IMPORTANT LESSONS FROM BLACK BOX THINKING

BY MATTHEW SYED

Today’s “black box” can be

vulnerable to the individual but

helpful overall to our society.

Should we change our perception

how we treat black boxes?

*All images used are copyrighted CC by Bing search engine,

educational sites, and articles in the sources of last slide, and

are used in here under fair use.

By Sokratis Anastasiadis*

Privacy? Norms?

Individual Experiences?

Actual Events?Self-interest?

Hiding Bad Habits?

WE USE THIS BOX FOR BOX INCLUDES

Black Box Version of 21st Century:

Pandora Box

Privacy? Norms?

Individual Experiences?

Actual Events?Self-interest?

Hiding Bad Habits?

WE USE THIS BOX FOR BOX INCLUDES

Liabilities = Costs

Credibility = Brand Depreciation for Organizations

Less Career Opportunities for Individual

Processes that we don’t want to face/analyze

/improve we circumvent in such way to

exclude liability.

Working for Ideologies against

Rival Organizations/Clients/Individuals

Due to profit/recognition/pride

They are only entertained. Actual

events are twisted through their

ideologies (= Cognitive Dissonance)

Careers that expect Perfectionism/High Prodigy

Due to long term experience/education

(Examples: P.H.D. , C suite executives, Doctors, etc.)

Are hidden with professionalism that it is beyond

their “habits” (= bad luck?)

Brand Depreciation for Organizations

Less Career Opportunities for Individual

against

Rival Organizations/Clients/Individuals

Due to profit/recognition/pride

Careers that expect Perfectionism/High Prodigy

Due to long term experience/education

THE MOTIVATIONS ALL SHARE A COMMON THREAD

The ME is becoming threatened by the external environment

And the easiest way for ME to not be threatened

is to stuff them in a Black Box

Aviation Industry Shows us how to take use of Black Box Thinking

The Story Of

Plane: United Airline 173

Date: December 28 1978

Route: New York to Oregon

Departure : 2:47 PM

Est Arrival : 5:15 PM

Landing Gear Lights not on (5:10)

Thud Sound (5:10)

5:10 PM: Near Arrival. landing gears not followed the usual pattern. (Risk landing with no landing gears: LOW)

5:10 PM: Placed plane onto “holding pattern”

5:10 PM: Captain worried about the Landing Gears. Could not identify problem.

5:46 PM: Engineer advised captain warning fuel reserves low (Risk increases from LOW to HIGH for every minute after

5:51PM for not doing a land attempt) Captain focused still on landing gears problem.

5:50 PM: Engineer advised captain warning fuel reserves 2nd time. Captain replied there were 15 minutes left. Captain

focused still on landing gears while engineers already knew fuel reserves was the highest risk but could not disobey the

captain orders.

6:06 PM: The plane was falling down 3,000 feet per minute. Captain was not aware of the cause until engineers told it was

due to fuel. (The plane crashed with 10 people killed out of 189 passengers and crew)

(Days after): Pilot in hospital wanted the investigator to check if there was any leaks on the fuel tank.

Warning Fuel Reserves low (5:46)

THE PROBLEM WAS THE LANDING GEAR?

Similar airplane accidents with more fatalities happened before

1. DC8: While flying to Chicago, had problem landing gear and ended crashing on a mountain

2. Eastern Airline 401: While flying to Miami, due to no landing gear lights, landed on everglades killing 101 people

Norms of the aviation industry was the problem

Problem: 1. Pilot was too focused on the landing gear and not for any other arising problems, losing the sense of time.

2. Pilot did not got the sense of urgency from others because engineers couldn’t challenge the captain’s orders.

Solution: 1. Have a checklist the pilot/crew would check every X minutes for the main components of the airplane

2. Assertiveness lessons must be addressed not only from engineers, but pilots too

Did the aviation industry said only sorry and forgot the problem?

Accidents reports are disclosed to everyone

Independent investigators are allowed to examine the issue The black box is opened

Airplane Industry gets less credibility, but addresses the problem

so future similar events do not happen

Answer: Aviation industry makes a black box become a white box

Healthcare industry NormsCurrent Situation

1. Under budget constraints.

2. Trying to cut as much costs as possible

3. Does not want in the short term to deal with liabilities

4. R&D: Improving procedures of better services not within the budget

The story of

Lucile Packard Children’s Hospital in Palo Alto vs Johns Hopkins Hospital

Meet Nora, the victim of 4 central line infections Children’s Hospital in Palo Alto

Symptoms: Fainting episodes due to pulmonary hypertension

October 2012 (Age 3): Admitted on hospital

November 2013 (Age 4): Last day of her Life

Children’s Hospital in Palo Alto

Had to be administered a drug through central line for her symptoms

February 13 2013: Central line infection identified.

February 14 2013: Doctors and surgeons had to "remove a lot of pus from the central line tunnel after the line was removed.“

April 2013: Another central line infection identified . Living in the hospital (Hearts and lungs become increasingly weak)

November 2013: Another central line infection identified. Contacted parainfluenza 1, a respiratory virus

Mother sent a letter to hospital investigate why her daughter died due to central line infections, with notes including, such as

“We also observed nurses …touching bedrails after they put their gloves on and then not changing their gloves before

accessing the line”

The hospital’s response?

Unfortunately, the placement of central lines is associated with a risk of infection.

There is a risk of infection — in the best of circumstances — which can never entirely be eliminated.

Please be assured that multiple procedural protocols are in place to promote hand washing techniques.

We understand and recognize your feelings regarding Nora's care, and we apologize that you were dissatisfied with your

experience at LPCH

They did not address the case

The mother filed a lawsuit

Did the hospital address the issue after her mother filed a lawsuit in order to get more information about the case?

Due to patient privacy issues, as well as the fact that the matter is now in

litigation, we cannot comment on the specifics of the allegations. But we

can say that our entire organization is committed to collaborating with

families on ways to continuously improve, and we are proud of our

commitment to quality and patient safety

Could it be that the sorry letters are:

Numerous studies show, somewhat counterintuitively, that patients

who receive apologies from hospitals are less likely to pursue legal

action.

Meet Johns Hopkins Hospital where “There is a risk of infection — in the best of circumstances — can entirely be eliminated.”

In summary, they found the problem like the airplane industry did, and added the following procedures to be done by using “a checklist” they had to explicitly check for every step done to every staff that inserted a central line (no exceptions)

ResultsCentral Line Infections

-Decreased by 50% in 3 months

-Decreased by 70% in 6 months

Old History Repeats Again

Dr. Semmelweis

Despite various publications of results where hand washing reduced mortality to below 1%, Semmelweis'sobservations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community

In 1865, Semmelweis was committed to an asylum, where he died at age 47 of pyaemia, after being beaten by the guards, only 14 days after he was committed (Wikipedia)

First Clinic: “No hand washing” Second Clinic: “Hand washing”

On April 1, 2016, the National Health Service of England has invited Matthew Syed, the author of "Black Box Thinking",

by the Secretary of State for Health to help draft the proposals that come into force for addressing such issues.

Health care may indeed be under-resourced, but it would save money by learning from mistakes.

Cost of medical errors United States: $17 billion

Criminal Justice: Are lawyers seeking the truth?

The story of:

Juan Rivera

Innocent man convicted for the rape murder Holly Staker

1992-2012

1992: Juan Rivera, having psychological problems, at age 19, was pushed under grueling examination,

became “psychotic”, confessed on the 3rd day of the examination that he was the murderer by signing a letter.

With no witnesses and physical evidence matching the murder, he was convicted first-degree murder.

2005: DNA tests found no match with the semen of the murder case with Juan Rivera. Lawyers twisted the story

that Juan Rivera murdered her after another person did intercourse and left.

2009: Re-trial of 2005 against DNA evidence. Prosecutors were able to wrap up a story Juan Rivera was still guilty.

2012: Re-trial of 2009 against DNA evidence. Juan Rivera found innocent and released from prison.

The trial of Juan Rivera

Aftermath of Aviation, Healthcare, Criminal Justice Systems Template

Evidence that I receive

Locked,

Theory

Cannot

Change

“My theory” black box Others theory story “black box”

Twist or warp the evidence to fit

Actual Evidence

Fits without altering

the content

Focus Only Ignore Motivation for suppressing this path

Aviation (Example 1)

Landing Gear

Locked,

Theory

Cannot

Change

My people rely on me fixing the landing gears Whatever is the highest priority, I should be attentive

about it. The low fuel sounds critical.

This is the most important thing

right now is the landing gear.

Landing Gear, Low Fuel

Find the highest priority,

Listen to crew (New Norms)

Focus Only Ignore

I am an expert at this. I cannot fail my people

Would be embarrassing for my career

If I land without gears (hiding bad habit)

Healthcare (Example 2)

Central Line Infections

Locked,

Theory

Cannot

Change

Central Line Infections, even at best circumstances, happens Central Line Infections are reduced with better

Sanitary practices.

It is impossible to avoid. Make sure

to apologize customer to avoid

Liabilities.

Central Line Infections

Admit mistakes.

Give more strict rules

For staff to follow

For inserting a line.

Focus Only Ignore

We still need be the top hospital accredited

(Privacy)

Criminal Justice System (Example 3)

Testimony, DNA not matching results

Locked,

Theory

Cannot

Change

All that matters is the guy testified It is reasonable that the suspect is less likely to

Be the murder with decisive evidence

The testimony is all that matters.

The DNA is due to someone else doing

Rape on her before he murdered her.

Testimony, DNA not matching results

The DNA confirms that the

Victim is less likely to be the

murderer, having less proof

for the individual being guilty

Focus Only Ignore I can’t lose face to my client (self-interest)

If a theory does not fit with the actual evidence

And we are forced to adjust our evidence to such theories for otherwise it makes us get the “stick”

Then we are doing a disservice to this society for not showing our correct methodology

Can a theory “king” still retain its seat

even when new evidence contests him?

When our individuality is threatened, is it actually “rightfully” threatened?

Or does the paradigm of society need to change for not punishing people who give a better theory?

Both us as well society has to change in a way that we can deal personal matters in scientific way.

Neurology, Neuroscience, and Human Behavior are the keys to unlocking the right formula how

people should behave to make a better community.

We should treat our personal matters in a scientific way and not as a mystery. Then we will be

more on the correct path and less dealing our personal matters like cavemen.

Main Sources:

http://www.bbc.com/news/health-35929557 (What can doctors learn from pilots and cyclists?)

http://www.vox.com/2015/7/9/8905959/medical-harm-infection-prevention (Medical Harm Infection Prevention)

http://www.amazon.com/Black-Box-Thinking-People-Mistakes-But/dp/1591848229 (Black Box Thinking, Matthew Syed)

Other acknowledgements

I want to thank also independent researcher Lorin Friesen. To read his research, go to www.mentalsymmetry.com

About Me

If you are interested, you can visit my blog http://softwaredeveloperlife.blogspot.sg/ for more info about my research and

contributions.

My Vision

I am planning to bootstrap a company, I don’t know how long it will be, but it will be a social network website like

Facebook, but its foundations will be based on neurology that focuses only on the personal, that will try to solve problems

like black box thinking and common organizational cultural problems, in such a way, that we don’t need to re-invent

these issues these days like throwing water out of fire. Neurology will have its own independent branch that will behave

In the same format as science and will run in parallel with science, which its role is doing iterative abstractions

that will improve the quality of relationship and communication of people instead of automating tasks in the physical

world so the human can have more time on focusing on abstract stuff instead of concrete manual work.