I was recently sitting in on an oversight meeting of Gemini management. Most of the meeting was spent in executive (ie. private) sessions, but during one of the two public sessions, one main topic was to explore how and what we have learned from past mistakes. This discussion made me realize that learning from mistakes is not an easy thing to do for many institutions. I’m not saying here that Gemini is doing all these things wrong, but I have seen all these issues first hand at various places, including Gemini. I’m sure that if asked, most people would say that they, personally, learn from their mistakes. Yet, institutions and corporations often don’t. Why not?
For one, you first have to be willing to acknowledge the mistake. This step can be a key roadblock for some. If you don’t have an atmosphere where honest inward looking thought and speech is encouraged, mistakes get covered up, denied, assigned to something else, and not brought out as potential lessons and means for improvement. If you believe in hiding bad news in an (ultimately futile) effort to look good, then you will never learn from mistakes.
Second, you need an environment where the mistake is viewed in context of the system that allowed the mistake to happen and that allowed its effect to be as big as it was. What you don’t need is an environment of blame – where mistakes are dealt with admonishments of “don’t do that again”. What you need is a faultless exploration of what in the system could be changed to prevent future similar mistakes. Making and acknowledging mistakes is not about placing blame, but about fixing the system. People will always make mistakes, but you want the system in which they work to be as fault-tolerant, and fault-preventive (if I can coin a new compound word) as possible.
Finally, you have to really broaden your horizons and fix the system, not the symptom. To make up a hypothetical example, if an instrument is damaged because a heating circuit failed (OK, the event is not so hypothetical, but the implicit bad response outlined below is), you could simply decide to remove the heating circuit from the instrument when it’s repaired. That fixes the symptom and you certainly must address the symptom, or you look really foolish if the same accident happens again, but you can’t stop there. What allowed this single point of failure to exist in the first place? What allowed the failure to occur unnoticed? Was there real-time monitoring? Was anyone overseeing the project? Was anyone contacted? Was there a timer on the heater? Are other possible single-point failures being identified and backed up and/or isolated by a fail-safe or some other subsystem? If you don’t start asking yourself these types of questions, there will be no learning from your mistakes. On the other hand, if you are not afraid to take a rigorously honest look at what other similar vulnerabilities might exist, if you are willing to go beyond placing individual blame and look at how the process allowed both the single point failure to exist in the first place and for the eventual failure to go unnoticed and un-contained, then you are probably on a continual course of improvement and empowerment. Isn’t that a better place to be than only a few instances of bad luck away from a repeat of a mistake you chose not to learn from?
Scot remembers several bits of advice he received about mistakes. His water-skiing cousin told him if he wasn’t falling, he wasn’t trying hard enough. His graduate advisor told him “wisdom is that sinking feeling that you’ve made this mistake before.” He learned from these people and others that making mistakes is part of life. Making the same mistake twice, doesn’t have to be.
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