Root Cause Analysis, After Action Review, Post Mortem … These are all excellent opportunities for reflection to help you and your team improve processes and systems.
But there are two questions that can send these reflections in a dangerous direction. One is obvious, the other, not so much.
The obviously dangerous question is, “Whose fault is this?” Not only does it drive people to hide potentially condemning information, but it also distracts from the more helpful questions that highlight systemic issues that transcend the specific actions — or inactions — of individual participants.
But there’s another dangerous question that’s often more insidious, because it feels helpful. And that is, “How will we make sure this never happens again?”
For truly catastrophic or fatal failures this can be a useful question, but I’ve heard it asked for failures that were merely costly, inconvenient, or embarrassing. “But Steve,” you say, “we don’t like costly, inconvenient, or embarrassing failures. What’s wrong with wanting to prevent them?”
Nothing’s wrong with wanting to prevent them.
The danger is in the way the question presumes that absolute prevention is a required outcome.
As you grow in your career, you’ll have to make decisions that come with a certain level of risk of unpleasant outcomes. Many times, the unavoidable cost of efforts to prevent those outcomes is greater than the unlikely cost of the outcomes themselves. An example of this is creating onerous new processes that slow development, increase stress, and promote blame, all in order to prevent specific flaws that are unlikely and embarrassing, just because one of them happened recently.
As you reflect on recent challenges, yes, look for ways to improve your processes to reduce risk and improve outcomes. But don’t let recency bias drive you to overreact and make absolute prevention a required outcome of your response.
These decisions can be hard. If you know someone who’s moving into a role where these kinds of decisions are required, why not let them know about the management and leadership coaching that can help them advance with excellence. Invite them to visit stevedwire.com/talk for a complimentary conversation and see if they qualify for a free, confidential 90-minute leadership coaching session to work through a challenge or decision they’re facing.


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