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.

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.

“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.

System 3 is where you start to find *management jobs — those that are entirely devoted to communication and administration within the organisation. It’s also where system-level accountability is established; the key activity of the integration and optimization function is to agree the resource bargains with the System I units, and to ensure that they are being kept. And consequently, it’s the first place you might start to look if you think that unaccountability is creeping into the system. We’ll be looking at this a lot, later.

It’s easy to get confused between systems 2 and 3. Both of them look like they’re doing the same thing, in making the operations accountable to one another and to the wider organisation. The difference is that System 2 is all about preventing clashes and managing conflicts, while System 3 is concerned with achieving a purpose. On the ground, a useful way of drawing the distinction is to look at the management functions which everyone agrees to be necessary as opposed to those that they complain about.

*Stafford Beer refers to the part of the system responsible for internal organisation as the ‘metasystem’, one of very, very many newly coined jargon words which I am going to attempt to shield you from.