Black box thinking
November 13, 2020
By Liza Robbins.
In January 1990, a Colombian plane crashed on Long Island, New York.
It had been in a holding pattern for over an hour, due to heavy traffic over JFK airport and bad weather.
During that time, it burned up all its reserve fuel, which it could have used to divert to another airport or to land.
One at a time, its four engines failed – and eventually it crashed into a hillside, killing 73 people.
What went wrong?
In his book “Outliers”, author Malcolm Gladwell speculates that there were cultural issues at play.
The pilots were overly deferential to the air traffic controllers, and reluctant to challenge their instructions. So while they hinted that they were running out of fuel, they never said so explicitly.
He says that the same dynamic was at play in several other crashes, particularly in airlines with very hierarchical structures, where junior pilots were afraid to challenge senior pilots.
If Gladwell is correct (and not everyone agrees on this), it shows how badly things can go wrong when people at different levels of authority feel unable to speak their mind and challenge each other.
Or – as we would put it – when a firm or company doesn’t have a “consultative environment”, where all points of view are welcomed.
According to Kreston International’s Director of Quality and Professional Standards, Andrew Collier, the problem can arise if you get “senior people in the organisation who think they need to take the lead and find it challenging to talk about difficult decisions.
“Bringing more people into the conversation will give a range of views and experience, helps reduce stress and minimises the risk of poor or incorrect decisions.
“You also have cultures where asking questions may be seen as detrimental to your standing within your firm and to your progression. The result is a bad atmosphere, good people leaving, and – again – bad decisions at all levels.”
This has been an ongoing concern for regulators, which are increasingly focusing on developing a supportive “tone at the top”. So creating more consultative environments is going to become a growing conversation in our industry.
Simply declaring that “all points of view are welcome” won’t help.
Andrew cites three principles:
- Change must come from the top
- Create systems and processes which help people become more consultative – don’t just rely on people’s goodwill
- Find ways to change the conversation in the firm, so consulting becomes normalised and desirable.
Now, I’m sure that there are many Kreston firms which are doing all this very well. But I recently came across a fantastic example, which I’d like to share with you.
Chris Walklett (who also featured in my email last week) is partner in charge of Bishop Fleming’s West Midlands office, in the UK.
When I spoke to him recently, he told me that the key is to “build cultures which eliminate blame and where people can positively engage with failure.
“If mistakes are made, people should be able to talk openly about what could have been done better without fear of recrimination, so everyone can learn from each other’s mistakes.”
In tune with Andrew’s principles, teams have monthly meetings to review mistakes and discuss what can be learned as a result. Senior members of staff lead by example.
But this attitude isn’t just reserved for once a month.
“We have specifically told trainees working on assignments for the first time that they are going to be outside their comfort zone, but they mustn’t worry about getting things wrong,” Chris told me.
“All we ask is that they take ownership of their mistakes and learn from them, and share the learning outcomes with others.”
The result, he says, is that these staff members actually make fewer mistakes because they feel under less pressure.
He recently looked over a piece of work done by a junior member of staff, and sent them review points to consider in the future.
“She immediately fired off an email to the rest of the team saying, ‘This is what I got wrong and these are the areas we need to look out for’. I was very impressed! She could have kept that to herself, but she treated it as a learning opportunity for everyone.”
The approach Chris is describing – where failure is considered part of the path to success – is commonly known as “Black Box Thinking”, because in the airline industry, failure is taken seriously.
When a plane crashes, investigators examine the black box to understand what went wrong – and change procedures so that the same mistakes can never happen again.
Indeed, according to Malcolm Gladwell, some of the airlines which were plagued with safety issues in the 1990s because team members did not have the confidence to challenge their superiors made a concerted effort to change their culture. They’ve had spotless safety records ever since.
We need to make sure that Black Box Thinking – or a ‘consultative environment’ – is equally embedded in our firms.