Précis: Chain of ‘Mistakes’

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Whether it is a physical disaster, a political blunder, a corporate misstep, or a strategic mistake, there’s a unique set of compounding errors that leads to every disaster. However, there’s a common pattern in the crises that end in disaster.

First, there is an initial problem, often relatively minor in isolation, which goes uncorrected.

Second, there is a subsequent problem that compounds the effect of the initial problem usually in conjunction with an inept attempt at correction.

Third, there is disbelief at the accelerating seriousness of the situation.

Fourth, an attempt is made to hide the truth about what is going on, while corrective efforts get under way.

Fifth, there is a sudden recognition that the situation is out of control, or “in extremis.”

And finally there is the play-out of the ultimate disaster involving significant loss of life, financial resources, or both … followed by recriminations.

A recurring theme is failure to acknowledge that there’s a problem, failure to investigate and get to understand the problem and failure to learn. A series of bad judgment calls leads to a series of interrelated, harmful consequences … and disaster.

What should you do as a manager of a complex organization, or part of it?

The first step is to acknowledge that most classic disasters are the result of an unbroken chain of ineffectively managed events; a single mistake seldom results in disaster.

Second, understand that the benefit/cost ratio of breaking the mistake chain early in most cases is almost infinite.

Third, create an atmosphere/culture that allows mistakes to be discovered and corrected in a positive fashion.

Fourth, use case studies and examples to educate others to the danger of not managing multiple mistakes.

Fifth, make it the personal responsibility of every individual in the organization to identify mistakes/failures and “stop the production line.” It’s a valuable opportunity to learn.

The goal is not for companies to be mistake-free, Mittelstaedt says. “If you do not make any mistakes, you may not be taking enough risks, and failing to take any risks at all may be the most dangerous type of mistake a business can make.” The objective instead is to “find ways to stop mistakes quickly once they are made, and to learn from them in the process.”

http://knowledge.wharton.upenn.edu/article.cfm?articleid=1068; http://knowledge.wharton.upenn.edu/article.cfm?articleid=1021 

Will Your Next Mistake Be Fatal? Avoiding the Chain of Mistakes that Can Destroy Your Organization (Pearson Prentice Hall, 2004) by Robert E. Mittelstaedt, available at

Roger Stewart.  April , 2020  

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