The Black Box Approach: Failure a springboard to success

Some years ago, we picked up a new client, they had an existing management system, and we were asked to undertake an audit prior to their external assessment because they hadn’t had time to do so, and they needed a quick fix.  Our consultant undertook, to my mind, a spectacular audit gently challenging the status quo and highlighted bundle of ideas for all sorts of simple improvements.

The MD took umbrage and called me. He readily admitted that they were great ideas but preceded to rant and rave saying the consultant had given them a whole load of work to do that they had never been expected to do before. Bizarre!

But I think it’s symptomatic of the way in which a lot of people think about things like mistakes; it’s as if we think everything’s got to be perfect, always and forever.  To my mind life isn’t like that it’s messy, there are grey areas, things change.  There isn’t a direct path to the destination you want to make and just like an airline pilot travelling from London to New York you zig zag across the “ideal course” and are in fact “off course” probably 99% of the time!  You are always having to make constant course corrections.  

Non conformances

What a horrible word non-conformance is.  But it is the one that the standard adopts.  To some, particularly those in manufacturing, non-conformance is a standard word, to others, those in service, it’s a horrible alienating word.  (I’m from manufacturing and even I think it’s horrible!)

If we were starting an ISO project from scratch, we’d suggest replacing the word non-conformance with ChIP.  So instead of having a non-conformance report we have a ChIP report where ChIP stands for:

  • Change
  • Improvement
  • Problem

We think, you may have a different idea, that this does two things:

  • It makes the whole idea of finding a problem more palatable than if it was called a nonconformance.
  • Assuming a non-conformance has been found something bad has occurred. Nonconformance is backward looking.  Creating a Change, Improvement or Problem report makes it both forward and backward looking.  People can report on things that haven’t necessarily gone wrong yet but might simply be better.

The concept behind the ChIP report is that it embraces the idea of failure can be, and should be, a friend – a springboard to success.

But there is an associated issue with the mindset that, unlike our ranting (now ex) client, is the difference between the way in which the aviation sector and the NHS approach failure.

Aviation v NHS

Did you know that the findings of the aviation accident and investigation branch are inadmissible in court proceedings!?  I didn’t know that until I read Matthew Syed’s great book Black Box Thinking.

In the aviation sector, in the aftermath of an accident investigation the subsequent report is made available to anyone.  Every pilot in the world has free access to this data.  This enables everyone to learn from the mistake which in turn turbo charges the power of learning from mistakes.

By contrast, in healthcare, doctors and consultants are treated like Gods – unquestionable, all-knowing and certainly not supposed to make mistakes.  The culture implies an air of infallibility.   In too many instances errors are stigmatised and systems are set up to deny rather than investigate and learn.   As a result, according to the latest figures I could find, the NHS Resolution’s provision at 31 March 2022 increased from £85.2 billion to £128.6 billion!

Failure should be used as a signpost.  We should seek to reveal features of our world we haven’t fully grasped so we can act on the vital clues that allow us to update our thinking, our strategies, our models of the world and our behaviours.  As the NHS figures above show, the question often asked in the aftermath of an “non-conformance” is “can we afford the time to investigate failure?” To me this seems to be the wrong question.  The better question is “can we really afford not to?”.

Seeking out marginal gains

The ChIP, or ISO nonconformance, process should be used as a platform to drive marginal gains in much the same way as sporting heroes like Brailsford, Woodward and others seek out weaknesses, that is, they see it with a different set of eyes.  Every error, every flaw every failure, however, small is a marginal gain in disguise.  ChIP’s are, or should be, regarded not as a threat but as an opportunity; a precious chance to avert an issue before it happens.


We should not insulate ourselves from failure.  To the contrary, we should embrace it.

If we can train ourselves to see an error as a learning opportunity, then we will stand half a chance of being motivated to investigate thoughtfully and thoroughly what happened with the sole purpose of learning.  Obviously, it may be that as part of the investigation we do discover someone had been negligent or malign, in which case blame will be fully justified.  But that shouldn’t be, as it so often is, the starting point.  I’ve quoted Deming before, he said something like “only 94% of the problems in an organisation are to do with the system”.  What he meant was that more usually errors are the result of a systemic defect.

Proper thoughtful and thorough investigation of Changes, Improvements and Problems achieves two things;

  • It reveals critical learning opportunities which means that the systemic problem can be fixed leading to meaningful evolution.
  • It also has a cultural consequence; staff will feel empowered to be open about honest mistakes because they know they will not be unfairly penalised.

Failure has many dimensions, but unless we see it in a new light, as a friend, rather than a foe, it will remain woefully underexploited.

As Henry Ford, who I believe was twice bankrupt, (a pretty spectacular failure in itself), articulated “Failure is simply the opportunity to begin again, this time more intelligently”.



Related tools and ideas

  • Audits – to be developed as a future blog.

Recommended references

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