Confronting Mistakes

The crisis on the financial markets began to unfold with increasing severity starting in 2007. Many were left dumbfounded that big-name banks had taken such disproportionately high risks with their structured securities. People saw the remuneration system in the investment banking sector, enormous bonus payouts, and the associated asymmetric risk distribution as the main causes of the crisis. They started asking how things could have spiraled so far out of control. Yet even before the crisis, some parties within the banks had urged caution. The question is why these warnings went unheard. Were they overlooked? Underestimated? What mistakes were made, how did they come about, who failed to pick up on them, and how were they allowed to trigger a series of further errors that ultimately culminated in such dramatic consequences?

We all remember mistakes we would rather forget. Often they have caused us embarrassment so intense that we wished to disappear completely — preferably to a place where no one knew us. As I said in the beginning, mistakes are nothing we welcome, and embarrassment is one of the many unpleasant emotions we experience after having made them. Still, if they were not relegated to the most hidden corners of our brains, we might learn a lot from them. The lesson may not always delight us, but it will at least give us the chance to comprehend why we — stupidly, mistakenly, or maybe only subconsciously — did what we did. No matter how big the blunder and no matter how much we wish someone else was responsible for it, we and others can still learn from the mistake — particularly if it was a major one.

The crew of United Airlines flight 811 (UAL 811) paved the way. Ten years after the introduction of Crew Resource Management, they were the first to publicly speak out in favor of the concept after being motivated by the following incident: on February 24, 1989, they were en route from Honolulu to Sydney in a Boeing 747–122 when, 17 minutes after takeoff, the front right cargo door sprang open. This caused an explosive decompression that ripped off the door, parts of the fuselage on the right of the plane, and sections of the cabin. Some of the debris entered both of the engines on the right, causing them to fail. Even in these circumstances, the crew managed to keep the heavily loaded plane under control and make it back to the airport in Honolulu.151 Much of this extraordinary achievement they attributed to their CRM training. Accordingly, we will see how strikingly different their interactions with one another were compared to the crews in our previous cases.

At the end of this book, we are left with the question of how CRM, which has proven to be so successful in aviation, can be transferred to other sectors and implemented in everyday business life. Or, to go back a step: to whom does this form of error management apply aside from those in the aviation industry? After all, unlike most other industries, aviation is a risk industry and although every industry or company has its own particular risk areas, managers do not arrive at work knowing that they are responsible for the safe transport of hundreds of people each day. They are, however, in charge of business processes, the success of their particular division, and for keeping their work force employed. So the number of errors they make should be limited as well. From this perspective, the answer to the question above is simple: error management is relevant to every organization that wishes to reduce error volumes, whether or not it is in a risk industry. In fact, most organizations will already have taken steps in this direction by trying to eliminate potential error sources and attempting to analyze and resolve errors that have occurred.