Black Box Thinking: What Can We Learn From Aviation Health & Safety?
Black Box Thinking by Matthew Syed
'Black Box Thinking' by Matthew Syed

Books about achieving greater success are all too common these days, but this book certainly communicates a message that resonates with me that I think will strike a chord with you too.

I started reading Black Box Thinking: The Surprising Truth About Success because I saw its author, Matthew Syed, on TV talking about how incremental change can produce greater success. What I had not anticipated just how poignant the content of Black Box Thinking would be from a health and safety management perspective.

There are a number of standout references in the book, the most explainable perhaps the different mind-set towards learning within the aviation industry and the healthcare industry.

The difference between aviation and healthcare

The aviation industry once was very dangerous, with many flights ending in disaster. However, through learning and the extreme focus on safety, flying is now the safest form of travel.

Conversely, the health care industry remains responsible for the third biggest killer in the western world: preventable medical mistakes.

This is not to say that in healthcare personnel are less caring - their career choice alone indicates strong diligence and desire to do right. So why is there such a difference in the safety performances of healthcare and aviation?

Once boiled down, the difference is primarily fuelled by attitude.

Mistakes are made over and over again where a profession stigmatises error.

Syed talks about the paradox of success, where the mistakes and often lives lost within the aviation industry have contributed to the safety of modern flying. This is partly down to appropriate feedback mechanisms being in place to ensure the industry learns from previous mistakes. If a pilot experiences a near miss, a report is logged.

In the health care industry where there is a significant presence of blame culture, or when a surgeon makes a mistake, it is not so openly addressed.

What can we learn from aviation?

The clue is in the title. Similar to an airplane's black box, we must record all critical data for investigations and, ultimately, improvements in safety.

In order to learn from our mistakes, an appropriate system must be in place for capturing and reporting on all relevant information. Syed suggests organisations must “interrogate errors as part of their future strategy for success”, which is all too important in the modern landscape of health and safety management.

Instead of viewing errors or near-misses as events that need blamed on someone, we should view them as opportunities for learning, and to improve the safety of our workplaces. We can do that by ensuring absolutely everything is recorded, analysed, and in-turn avoided in future.

Spanish philosopher George Santayana put it quite nicely when he said “Those who do not remember the past are condemned to repeat it.”

Reporting near-misses and incidents is extremely important, but how we then deal with this information is even more integral. Below are some pointers on how you can add value to your safety data.

Turn data into information

The options for safety software seem endless. To get the most out of your data, you need to be looking at a solution that has powerful reporting capabilities and that is able to generate KPIs and understandable, tailorable charts of information.

Analyse what went wrong

Putting the effort into investigating what caused an incident is paramount in improving your safety performance. It’s all very well to produce a fancy report of the data, but what you do with that information is what makes the difference.

Having a safety program that can provide investigation workspaces will be useful in this process. Once you’ve conducted root cause analysis and determined the cause, steps can be taken to avoid the same problem in the future.

Monitor, learn, and improve

The data’s been recorded, reports have been produced, investigations have discovered causes, and changes have been made. What to do now?


An essential part of making changes is checking in on their impacts. Has altering that practice as a result of that incident reduced subsequent unsafe observations?

Effective health and safety management should promote continual progress; without progress, words such as success, improvement and achievement have little meaning (and if you’re big on quotes, you’ll have picked up the Franklin reference).

This is essentially Syed’s message, but with a safety spin: just like the aviation industry, we must treat failure as a learning experience in order to progress in solving problems and forming strategies for the future.

Anyone looking to promote near miss reporting within their business should add this book to their Christmas list. It’s full of facts, figures, studies and true insight into the possibility of improving the workplace and the wider world we live in by turning failure into success.

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  • Murray Ferguson

    Murray is the Commercial Director at Pro-Sapien Software and has been involved in providing business intelligence IT solutions to some of the world's largest companies for over 15 years. He is particularly interested in using modern technologies for improvements in EHS performances, striving to support business processes and promote safety best practice in high-risk industries.

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