Last week I forgot to do something that was very important to me. I can’t explain my memory lapse except that I had many distractions, but the situation reminded me of a book that I read recently. It is called “The Up Side of Down: Why Failing Well Is the Key to Success” by Megan McArdle. Her main point is that, without experience we can’t succeed, but experience involves risk which means that we will occasionally fail. We learn from these failures and that prepares us for future successes.
In the chapter called “Accidents, Mistakes, Failures, and Disasters,” McArdle describes the different kinds of failures that happen in systems. She says that:
- Accidents are purely coincidental and cannot be expected or avoided.
- Mistakes are the opposite of accidents because they could have been prevented if the rules had been followed.
Mistakes can have major consequences or be minor, but there are four basic types:
- A technical error is the inadequate execution of the tasks of a function. Technical errors are most common when the performer is inexperienced. Once the activity is learned, this kind of mistake is much less likely. A journeyman carpenter may be excused for creating defective pieces that would be unacceptable from a master carpenter but even experts slip up sometimes.
- A judgmental error indicates a lack of insight and wisdom and the incidence of these errors will decrease with experience. The abilities to prioritize and manage resources develops over time; if they don’t, the offender is not a good fit for the role.
- A normative error is one that results from a lack of commitment to the system. For a system to work, it must have a series of norms of behavior that are based on values that have been arrived at by the consensus of master practitioners. Normative errors occur when those expectations are not followed by well-informed members of the system. For instance, if you falsify data in research, the results may be popular but they will not extend scientific knowledge and they may be dangerous.
- A quasi-normative error is when the idiosyncratic expectations of one member of a system are not really in compliance with the generally accepted standards. When rules are capricious or in opposition to overriding normative values, meeting those expectations can be difficult. Not following orders when they contradict morals or accepted best practices can be even be wise.
Occasional typos or fender benders occur when experienced people lose their focus and the normal processes are not followed. That’s what happened to me. Redundancy will make these slip-ups less frequent because backups often catch mistakes. If I had checked my calendar late in the day or noticed the clothing I laid out, I would have arrived at my appointment as I intended. I was preoccupied with other things and so the cues that should have reminded me, didn’t.
Unfortunately, when there are problems, managers, parents, teachers, and officers don’t always take the time to analyze the underlying issue. Is this the result of an accident? If it is a mistake, how could it have been avoided? How can the frequency of similar errors be minimized in the future?
This week the US Supreme Court agreed to review the legitimacy of firing an air marshal who leaked procedural information from the TSA to the media. The marshal contended that a newly implemented policy would put travelers at greater risk and shared the information because his first duty is to protect the public. The federal government argued that the information was classified and shouldn’t be shared because then it might let terrorists know when to strike.
From the government’s perspective, the marshal committed a normative error and the firing was justified. The employee sees himself as a whistleblower and believes it was a quasi-normative error. From his point of view, the new policy contradicted the fundamental values of organization and his responsibility was to inform air passengers about their increased risks. The motivation behind the actions of the wrongdoer is an important aspect of the incident. Determining the nature of the situation is the stuff of court cases.
When things go wrong, it is important to figure out whether it results from an accident or a mistake. If there is a history of technical or judgmental errors of a consistent kind, perhaps the person is unable to become proficient and should be relieved of the responsibility. If it is a normative error, it may be best to sever the relationship with the organization. Quasi-normative errors are not so clear cut and may need to be reexamined by an objective third party like a judge, counselor, or ombudsman. Mistakes happen—let’s understand why.
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