Black Box Thinking

by Matthew Syed

  ALSO BY MATTHEW SYED

  Bounce: The Myth of Talent and the Power of Practice

  PORTFOLIO / PENGUIN

  An imprint of Penguin Random House LLC

  375 Hudson Street

  New York, New York 10014

  penguin.com

  Copyright © 2015 by Matthew Syed

  Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader.

  First published in Great Britain by John Murray (Publishers), an imprint of Hodder and Stoughton, a member of The Hachette UK Group

  ISBN 978-0-698-40887-6

  Version_1

  For Kathy

  Contents

  Also by Matthew Syed

  Title Page

  Copyright

  Dedication

  Part I

  THE LOGIC OF FAILURE

  Chapter 1

  A Routine Operation

  Chapter 2

  United Airlines 173

  Chapter 3

  The Paradox of Success

  Part II

  COGNITIVE DISSONANCE

  Chapter 4

  Wrongful Convictions

  Chapter 5

  Intellectual Contortions

  Chapter 6

  Reforming Criminal Justice

  Part III

  CONFRONTING COMPLEXITY

  Chapter 7

  The Nozzle Paradox

  Chapter 8

  Scared Straight?

  Part IV

  SMALL STEPS AND GIANT LEAPS

  Chapter 9

  Marginal Gains

  Chapter 10

  How Failure Drives Innovation

  Part V

  THE BLAME GAME

  Chapter 11

  Libyan Arab Airlines Flight 114

  Chapter 12

  The Second Victim

  Part VI

  CREATING A GROWTH CULTURE

  Chapter 13

  The Beckham Effect

  Chapter 14

  Redefining Failure

  Coda: The Big Picture

  Acknowledgments

  Notes

  Index

  Part I

  THE LOGIC OF FAILURE

  Chapter 1

  A Routine Operation

  I

  On March 29, 2005, Martin Bromiley woke up at 6:15 a.m. and made his way to the bedrooms of his two young children, Victoria and Adam, to get them ready for the day. It was a rainy spring morning, a few days after Easter, and the kids were in high spirits as they sprinted downstairs for breakfast. A few minutes later, they were joined by Elaine, their mother, who had snatched a few extra minutes in bed.

  Elaine, a vivacious thirty-seven-year-old who had worked in the travel industry before becoming a full-time mother, had a big day ahead: she was due in the hospital. She had been suffering from sinus problems for a couple of years and had been advised that it would be sensible to have an operation to deal with the issue once and for all. “Don’t worry,” the doctor had told her. “The risks are tiny. It is a routine operation.”1

  Elaine and Martin had been married for fifteen years. They met at a country dance through a close friend, had fallen in love, and eventually moved in together in a house in North Marston, a cozy village in the heart of rural Buckinghamshire, thirty miles northwest of London. Victoria had arrived in 1999 and Adam two years later, in 2001.

  Life was, as for many young families, hectic, but it was also tremendous fun. They had been in an airplane for the first time as a family the previous Thursday and had gone to a friend’s wedding on the Saturday. Elaine wanted to get her operation out of the way so she could enjoy a few days’ break.

  At 7:15 a.m., they left home. The kids chatted in the car as they made the short journey to the hospital. Martin and Elaine were relaxed about the operation. The ear, nose, and throat (ENT) surgeon, Dr. Edwards, had more than thirty years of experience, and was well regarded. The anesthetist, Dr. Anderton, had sixteen years of experience.* The hospital had excellent facilities. All was set fair.

  When they arrived they were shown to a room where Elaine was put into a blue gown for her operation. “How do I look in this?” she asked Adam, who giggled. Victoria climbed up onto the bed so that her mother could read to her. Martin smiled as he listened to a plot that was, by now, familiar. On the windowsill, Adam played with his toy cars.

  At one point Dr. Anderton came in to ask a couple of standard questions. He was chatty and in fine humor. Like any good doctor, he understood the importance of setting a relaxed tone.

  Just before 8:30 a.m., Jane, the head nurse, arrived to wheel Elaine into the operating room. “Are you ready?” she asked with a smile. Victoria and Adam walked alongside the gurney as it rolled down the corridor. They told their mother how much they were looking forward to seeing her in the afternoon, after the operation. As they reached a junction in the corridor, Martin ushered his children to the left as Elaine was wheeled to the right.

  She leaned up, smiled, and cheerily said: “Byeeee!”

  As Martin and the kids were walking into the parking garage—they were going to the supermarket to do the weekly shopping and buy a treat for Elaine (cookies)—Elaine’s gurney was being wheeled into the pre-operating room. This room, adjacent to the operating room, is where last-minute checks are made and the general anesthetic administered.

  Dr. Anderton was with her: a familiar and reassuring face. He inserted a straw-shaped tube called a cannula into a vein in the back of her hand, which would deliver the anesthetic directly into her bloodstream.

  “Nice and gently,” Dr. Anderton said. “Here you go . . . into a deep sleep.” It was now 8:35 a.m.

  Anesthetics are powerful drugs. They don’t just send a patient to sleep; they also disable many of the body’s vital functions, which have to be managed artificially. Breathing is often assisted using a device called a laryngeal mask. This is an inflatable pouch that is inserted into the mouth and sits just above the airway. Oxygen is then pumped into the airway, and down into the lungs.

  But there was a problem. Dr. Anderton couldn’t get the mask into Elaine’s mouth: her jaw muscles had tightened, a familiar problem during anesthesia. He delivered an additional dose of drugs to loosen the muscles, then tried a couple of smaller laryngeal masks but, again, couldn’t insert them.

  At 8:37, two minutes after being put under, Elaine was beginning to turn blue. Her oxygen saturation had fallen to 75 percent (anything below 90 percent is “significantly low”). At 8:39 Dr. Anderton responded by trying an oxygen face mask, which sits over the mouth and nose. He still couldn’t get air into her lungs.

  At 8:41 he switched to a tried-and-tested technique called tracheal intubation. This is standard protocol when ventilation is proving impossible. He started by delivering a paralyzing agent into the bloodstream to completely disable the jaw muscles, allowing the mouth to be fully opened. He then used a laryngoscope to cast a light into the back of the mouth, helping him to place a tube directly into the airway.

  But he hit another snag: he couldn’t see the airway at the back of the throat. Normally, this is a neat, triangular hole, with the vocal cords to either side. It is usually quite easy to push the tube into the airway and get the patient breath
ing. With some patients, however, the airway is obscured by the soft palate of the mouth. You just can’t see it. Dr. Anderton pushed on the tube again and again, hoping that he would find the target, but he couldn’t get it in.

  By 8:43 Elaine’s oxygen saturation had dropped to 40 percent. This was so low it represented the lower limit of the measuring device. The danger is that, without oxygen, the brain will swell, causing potentially serious damage. Elaine’s heart rate had also declined, first to 69 beats per minute, then 50. This indicated a lack of oxygen to the heart too.

  The situation was becoming critical. Dr. Bannister, an anesthetist in the adjacent operating room, arrived to provide assistance. Soon Dr. Edwards, the ENT surgeon, had joined them too. Three nurses were on standby. The situation was not yet disastrous, but the margin for error had started to shrink. Every decision now had potentially life-and-death consequences.

  Thankfully, there is a procedure that can be used in precisely this situation. It is called a tracheotomy. All the setbacks so far had been in trying to access Elaine’s airway via her mouth. A tracheotomy has one huge advantage: you don’t go near the mouth. Instead, a hole is cut directly into the throat and a tube inserted into the windpipe.

  It is risky, and used only as a last resort. But this was a last resort. It was now possibly the only thing standing between Elaine and life-threatening brain damage.

  At 8:47 the nurses correctly anticipated the next move. Jane, the most experienced of the three, darted out to fetch a tracheotomy kit. When she returned, she informed the three doctors who were now surrounding Elaine that the kit was ready for use.

  They shot a glance back, but for some reason they didn’t respond. They were continuing to try to force the tube into Elaine’s concealed airway at the back of her mouth. They were absorbed in their attempts, craning their necks, talking hurriedly with each other.

  Jane hesitated. As the seconds ticked by, the situation was becoming ever more critical. But she reasoned that three experienced consultants were at hand. They had surely considered the use of a tracheotomy.

  If she called out again, perhaps she would distract them. Perhaps she would be culpable if something went wrong. Perhaps they had ruled out a tracheotomy for reasons she hadn’t even considered. She was one of the most junior people in the room. They were the authority figures.

  The doctors had, by now, significantly elevated heart rates. Perception had narrowed. This is a conventional physiological response to high stress. They continued to try to insert the tube into the airway at the back of the throat. The situation was becoming desperate.

  Elaine was now a deep blue. Her heart rate was a mere 40 beats per minute. She was starved of oxygen. Every second delayed was narrowing her chances of survival.

  The doctors persisted in their increasingly frantic attempts to access the airway via the mouth. Dr. Edwards tried intubation. Dr. Bannister attempted to insert another laryngeal mask. Nothing seemed to work. Jane continued to agonize over whether to speak up. But her voice died in her throat.

  By 8:55 it was already too late. By the time the doctors had finally gotten oxygen saturation back up to 90 percent, eight minutes had passed since the first, vain attempt at intubation; in all, she had been starved of oxygen for twenty minutes. The doctors were astounded when they looked at the clock. It didn’t make sense. Where had the time gone? How could it have passed so quickly?

  Elaine was transferred to intensive care. A brain scan would later reveal catastrophic damage. Normally, with a scan, it is possible to clearly make out textures and shapes. It is recognizably a picture of a human brain. For Elaine the scan was more like television static. The oxygen starvation had caused irreparable harm.

  At 11 a.m. that morning, the phone rang in the living room of the Bromiley home in North Marston. Martin was asked to return to the hospital as soon as possible. He could tell that something was wrong, but nothing prepared him for the shock of seeing his wife in a coma, fighting for her life.

  As the hours passed, it became clear that the situation was deteriorating. Martin couldn’t understand it. She had been healthy. Her two kids were at home waiting for her to return. They had bought the cookies from the supermarket for her. What on earth had gone wrong?

  He was taken to one side by Dr. Edwards. “Look, Martin, there were some problems during the anesthesia,” he said. “It is one of those things. Accidents sometimes happen. We don’t know why. The anesthetists did their very best, but it just didn’t work out. It was a one-off. I am so sorry.”

  There was no mention of the futile attempts at intubation. No mention of the failure to perform an emergency tracheotomy. No mention of the nurse’s attempt to alert them to the growing disaster.

  Martin nodded and said: “I understand. Thank you.”

  At 11:15 p.m. on April 11, 2005, Elaine Bromiley died after thirteen days in a coma. Martin, who had been at her bedside every day, was back at the hospital within minutes. When he got there Elaine was still warm. He held her hand, told her that he loved her, and said that he would look after the kids as best he could. He then kissed her good night.

  Before returning the following day to collect her belongings, he asked the children if they wanted to see their mother one last time. To his surprise, they said yes. They were led into a room and Victoria stood at the end of the bed, while Adam reached out to touch his mother and say good-bye.

  Elaine was just thirty-seven.

  II

  This is a book about how success happens. In the coming pages, we will explore some of the most pioneering and innovative organizations in the world, including Google, Team Sky, Pixar, and the Mercedes Formula One team as well as exceptional individuals like the basketball player Michael Jordan, the inventor James Dyson, and the soccer star David Beckham.

  Progress is one of the most striking aspects of human history over the last two millennia and, in particular, the last two and a half centuries. It is not just about great businesses and sports teams, it is about science, technology, and economic development. There have been big-picture improvements and small-picture improvements, changes that have transformed almost every facet of human life.

  In these accounts we will attempt to draw the strands together. We will look beneath the surface and examine the underlying processes through which humans learn, innovate, and become more creative: whether in business, politics, or in our own lives. And we will find that in all these instances the explanation for success hinges, in powerful and often counterintuitive ways, on how we react to failure.

  Failure is something we all have to endure from time to time, whether it is the local soccer team losing a match, underperforming at a job interview, or flunking an examination. Sometimes, failure can be far more serious. For doctors and others working in safety-critical industries, getting it wrong can have deadly consequences.

  And that is why a powerful way to begin this investigation, and to glimpse the inextricable connection between failure and success, is to contrast two of the most important safety-critical industries in the world today: health care and aviation. These organizations have differences in psychology, culture, and institutional change, as we shall see. But the most profound difference is in their divergent approaches to failure.

  In the airline industry the attitude is striking and unusual. Every aircraft is equipped with two almost-indestructible black boxes, one of which records instructions sent to the onboard electronic systems, and another that records the conversations and sounds in the cockpit.* If there is an accident, the boxes are opened, the data is analyzed, and the reason for the accident excavated. This insures that procedures can be changed so that the same error never happens again.

  Through this method aviation has attained an impressive safety record. In 1912, eight of fourteen U.S. Army pilots died in crashes: more than half.2 Early fatality rates at the army aviation schools were close to 25 percent. At the time this didn’t
seem entirely surprising. Flying large chunks of wood and metal at speed through the sky in the early days of aviation was inherently dangerous.

  Today, however, things are very different. In 2013, there were 36.4 million commercial flights worldwide carrying more than 3 billion passengers, according to the International Air Transport Association. Only 210 people died. For every one million flights on Western-built jets there were 0.41 accidents—a rate of one accident per 2.4 million flights.3

  In 2014, the number of fatalities increased to 641, in part because of the crash of Malaysia Airlines Flight 370, where 239 people died. Most investigators believe that this was not a conventional accident, but an act of deliberate sabotage. The search for the black box was still ongoing at the time of publication. But even if we include this in the analysis, the jet accident rate per million takeoffs fell in 2014 to a historic low of 0.23.4 For members of the International Air Transport Association, many of whom have the most robust procedures to learn from error, the rate was 0.12 (one accident for every 8.3 million takeoffs).5

  Aviation grapples with many safety issues. New challenges arise almost every week: in March 2015, the Germanwings plane crash in the French Alps brought pilot mental health into the spotlight. Industry experts accept that unforeseen contingencies may arise at any time that will push the accident rate up, perhaps sharply. But they promise that they will always strive to learn from adverse events so that failures are not repeated. After all, that is what aviation safety ultimately means.

  In health care, however, things are very different. In 1999, the American Institute of Medicine published a landmark investigation called “To Err Is Human.” It reported that between 44,000 and 98,000 Americans die each year as a result of preventable medical errors.6 In a separate investigation, Lucian Leape, a Harvard University professor, put the overall numbers higher. In a comprehensive study, he estimated that a million patients are injured by errors during hospital treatment and that 120,000 die each year in America alone.7