Na sequência da conversa trocamos algumas referências de livros. Uma das referências que recebi e que me deixou super curioso foi "Black Box Thinking: The Surprising Truth About Success" de Matthew Syed.
Sei que ando a ler dois livros em simultâneo, mas não resisti a espreitar:
"But what is important for our purposes is not the similarity between the two accidents; it is the difference in response. We have already seen that in health care, the culture is one of evasion. Accidents are described as "one-offs" or "one of those things." Doctors say: "We did the best we could." This is the most common response to failure in the world today. [Moi ici: Como não recordar "O Erro em Medicina" e o mais recente horror do presidente Marcelo - "Foi tudo muito rápido. Nestas situações, é tudo aleatório. Há pessoas que acabam por ter sorte e outras que não tem" - Como se se tratasse de uma roleta russa]
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In aviation, things are radically different: learning from failure is hardwired into the system. All airplanes must carry two black boxes, one of which records instructions sent to all on-board electronic systems. The other is a cockpit voice recorder, enabling investigators to get into the minds of the pilots in the moments leading up to an accident. Instead of concealing failure, or skirting around it, aviation has a system where failure is data rich.[Moi ici: Este trecho deixou-me knock-out com aquele "where failure is data rich". Quantas vezes nas empresas, perante uma falha, só nos deparamos com "perhaps", "será que" e "e se"]
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In the event of an accident, investigators, who are independent of the airlines, the pilots' union, and the regulators, are given full rein to explore the wreckage and to interrogate all other evidence. Mistakes are not stigmatized, but regarded as learning opportunities. The interested parties are given every reason to cooperate, since the evidence compiled by the accident investigation branch is inadmissible in court proceedings. This increases the likelihood of full disclosure.
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In the aftermath of the investigation the report is made available to everyone. Airlines have a legal responsibility to implement the recommendations. Every pilot in the world has free access to the data. This practice enables everyone—rather than just a single crew, or a single airline, or a single nation—to learn from the mistake. This turbocharges the power of learning. As Eleanor Roosevelt put it: "Learn from the mistakes of others. You can't live long enough to make them all yourself."
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And it is not just accidents that drive learning; so, too, do "small" errors. When pilots experience a near miss with another aircraft, or have been flying at the wrong altitude, they file a report. Providing that it is submitted within ten days, pilots enjoy immunity. Many planes are also fitted with data systems that automatically send reports when parameters have been exceeded. Once again, these reports are de-identified by the time they proceed through the report sequence.!
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Aviation, then, takes failure seriously. Any data that might demonstrate that procedures are defective, or that the design of the cockpit is inadequate, or that the pilots haven't been trained properly, is carefully extracted. These are used to lock the industry onto a safer path. And individuals are not intimidated about admitting to errors because they recognize their value."
Isto é tão urgente mas tão urgente.
Claro que olhamos para isto e gostaríamos de o replicar para uma e outra e mais outra PME, mas tal seria errado. O caminho é procurar um ponto que possa servir de alicerce e criar dia após dia o mecanismo mais adequado a cada uma. No entanto, o maior problema é perceber que não há acidentes, tudo o que acontece é um produto perfeitamente normal do sistema que temos.
O título é uma das frases que apontei enquanto que decorria a conversa
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