an ever-present risk that can nonetheless be consistently averted.

Reducing complex failures starts with paying attention to what I call ambiguous threats. Whereas clear threats (a Category 5 hurricane will hit your neighborhood tomorrow) readily trigger corrective action (evacuate your house), we tend to downplay ambiguous threats—missing chances to prevent harm. Downplaying ambiguous threats is the opposite of what occurs in high reliability organizations. I’ve observed this downplaying in settings ranging from the NASA Space Shuttle program to Wall Street to pharmaceutical drug development. What do to these disparate settings have in common in addition to complexity? High stakes and a drive to succeed—a drive so powerful it blinds people to subtle warning signals.

In retrospect, the erosion seen in the engineer’s Champlain Towers South inspection seems a clear signal of imminent collapse—but at the time it was undeniably ambiguous. Ambiguous threats are problematic because of the natural human tendency to downplay them. It’s natural, and more pleasant, to assume nothing’s wrong and to adopt a wait-and-see attitude. Perhaps you’ve heard of confirmation bias-our tendency to see what we expect, thereby reinforcing an existing belief or prediction by paying attention to confirming data and failing to notice disconfirming data. Becoming more self-aware, as you will see in the next chapter, is one element of learning to notice early warnings—and to actively seeking disconfirming data, just in case. But it’s natural to adopt a wait-and-see attitude instead of getting curious and taking a closer look at some subtle signal of irregularity. The financial industry turned a collective blind eye to the risk of mortgage-backed securities, composed of shaky loans granted to people with neither assets nor income to ensure repayment.

It starts with changing your attitude about false alarms. Recall that any worker in a Toyota factory can pull an Andon Cord to alert a team leader of a possible error before it turns into a production failure. The team leader and team member examine the potential problem, however small, and together either fix or dismiss the threat. If only one of twelve pulls of the Andon Cord stops the assembly line for a genuine problem, you might think the company would be upset by wasting supervisors’ time chasing the eleven false alarms. It turns out that the opposite is true. A pulled Andon Cord that does not identify an actual error is framed as a useful drill. The false alarm is instead experienced as a valuable learning moment, a welcome education on how things go wrong and how to adjust so as to reduce that possibility. This is not a cultural nuance. It’s a practical approach. Every Andon Cord pull is seen as a valuable episode that in the long run saves time and promotes quality.

To help overcome this ubiquitous tendency, best practices for RRTs included a list of early warning signals nurses could consult to legitimize their calls. This list helped nurses build on their vague hunch—because they’d simply be following the protocol. When the RRT showed up, it brought more trained eyes to the bedside to assess whether the patient was failing.

This is more than vigilance. When people are given permission to amplify and assess weak signals (such as with an Andon Cord or a rapid response team), they are invited to engage wholeheartedly in the work—to embrace its inherently uncertain nature, to believe that their own eyes and ears and brains matter.

Embracing the Possibility of Failure to Reduce the Occurrence of Failure

My decades-long fascination with error, harm, and failure has left me humble about the complexity of these topics. The mix of factors—technology, psychology, management, systems—means none of us can master every aspect of the relevant knowledge to feel “we’ve got this.” But a few simple practices have emerged from my work that can help prevent complex failures. With these, we all have the power to make that kind of difference—in our own lives and in the organizations we care about.

It starts with framing. Explicitly emphasizing the complexity or novelty of a situation helps put you in the right state of mind.

Next, make sure to amplify, rather than suppress, weak signals. Imagine standing in front of a crowd and trying to be heard.

Amplify doesn’t mean exaggerate or dwell on it endlessly; it simply means make sure a signal can be heard. And if its message ends up being “all is well,” we must learn to be nonetheless glad we asked.

Finally, make a habit of practicing. Musicians, athletes, public speakers, and actors all rehearse before a performance to be as prepared as possible.

Part Two: Practicing The Science of Failing Well

Chapter Five: We Have Met the Enemy

“Today, Dalio credits this failure as a major cause of his subsequent extraordinary success, including his firm’s becoming the largest and most profitable hedge fund in history: “In retrospect, that failure was one of the best things that ever happened to me. It gave me the humility I needed to balance my aggressiveness and shift [my] mindset from thinking, ‘I’m right,’ to asking myself, ‘How do I know I’m right?’”

How do I know I am right?

It’s a powerful question. Failing well, perhaps even living well, requires us to become vigorously humble and curious—a state that does not come naturally to adults.

People such as James West and Jennifer Heemstra and Clarence Dennis skillfully applied the lessons they gleaned from painful setbacks as part of building successful and fulfilling lives. But we’re not hardwired to confront failure thoughtfully; we have to learn to do it.

I first learned about the interrelated dynamics of o brains and social systems back in 1987 from Daniel Goleman’s thoughtful book Vital Lies, Simple Truths: The Psychology of Self-Deception.

Slow (high road) processing is thoughtful, rational, and accurate, while fast (low road) processing is instinctive and automatic. Why are these distinctions important? It’s easy and natural for us to process a failure through fast, instinctive, automatic low road pathways in our brain. The problem is that low road cognition triggers an immediate response to failure in the brain’s amygdala (that fear module for self-protection that in today’s world sometimes holds us back from risk-taking). As we have already seen, how we interpret events affects our emotional responses to them. Fortunately, we can learn how to reinterpret events in our lives to avoid persevering in unproductive negative feelings. To do that, you must override the amygdala, with its superfast pathway from perceived threat to fear, to challenge its automaticity with information and reasoning.

We are saddled with what psychologists call prepared fears. These include fears of dangerous animals, loud noises, and sudden movements. To this list of prepared fears add that of being expelled by the tribe. University of Virginia professor James “Jim” Detert and I consider being rejected by a group as a survival-based prepared fear. The risk of coming up short in the eyes of an authority such as one’s boss triggers a prepared fear in the brain related to being expelled from the tribe, a reality that might long ago have resulted in death from exposure or starvation. But today when we’re afraid to speak up about failure, our colleagues lose valuable opportunities to learn vicariously. Also, we miss out on opportunities to avoid preventable failures. Meanwhile, distracted by irrational prepared fears, we miss signals of longer-term peril that require slower thinking but constitute true threats to survival, such as the impact of climate change on food supplies and sea levels. Fast, automatic low road processing feeds the confirmation bias, encourages complacency, and hides failure’s useful lessons. Slow high road processing happens when we stop to question the automatic to wonder what is happening and what it might mean. Most important, it happens when we stop to ask ourselves, How might I have contributed to the failure?

Eskreis-Winkler and Fishbach conducted five studies to test the hypothesis that failure, rather than promoting learning, actually undermines it. In one study they asked participants a series of questions starting with identifying which of two symbols from a fictional ancient script represented an animal. Afterward, one group of study participants was told, “You are correct” (success feedback). The other group was told, “You are incorrect” (failure feedback). To see how well they learned from each type of feedback, participants were given a follow-up test. This time they were asked to look at the exact same symbols and asked to identify which one represented a nonliving entity. Sounds pretty straightforward, right? Yet those who had been told they were correct in the first round scored higher in their second test than those told their answers were incorrect. Over and over, people learned less from being given information about what they got wrong than about what they got right.

Eskreis-Winkler and Fishbach concluded that unawareness of failures’ useful information made learning from failure difficult. So they designed an experiment in which participants were helped to identify the useful information in their failures, and this made them more likely to share them.

In a very different study with similar conclusions, my colleagues Bradley “Brad” Staats and Francesca Gino—then professors at the University of North Carolina—studied how seventy-one surgeons learned from failure versus success on a total of 6,516 cardiac surgeries in ten years. The surgeons learned more from their own successes than from their own failures, but learned more from others’ failures than from others’ successes. This effect—again ego protecting—was less pronounced if a surgeon had a history of personal success. Failures presumably stung less sharply with that cushion of prior success.

You didn’t have to suffer embarrassment or worse. Does this mean we’re able to look more dispassionately at near misses than at actual failures and are thus more able to learn from them? A growing body of research—some of which I’ve contributed to—explores this idea. What you can take away from this research is that framing matters. For instance, how did you think about that close call? Did you see it as a failure (a miss that almost happened) or as a success (a good catch)? If you’ve framed the close call as a success, you’re more likely to tell your colleagues or family about it, making all of you more able to learn from it.

When we see failures as shameful, we try to hide them. We don’t study them closely to learn from them. Brown distinguishes between shame and guilt. Shame is a belief that “I am bad.” Guilt, in contrast, is a realization that “what I did is bad.” “I am bad because I didn’t do my homework” engenders feelings of shame. But if I see my actions as bad (guilt), it fosters accountability. It is thus better to feel guilty than ashamed; as Brown tells us, “Shame is highly, highly correlated with addiction, depression, violence, aggression, bullying, suicide, eating disorders... [while] guilt [is] inversely correlated with those things.

A 2018 study in the Journal of Social and Clinical Psychology found that reducing the amount of time you spend on social media makes you feel better. Discussing the paper in a Forbes interview, the lead researcher, Melissa Hunt, from the University of Pennsylvania, commented, “It is a little ironic that reducing your use of social media actually makes you feel less lonely.

It stands to reason that social media is shaping our behavior in ways that make sharing problems, mistakes, and failures harder than ever. Both research and firsthand accounts focus on the harmful effects of constant exposure to others’ success, fun, and photoshopped perfect looks. Explicit mentions of failure, or failure avoidance, are rare, and social media’s emphasis on unblemished successes further inhibits healthy attitudes toward failure. Spending considerable time on social media creates a risk of seeing ourselves as failures by comparison to the edited lives that others are living.

Fortunately, reframing is possible. This means learning to pause long enough to challenge automatic associations. Realizing you will be late for an important meeting, you can challenge the spontaneous panic response—taking a deep breath and reminding yourself that it will be possible to make amends, and your survival is not at stake. In a far more dramatic example, Nazi concentration camp survivor Viktor Frankl elucidated the power of reframing for readers of his timeless book, Man’s Search for Meaning. Enduring concentration camps, including Auschwitz, in part by imagining himself in the future sharing stories with those on the outside of the courage he saw in others, Frankl deliberately reframed the meaning of the horrors he was experiencing.

Each of these thinkers—from wildly different backgrounds—sees the nonlearning frame, geared toward self-protection, as the norm for most adults.

Ironically, as Cohen’s story illustrates, a learning frame is not only healthier, it’s also more rational than a performance frame. It’s more in tune with the uncertainty and constant challenges found in any life or job. We can’t shield ourselves from disappointments and failures. But we can learn healthy, productive responses to setbacks and accomplishments alike.

Making mistakes was not evidence of stupidity but rather of inexperience. Making mistakes was a necessary part of learning something new—especially something difficult.

Larry Wilson put it simply: Are you playing to win? Or playing not to lose? Playing to win meant a willingness to take risks in pursuit of challenging goals and satisfying relationships. Playing not to lose, which most of us do most of the time, meant avoiding situations where failure was possible. Playing to win, Larry maintained, was the stuff of great advances and great joy alike but necessarily brought setbacks along the way. Playing not to lose meant playing it safe, settling for activities, jobs, or relationships where you feel in control. The decision, Larry would be quick to explain, was essentially cognitive. You could make up your mind to play to win and thus start on the path to changing your thinking.

To put its wisdom simply, one could say the fundamental human challenge is this:

It’s hard to learn if you already know.

Unfortunately, we are hardwired to feel as if we know—as if we see reality itself rather than a version of reality filtered through our biases, backgrounds, or expertise. But we can unlearn the habit of knowing and reinvigorate our curiosity.

Recall how Ray Dalio, who had been so sure he was right about where the economy was headed until he was catastrophically wrong, shifted his mindset “from thinking, ‘I’m right,’ to asking myself, ‘How do I know I’m right?’” A powerful question for cultivating self-awareness.

Chapter Six: Contexts and Consequences

“A key takeaway from the Electric Maze exercise is have fun experimenting when the stakes are low. Gaining experience with failures in a low-stakes environment helps to stave off perfectionism. You can learn to stop to consider whether the stakes are high. Just as we spontaneously underestimate uncertainty, we spontaneously overestimate what’s at stake. For most of us, appearing on national television would qualify as high stakes.

Getting into the habit of recoding the risk level in many of our activities, along with the stakes we incur in carrying them out, is a vital, life-enhancing capability. By cultivating this habit, we lighten the emotional load. We have more than enough situations in our lives where vigilance is essential; when it’s not, we can proceed in a more playful and lighthearted way—even when we’re doing things that are important to us (cooking, writing an essay, learning a new language). In consistent contexts with low stakes (folding the laundry, going for a run), a casual, business-as-usual approach is fine. Pausing to consider (or, more typically, reconsider) the stakes allows us to titrate vigilance, mitigating its emotional and cognitive tax.

A lack of situation awareness can spawn a variety of preventable failures—usually due to a cognitive bias called naïve realism. As described by Stanford psychologist Lee Ross, naïve realism gives you an erroneous sense that you see reality itself—not a version of reality filtered through lenses created by your background or expertise. It’s a source of overconfidence that can lead to preventable failures. Naïve realism makes us interpret a variable or novel situation as predictable. We’ve already seen examples of this with the child left in the taxi, or my classroom experiences, but perhaps you’ve lost a sale you thought was in the bag or believed a date was going well only to never hear from the person again. Overestimating a situation’s familiarity and underestimating its uncertainty sets us up for failures that are preventable rather than intelligent.

Great managers are those who diagnose the context to organize people and resources accordingly. Otherwise, they set themselves up for embarrassing preventable failures.

He’s also wise enough to call attention to the context variability that lies ahead in any air

journey. To do that in the commercial flights he led, Captain Berman would routinely tell the cockpit crew members with whom he was newly paired, “I’ve never done a perfect flight.” What this tells us is that Berman understands that even the best and most experienced pilot may face unexpected challenges and cannot be counted on to respond perfectly. In my research, I’ve called this a framing statement. Framing is something experienced leaders do naturally because they recognize that people need help to diagnose and recode the context to be most effective. Berman recalled, when I spoke with him in early May 2022, how he thought about those early moments with each new team:

Experts in almost any field take context into account habitually. The rest of us have to remind ourselves to do it. To practice situation awareness is to appreciate where you are right now, so you can adopt the right mindset for the context and the stakes. Perhaps you can think of a time at work when you tormented yourself with anxiety about whether you would succeed in a role or a project. I know I can. It happened many times while I was writing this book! Situation awareness allows you to take stock of where you are and proceed appropriately, sometimes to reduce unhelpful anxiety and other times to lower risk. It’s about developing the habit to pause and check—both for in-the-moment reactions and when planning some project or event—by asking yourself two essential questions: Where am I on the context spectrum? And what’s at stake?

Chapter Seven: Appreciating Systems

“In addition to organizational systems such as 3M, all of us operate in systems in our everyday lives—family systems, ecosystems, and school systems, to name a few. This makes system awareness—especially understanding how systems can produce unwanted failures—a crucial skill in the science of failing well. A system’s results are less shaped by its individual parts than by how the parts relate to one another. This simple but powerful idea can help you analyze and design various systems in your life to get better results. Later in this chapter I’ll return to how 3M designed a system to generate the right kind of wrong and thereby spawn countless innovations. But first, let’s take a closer look at what it means to think in terms of systems.

Put slightly differently, the behavior of the whole can’t be predicted by the behavior of the parts examined separately. Only by considering the relationships between parts can you explain a system’s behavior. There are man-made systems and nature-made systems. In every case, how elements interrelate is what matters most. Consider the striking difference between graphite, the soft gray substance in pencils, and a diamond, that sparkling gemstone so prevalent in engagement rings. Although we know them as profoundly different substances, both consist exclusively of carbon atoms.

Boston University professor Anita Tucker and I studied nurses carrying out the dozens of tasks that occupied them throughout long hospital shifts. Taking detailed notes, complete with time stamps, to document the work of these dedicated caregivers at nine hospitals, Anita observed that nurses confronted “process failures” surprisingly often—almost one an hour. A process failure was anything that disrupted a nurse’s ability to complete a task, such as an unexpected supply shortage in bed linens or medications. The nurses were acutely aware of these frustrating daily hurdles. Their jobs were hard enough! On average nurses were working an extra (unpaid) forty-five minutes simply to tie up loose ends before leaving the hospital.

In contrast, for 7 percent of the process failures, nurses engaged in what we dubbed “second-order problem-solving.” This could mean simply informing a supervisor or someone in charge of linens about the shortage. Second-order problem-solving got the immediate task done and did something to prevent the problem from recurring.

We can easily understand why busy nurses rarely engaged in second-order problem-solving. But this left them vulnerable to continued frustration because the work-arounds didn’t reduce the frequency of future process failures. The average time a nurse spent on work-arounds (a few minutes here, a few minutes there) added up to about half an hour per shift—a substantial waste of skilled professionals’ time. Like all quick fixes, the nurses’ work-arounds created an illusion of effectiveness. Confront a problem, implement a work-around, get on with your day. End of story.

The levers for improving the system were outside what initially looked like the relevant system: the barriers and the typical nurse responses. By consciously redrawing the boundary of the system, you identify other factors affecting the results you care about. You’re looking for factors that produce unwanted results as well as those that might help change them.

A system for innovation

How do you increase the chances that a failed adhesive turns into a brilliant product? With a system designed to bring curious risk-takers together. Encourage and celebrate boundary spanning. Provide resources and slack time. Normalize intelligent failure and celebrate pivots. Declare that you want a significant portion of your company’s revenues (or school’s curricula or family’s activities) to come from new and different products, courses, or experiences. Successful innovation does not come from the lone genius. Importantly, each of these familiar elements of innovation is reinforced by each of the others. The whole is more than the sum of the parts.

The colleague then described Silver’s odd sticky substance. The matter might have ended there except for another element of 3M’s innovation system: the Technical Forum. This was a lecture series that encouraged people to share ideas and discoveries made inside the company.

After more usability test runs within the company—pallets of the pads that were set out in the halls quickly emptied!—3M was finally convinced to launch an intensive marketing campaign in 1980. The rest, as they say, is history.

What Wiseman noticed that day can be seen as a vital element of TPS: a deeply ingrained belief that problem-solving is a team sport. Failures are opportunities for improvement. Competent professionals are expected to successfully execute most of their tasks, so successes are not seen as worthy of colleagues’ valuable time. Hence the “puzzled” look on Mr. Cho’s face. Puzzlement occurred because an expected behavior (share your problems so we can work on them together) didn’t happen, while an unexpected one (bragging) did. What I love most about this story is that Wiseman’s boasting would not have raised an eyebrow in 99 percent of work environments I’ve studied. We are socialized to share accomplishments and good news in front of the boss. Nothing puzzling about it! The most impressive result of TPS in my view is that the system normalizes failure—bad news, requests for help, and problems alike. It creates a community of scientists. Not incidentally, the essence of failing well is thinking like a scientist.

“Use Systems Thinking to Change How We Think about Error …

Rely on inquiry

So Morath faced a challenge: How to help people to see and accept their hospital’s failures? Rather than doubling down on her logic—You work in a complex error-prone system, don’t you see? Things will go wrong!—she instead invited clinicians to reflect on their experiences that week with their patients, then prompted, “Was everything as safe as you would have liked it to have been?” Her aspirational question opened the floodgates. Most people had been in what Morath called “a health-care situation where something did not go well,” and

once they reflected on the many problems they had noticed, they became eager to talk about what had happened and how they might improve…

New language

Another element of the patient safety system was what Morath called Words to Work By—a roster of suggested terms designed to help shift mindsets from blaming to learning. Morath substituted neutral-sounding words such as study for the more threatening word investigation, which put people on the defensive…

Synergy…

As with the system at 3M that supported people’s intelligent failures in ways that encouraged product innovation, and the system at Toyota that made quality improvement second nature, Children’s Minnesota built a robust learning system that turned everyone into an active participant in patient safety. Morath’s approach reminds us that system design is more than simply coming into an organization and flipping a single switch. It’s flipping multiple switches understanding how they work as a system.

Understanding Systems to Better Navigate Failure

Appreciating the dynamics of systems is the last of the three competencies for practicing the science of failing well. After self-awareness and situation awareness is system awareness. Mastering system awareness starts with training yourself to look for wholes rather than zooming in, as we naturally do, on the parts. It’s about expanding your focus, even if briefly, to redraw the boundaries and see a larger whole and the relationships that shape it.

Much of our education and work experience has taught us to diagnose and become experts in parts, shortchanging the value of looking at the relationships that tie them together. We can learn to see and appreciate systems and use this knowledge to reduce preventable failures. Don’t forget that appreciating systems helps us see that we are not wholly responsible for all the failures in our vicinity. This is not to let us off the hook for our contributions to failures, but rather to help us see that we are parts of larger systems, with complex relationships, some of which are beyond our ability to predict or control.

Chapter Eight: Thriving as a Fallible Human being

“For me, losing a tennis match isn’t failure. It’s research.—Billie Jean King

At the end of her life, in the 1860s, when she had become the Grande Dame of Champagne, Barbe-Nicole wrote to a great-grandchild, “The world is in perpetual motion, and we must invent the things of tomorrow. One must go before others, be determined and exacting, and let your intelligence direct your life. Act with audacity.” Act with audacity! In other words, play to win.