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Black Box Thinking: A Book Review

I am forever sharing books I have read with delegates, colleagues, or friends, which encourages them to share book recommendations with me – a neat way of always having a ‘wish list’ of books to catch up on.  This month’s book recommendation, “Black Box Thinking” by Matthew Syed came from a delegate in one of my courses.

Two things my delegate mentioned about this book made me tingle: – ‘marginal gains’ and ‘growth mindset’.  These are two topics that fascinate me and which I have been referring to in my classes for a little while now – but more on these later.

I’m not a fan of failure and I think most people probably feel the same.  We may feel shame, fear, or even humiliation.  If facing public condemnation due to failure, many individuals and institutions yield to the self-serving need to cast blame on others, including the victims.  Much as it hurts me to admit, I have reverted to these tactics on occasion in the past.

Matthew Syed kicks off with a couple of examples from two very different industries; unfortunately, they were both tragedies. However, it showcases how these industries responded to failure and it is quite enlightening.

One industry is healthcare and a medical team that made mistakes in what should have been a minor surgery.  The other is aviation and a flight crew who failed to make a safe landing.  Both examples resulted in a loss of life that could have been avoided.

Both team leaders held to their initial assessments and ignored fatal contributing factors.  Both professionals remained calm but fixated on their solutions.  In each case, subordinate employees didn’t assert their suggestions and observations.  A professional pecking order held back employees from mentioning facts that could have potentially averted these tragedies.  Even in an emergency, a subordinate frequently feels too intimidated to break this workplace taboo.  This is an issue unto itself, but what fascinated me is the way that the industries dealt with the aftermath of these tragedies.

In the healthcare example, evasion was epidemic.  An in-house panel absolved the operating team after hearing the physicians’ and team members’ accounts.  The doctor described the surgery’s outcome as inevitable or unfortunate.  The hospital culture prevented its executives from seeking or adopting effective error management.

Health care by its nature is highly error-provoking – yet health workers stigmatize fallibility and had little or no training in error management or error detection,” according to Syed.

On the other hand, the aviation industry traditionally regards failures as learning opportunities.  Independent aviation inspectors did more than interview the individuals involved.  They double-checked information from those interviews against data from the airplane’s black box.

Every plane has two black boxes that record data from a flight in progress.  One records electronic instructions and the other records cockpit conversations.  This provides objective information for recreating the circumstances of the crash.  The airline’s independent review panel issued new guidelines within weeks.  It provided assertiveness procedures for junior officers, restructured crew responsibilities to promote better perception, and clarified ambiguous instructions.

This ‘black box thinking’ strategy, which looks at what went wrong, what did we learn and how are we going to prevent this from happening again, has encouraged innovations in aviation since its inception.

Thankfully aviation disasters are few and far between and air travel is considered safer compared to other modes of transport because they use mistakes to learn, inform thinking and improve safety.  The industry’s mindset reflects the scientific methodology that encourages practical tests, like trial and error.  Failure can reveal new perspectives and suggest whether you should support, change, or stop current behaviors and strategies.

“…aviation takes failure seriously…and individuals are not intimidated about admitting to errors because they recognize their value,”

Hence the title of the book ‘Black Box Thinking’ – truly learning from mistakes and failures –– sets the scene to drive high performance by changing your way of thinking.

The author used multiple case studies to illustrate this new way of thinking which was powerfully engaging.

Even small lessons learned can become important because when you put these all together, they can make a big difference in an outcome.

“Marginal gains as a philosophy absolutely depends on the ability to detect and learn from small, often latent weaknesses,”

Marginal gains is the innovative concept of Sir Chris Brailsford, former performance director of British Cycling, and the man who took British Cycling to new heights at the 2008 and 2012 Olympic games and beyond.   When asked about the team’s success, Brailsford said,

It is about marginal gains…The approach comes from the idea that if you break down a big goal into small parts, and then improve on each of them, you will deliver a huge increase when you put them all together.”

This concept has not only been adopted by other sporting disciplines but also in other organizations and there are some great examples in the book.

The author then goes on to explore how black box thinking has helped make breakthroughs in other industries as well.

One example happened at Unilever and the problem they experienced at one of their laundry detergent factories, where severe blockages were occurring in the nozzles of their detergent making machines.  So, they turned to their mathematicians and physicists to study every dynamic of the problem.  They came up with a brilliant design based on their sophisticated theory.  The only problem was that it did not work in practice!

Unilever then turned to their field biologists.  These non-theoretical experts employed the practical power of failure.  After discarding 449 informative failures, they came up with the ideal nozzle for the machines.  Thomas Eddison came to mind as he made 1,000 unsuccessful attempts at inventing the light bulb!

This demonstrates how practical testing supersedes brilliant, untested theory.  Theorists believe scientific progress proceeds down from a well-developed theory through final testing – and initial success improved with minor tweaks.  Field scientists see progress stemming from a complex web of mistakes – with initial failures indicating changes that lead to final success – an iterative process.

Most people share the theorists’ top-down view of progress.  This point of view simplifies life’s complexity to the point of resisting any test of assumed knowledge and denying facts that contradict it.  Top-down denial and a fear of failure may result in paralyzing perfectionism.  For my part, I love the iterative process and use this a lot when looking at designing solutions.

As mentioned at the start, it was both the reference to marginal gains and the growth mindset that piqued my interest in this book.  I immensely enjoyed the book, ‘Mindset’ by Carol Dwek, so I already knew about the benefits of a growth mindset vs. a fixed mindset.  Incidentally, I always thought I would be a growth mindset type of person and for the most part, I am, but it also highlighted how fixed mindsight I sometimes am or have been!

Syed relates the story of David Beckham, an English footballer, and world-class star.  Beckham scored an amazing 65 goals from free-kicks in his career.  From the age of 6, he practiced his techniques in his tiny backyard.  At first, he was pretty average.  Despite failure, he persevered and learned from his mistakes and he finessed his techniques every afternoon as soon as he got home from school.  His mother Sandra, who watched him through the kitchen window, was amazed at how devoted he was.  He had a real appetite for hard work, and this is how he built up his mastery.  When interviewed by Syed, Beckham commented about his free-kick talent,

“When people talk about my free kicks, they focus on the goals.  But when I think about free-kicks, I think about all those failures.  It took tons of misses before I got it right.”

Here are my key take-aways:

  • The way you react to failure is important. Use the lens of study and insight rather than shame and blame.
  • The fear of failure can prevent you from learning from your mistakes.
  • The ‘marginal gains’ strategy calls for breaking down a long-term goal into short-term goals and failures.
  • A ‘growth mindset’ means believing you can improve with practice and perseverance.
  • Members of a ‘pre-mortem’ team pretend it has already failed so they can review it with ‘prospective hindsight’ – which I think is a great idea.

I hope you can put some of these concepts into your daily practices and I highly recommend reading “Black Box Thinking” by Matthew Syed.

Author – Julio Arquimbau 


About InteraWorks

InteraWorks is a global learning company on a mission to elevate the human experience at work. Specializing in professional development and performance enablement, we offer top-rated learning programs based on four defined conditions that must exist for individuals, teams including Effective Edge, Best Year Yet, and the Essentials series. Our integrated learning framework and online tools generate immediate and sustainable breakthroughs in performance. Through decades of working at all levels in enterprise companies across many industries, we’ve built a reputation for helping people and organizations harness their focus, mindset, talent, and energy to produce results that matter most. 


We’ve defined four conditions that must exist for an individual, team, or organization to be effective within the arena of performance and development; Accountability, Focus, Alignment, and Integrity. We’ll continue to explore these and more in our blog and look forward to your engagement and interaction with us. Stay tuned as we engage the edges.