"This decision was a mistake" or "You made the wrong decision", "what a disastrous decision", we all know these statements only too well, don't we?

In most cases, however, they are only an expression of the diluted and misunderstood handling of the construct "error" and the lack of differentiation between error and fallacy in highly dynamic contexts. 

The small series on the subject of error management comes to an end for the time being summarizing my philosophy about errors, fallacy, decision making in high dynamic markets as well as continuous organizational improvement. 

In Part 1 “Error Management - keeping your mouth shut is the worst thing you can do” I described how to deal with real errors and offered some basic requirements to avoid so-called errors. 

In Part 2 “Error management Part 2 - when overconfidence is knocking on your door to kill you” I outline an experience in which cockiness and arrogance led to a real mistake and almost to me killing myself.

In Part3 “Error Management part 3 - Maintain aircraft control, analyze situation, take proper action” I describe the difference between error and real mistakes based on a dramatic experience, which almost not only cost my life, but also that of my student pilot.

In Part 4 “Error Management Part 4 - in the absence of knowledge” I used the situations from Part 2 and 3 to explain the difference between fallacy following decision making and real mistakes/errors.

In Part 5 - “Error Management Part 5 - The final cut” I would now like to give brief food for thought to think about the differentiation between error and fallacy, the dangerous effect of tolerating errors and the potential of errors and fallacy to improve one's own organization and thus value creation.

Food for thought

• Mistakes happen and are inevitable
• Real mistakes must not be tolerated, because they damage the organization, the company's added value and thus the customer
• In the absence of complete knowledge, you have to decide between options
• Who decides can be wrong, but does not make a mistake
• If complete knowledge is available , there is only one option and a decision is needless
• Mistakes can only occur if no decisions have to be made.
• The unpredictability - see also the article “Preparation vs Planning - the illusion of predictability” - of future developments in dynamic markets/context/environment requires the willingness to make decisions and accept the uncertainty that comes with it
• Risk taking, acceptance of uncertainty and decision making are directly connected and go hand in hand
• A fallacy is not a mistake and as such is only an expression of the willingness to make decisions in high dynamic environments
• Mistakes must not be tolerated and are inevitably subject to consequences in order to protect the organization, the value creation and the customer 
• When real errors are tolerated the organization will slowly learn that laws, processes and specifications are irrelevant and hence the organization will degrade in it´s quality
• The consequences of mistakes can be depersonalized to increase the improvement potential for value creation

When I write that real mistakes must not be tolerated, it seems to contradict my view from Part 1. This statement may even give the impression of a sanction-driven attitude towards dealing with errors. This is by no means the case. Mistakes/errors do not necessarily have to be sanctioned, although they cannot be tolerated. See also Part 3 of the series. I made a real mistake by prematurely taking control of the aircraft -> full knowledge was available and the situation was therefore decision-free. And yet this error was not sanctioned. Rather, the analysis was used to avoid future errors of this type. I personally made sure to do my part to avoid this mistake by re-professionalizing before attempting any training flights of this type again.

That's what error management is all about. It's not about finding people responsible in order to sanction them. It's about avoiding mistakes made in the future and letting the organization learn from them -> Adaptation of processes, specifications to the needs of value creation. To do this, it is necessary to understand how these errors come about -> systemic analysis. Do they have a systemic cause or an external, environmental one? A technical or humannic? What can be done to avoid real mistakes of this kind in the future?

In today's society and thus also in companies, organizations and teams too often tend to personify mistakes and problems in order to be able to sanction them. 

How often do we hear the call to blame?

The problem is, tah this encourages a less conducive culture that is not geared towards understanding and avoiding the causes of mistakes, continuous improvement and enhancing value creation but rather towards punishing mistakes made, blaming and maintaining status quo, which will also avoid people making valuable decisions just in order to avoid blaming and sanctions. This will inevitably lead to a degradation of value creation for the customer. In the cockpit and in aviation in general, a fatal culture that would not lead to more safety but to less safety with fatal consequences. 

Error Management is all about understanding and improvement.

Mistakes are made, errors occur, we cannot and should not deny this fact. We can only deal with them constructively if we differentiate errors from fallacy following decision making and seek best ways to improve. From my point of view, this is an indispensable element for working together in teams and organizations especially in today's high dynamic markets.

Want to learn more about my experience and philosophy in error management and leadership in high dynamic markets? Give me a call, then I´ll fly with you……

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