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.

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.

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.

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.