It’s the first time we’ve had a pop-up where the hosts are in the cockpit of a Boeing 737 flying somewhere over Germany! More exactly, Howard and Paul hosted us on the flight deck of their simulator live from their actual location at Luton airport, and led us through a brilliant exploration of the links between learning among flight crew and our more familiar organisational settings.
As usual I’m not going to attempt a summary – I wouldn’t do it justice and there’s a link to the recording below – instead I’m going to give a few personal observations and reactions.
What I really appreciated, personally, with the rigour with which Paul and Howard took us through the sources of fallibility that often cloud decision making, and in the case of air crew can lead to catastrophe. They skilfully led us through an examination of the links between kinds of fallibility and incidents analysed by air crash investigators. The sources of failure included:
It was fascinating, in the group discussion that followed, just how many of us had experienced some or all of these in play in ourselves and in our organisational work.
The session also looked at what we might do as a result of all of this – and offered some helpful questions to guide us, including:
What is the focus on our inquiry into failure – the individual or the system? Do we manage to pay attention to both? Often in organisational life we are quick to find someone to blame, but often understanding gets lost in that simplification. Individuals are part of the culture, and leaping quickly to allocating blame to an individual is likely to lead to cover-ups and repeat failures. Starting with a focus on inquiry and understanding is more likely to lead to systemic learning and a culture of reporting risks and unexpected events that makes repeat failure less likely. This led to a powerful discussion on the cultural aspects of organisations that make it safe enough to speak up – and the work of our own John Higgins and Megan Reitz in this field (see their Speak Up! book here).
The session made me think of Matthew Syeds book Black Box Thinking. It also brought to mind the work of Rob Briner and his rigorous pursuit of evidence-based practice.
I’m sure we will come back to this topic – the session was extremely rich and deserved way more time than one pop-up could give it. I was struck by parallel conversations in health care and in manufacturing, and in the coming year we will almost certainly revisit Howard and Paul’s lessons with teams from these fields.
In the meantime, it was as ever an excellent pop-up with a terrific group. The recording is above and we are all looking forward to more in the New Year.