Mergulhei entretanto na leitura do capítulo 11, "Libyan Arab Airlines Flight 114", de "Black Box" de Matthew Syed e ... devorei-o todo de uma vez. Impressionante!!!
Quando acontece o erro, quando acontece a falha, imediatamente saltamos para o pelotão de fuzilamento: é preciso encontrar e punir o culpado. Todo ele não podia estar mais relacionado com a parte II.
Voltarei ao capítulo para apresentar os meus sublinhados. No entanto, para já fiquei com trabalho de casa. O livro menciona um trabalho de Amy Edmondson o que me fez googlar o seu nome e escolher para leitura futura:
- Psychological Safety, Trust, and Learning in Organizations: A Group-level Lens (julgo que é o trabalho citado no capítulo)
- Organizational Learning in Hospitals: Frequent Opportunities, Pervasive Barriers
- Strategies for Learning from Failure
- Teamwork on the Fly
- Learning from Mistakes Is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error
- TEAM UP FAIL WELL LEARN FAST
"the psychology of blame. We will see that this is an all-too common response to failures and adverse events of all kinds. When something goes wrong, we like to point the finger at someone else. We like to collapse what could be a highly complex event into a simple headline
...
The instinct to blame creates powerful and often self-reinforcing dynamics within organizations and cultures that have to be addressed if meaningful evolution is going to take place.
...
if our first reaction is to assume that the person closest to a mistake has been negligent or malign, then blame will flow freely and the anticipation of blame will cause people to cover up their mistakes. But if our first reaction is to regard error as a learning opportunity, then we will be motivated to investigate what really happened.
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Proper investigation achieves two things: it reveals a crucial learning opportunity, which means that the systemic problem can be fixed, leading to meaningful evolution. But it has a cultural consequence too: professionals will feel empowered to be open about honest mistakes, along with other vital information, because they know that they will not be unfairly penalized—thus driving evolution still further. In short, we have to engage with the complexity of the world if we are to learn from it; we have to resist the hardwired tendency to blame instantly, and look deeper into the factors surrounding error if we are going to figure out what really happened and thus create a culture based upon openness and honesty rather than defensiveness and back-covering.
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And yet if professionals think they are going to be blamed for honest mistakes, why would they be open about them? If they do not trust their managers to take the trouble to see what really happened, why would they report what is going wrong, and how can the system adapt? And the truth is that companies blame all the time. It is not just because managers instinctively jump to the blame response. There is also a more insidious reason: managers often feel that it is expedient to blame. After all, if a major company disaster can be conveniently pinned on a few “bad apples,” it may play better in PR terms. “It wasn’t us; it was them!”
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Penalizing these mistakes has a simple outcome: it destroys innovation and enlightened risk-taking. In short, blame undermines the information vital for meaningful adaptation. It obscures the complexity of our world, deluding us into thinking we understand our environment when we should be learning from it."
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