Will Your Next Mistake Be Fatal?: Avoiding the Chain of Mistakes That Can Destroy Your Organization

by Robert Mittelstaedt

Overview

What catastrophes have in common -- and how to keep them from happening to you!

Introducing M3: the first systematic approach to

• Managing mistakes so they don't lead to disaster
• Building systems that prevent 'failure chains' from spiraling out of control
• Avoiding failures in preparation, strategy, execution, and culture
• Reducing the impact and cost of the mistakes you do make

Also includes coverage of the unique 'mistake chains' facing entrepreneurs and small businesses.

Every business disaster has one thing in common: the people in charge never saw it coming. The warnings were there. They didn't have to wreck their companies and their careers. But they let it happen. This book can keep it from happening to you.

You will make mistakes. If you don't, you're not taking enough risk. But you can make fewer of them. You can catch them early. Keep them cheap. Learn from them. Whether you're in a global enterprise or a garage startup, Robert Mittelstaedt shows how. His techniques apply to everything from culture to strategy, customer safety to market share. They won't just help you avoid catastrophe: they'll help you improve profitability and business value, too.

Stay on track. Stay off the front page of The Wall Street Journal. Read this book.

Product Details

ISBN-13:	9780132716475
Publisher:	Pearson Education
Publication date:	09/28/2004
Sold by:	Barnes & Noble
Format:	eBook
Pages:	336
File size:	1 MB

About the Author

Robert E. Mittelstaedt Jr. is Dean and professor of the W. P. Carvey School of Business, Arizona State University, and former, Vice Dean and Director, Aresty Institute of Executive Education, The Wharton School. He has consulted with organizations ranging from IBM to Weirton Steel, Pfizer to the U.S. Nuclear Regulatory Commission, and is a member of the board of directors of three corporations in electronics and healthcare services businesses.

Mittelstaedt's research interests have included executive learning, corporate governance, IT, and strategy. He formerly directed the Wharton Innovation Center and the Wharton Applied Research Center. Mittelstaedt founded Intellgo, Inc. He served as an officer in the U.S. Navy in nuclear submarines at the height of the Cold War. He is also a licensed commercial pilot with multi-engine and instrument ratings.

© Copyright Pearson Education. All rights reserved.

Read an Excerpt

Introduction: What me worry?

What do the failure of Enron, the Watergate scandal, Three-Mile Island, and most airline crashes have in common? Quite simply, it would be almost impossible to make each of these things happen without a serious sequence of errors that goes unchecked. Whether it is a physical disaster, a political blunder, a corporate misstep, or a strategic mistake, as the investigation unfolds, we always find out that it took a unique set of compounding errors to bring the crisis to front-page status.

In many cases these blunders are so complex and the impact so serious that we find ourselves saying, "You couldn't make that happen if you tried." The difference between organizations that end up on the front page of a national newspaper in a negative light, those you never hear about, and those that end up on the front page in a positive light, is the process of "Managing Multiple Mistakes (M3)."

It has long been known that most man-made physical disasters are the result of a series of mistakes. In most cases, if one can find a way to "break the chain" a major catastrophe can be avoided. This recognition of failure chains in operating aircraft, trains, nuclear power plants, chemical plants, and other mechanical devices has led to an emphasis on understanding causes and developing procedures, training and safety systems to reduce the incidence of accidents and mitigate damage if one does occur. Strangely, there has been little emphasis on extending this process to help avoid business disasters – whether operational or strategic.

Enron, WorldComm and HealthSouth are now widely known as major business disasters.Enron might even be classified as a major economic disaster given the number of employees, pensions and shareholders affected at Enron and their accountants, Arthur Andersen. As investigations unfolded we learned that none was the result of a single bad decision or action. Each involved a complicated web of mistakes that were either unnoticed, dismissed as unimportant, judged as minor or purposely ignored in favor of a high-risk high-payoff gamble.

This book is about the avoidable traps that we set for ourselves as business people that lead to disasters. It is about what we can learn from the patterns of action or inaction that preceded disasters (sometimes called "accidents") in a variety of business and non-business settings in order to avoid similar traps and patterns of mistakes. This goes beyond kaizen and six-sigma on the factory floor to M3 or "Managing Multiple Mistakes" in the executive suite and all operational levels of companies.

This is not a book about crisis management. It is not about managing public relations, the victims, the lawyers or the shareholders. It is about discipline, culture and learning from the experiences of others that will improve the odds you can avoid the things we label as accidents, disasters or crises altogether. Even if you do not totally avoid such a situation, knowledge of the typical patterns that occur should help you create an organization that is observant enough to intervene early and minimize damage. Learning and implementing the lessons described here will not mean that you throw away your plans for handling problem situations. But it could mean that you will never have to manage the aftermath of an unpleasant situation.

There are lessons to be learned from looking at the mistake patterns and commonalities in other organizations, especially since most organizations do not do a very good job of evaluating their own mistakes where they have the most information. We miss learning opportunities by not being curious enough to look deeply at our own failures, but we miss a very rich set of opportunities when we do not look at the mistakes others have made, especially when they have been well documented. We often miss these opportunities to learn from others because we believe "Their situation was different – we don't have much to learn from them."

The reality is very different, because study shows that while the specifics may be different across industries and situations, the patterns of mistakes preceding accidents are quite similar. Learning is not always from the sources that you expect like you own experience, your own industry or very similar companies. It takes a bit of extra effort, but you can often learn more by looking at examples in an industry or situation that is markedly different from your own and recognizing that there are great similarities in the patterns of actions and behaviors. This is because without the burden of a set of assumptions around what you "know" is the right or wrong way to do something, it is easy to observe the salient facts, absent all the distracting details and quickly say to yourself something like:

• Didn't they know water would boil if they lowered the pressure? (Three Mile Island)
• Why did they fail to follow the procedure and fly into the ground? (Korean Air)
• Didn't they know customers would want a replacement for a defective chip? (Intel)
• Don't they know that customers are often more loyal if you admit a mistake and fix it? (Firestone)
• Didn't they know the leverage and/or fraud might kill the company? (Enron, WorldComm, HealthSouth)
• Didn't NASA learn anything the first time? (Columbia)
• Why is J&J legendary for its handling of the Tylenol crisis over 20 years ago?
• How did a United Airlines crew minimize loss of life with a crash landing where "everything" went wrong? (UA-232 at Sioux City, Iowa)

In each case with crises that have adverse outcomes there is a very common pattern:

• An initial problem, often minor in isolation, that goes uncorrected
• A subsequent problem that compounds the effect of the initial problem
• An inept corrective effect
• Disbelief at the accelerating seriousness of the situation
• Generally, an attempt to hide the truth about what is going on while an attempt is made at remediation
• Sudden recognition that the situation is out of control, or "in extremis"1
• 
  Finally, the ultimate disaster scenario involving significant loss of life, financial resources, or both and ultimately, the recriminations.

We will explore a number of famous and not so famous disasters or near disasters from the perspective of the mistake sequence and where it might have been broken to change the outcome, or was broken to minimize the damage. We will call your attention to the mistakes so that you might think about the signals that were present and how you, in an ideal world, might have acted differently.

The mistakes identified are usually the result of direct action or inaction by humans. In many scenarios the mistake sequence was initiated with equipment malfunctions that were known but not taken into account in decision making. In other situations the mistakes may have been in the design of systems or business procedures that were based on faulty assumptions. Sometimes there were significant uncontrollable initiating or contributing factors, such as equipment failure, a natural weather occurrence or other "act of God." These initiating factors must be considered in decision-making when they are present because while they are not always human in origin, they are a part of the chain of causes that lead to disasters where humans have an opportunity to intervene effectively or ineffectively.

In the past you may have looked at the occurrence of disasters or recovery from near-disasters as a matter of passing interest in the news. We are suggesting that you look a little deeper, learn a little more and stretch a little further for the implications that you can use:

• Is there a disaster waiting to happen in my organization?
• Will we see the signs?
• Will we stop it soon enough?
• Do we have the skills to see the signals and the culture to "break the chain?"
• Are we smart enough to realize that it makes economic sense to care about reducing or stopping mistakes?

Learn from the mistakes of others and envision business success without mistakes, because your future may depend on your ability to do just that. To aid in this quest we will identify some "Insights" linking common themes that come out of the study of mistakes across industries and situations. These will appear appropriately in each chapter and be summarized in a broad way again in Chapter 10.

1 A term from the nautical rules of the road indicating that a collision is virtually unavoidable and the most extreme actions possible must be taken to minimize or avoid damage.

© Copyright Pearson Education. All rights reserved.

Table of Contents

Introduction.

1. The Power of M3 and the Need to Understand Mistakes.

    Patterns of Mistakes and Exponential Growth.

    Deadly Business Mistakes–Strategy, Execution, and Culture.

    Can Technology Change the Odds?

    Mental Preparation, Patterns, and Warning Signs.

2. Execution Mistakes.

     “Fly the Airplane”–Christmas Carols in the Everglades.

    Coca-Cola–Don’t Change the Formula, Change the CEO.

    American Express Surprises the Market with Optima–Then Optima Surprises AmEx.

    Failing to Learn–Air Florida Flies North.

    Breaking the Chain with Skill and Extraordinary Luck–The “Gimli Glider”.

    Webvan–Do You Want Someone to Deliver Your Groceries?

    Why Do We Fail to Learn?

    Insights.

3. Execution Mistakes and Successes as Catalysts for Change.

    Intel and the “Father Knows Best” Response.

    Tylenol Relieves a Headache =.

     “We’re Not Going to Make the Airport”–The Case for CRM.

    New Coke–Understanding Customers and Capabilities.

    Insights: Different Products and Services with Similar Lessons for Transformation.

4. Strategy–How Do You Know It’s a Mistake?

    Xerox–No Walk in the PARC.

    Motorola’s Reinventions–Does a Cat Have Nine Lives?

    Kodak–Doing Everything “Right” for 100 Years.

    Recognizing Strategy Mistakes and Competitive Changes.

5. Physical Disasters with Cultural Foundations and Business Implications

    Titanic.

    Three Mile Island.

    NASA–Launch Unless Proven Unsafe.

    Common Cultural Issues.

    Insights.

    A Note on Big Ships, Big Planes, and Nuclear Power.

    Business Parallels

6. Cultures that Create “Accidents”.

    Myopia as a Fatal Business Disease.

    Ford/Firestone–When the Rubber Leaves the Road.

    Enron–Living on the Edge and Loving It.

7. Mistakes as Catalysts for Cultural Change.

    Fast Food: Customers Will Have It Their Way–Whether You Want Them to or Not.

    Rapid Culture Change in the U.S. Navy Submarine Force: No Second Chances.

    The Grand Canyon Changes Air Traffic Control

    Flying into the Ground–with Everything Working

    Cultural Success: Working Together to Learn in an Emergency–United 232.

    Marketing Your Culture Change.

    Companies/Industries in Need of Cultural Change–for Different Reasons.

8. Economics at Work: Watching Entire Industries Lose It.

    The World Automobile Industry–Trying to Defy the Laws of Economics.

    Number 1 or 2 in Your Industry–Where Did It Come From?

    Old and New Companies: Convergence, Specialization, and Evolution.

    Economic Business Visioning–the EBV Model.

    Flying High and Broke–Applying EBV in Undifferentiated Cutthroat Competition.

9. Mistakes Aren’t Just for Big Companies–Small Company Chains.

    Choose the Right Idea–Then Change It.

    Planning Your Mistakes–The Business Plan.

    Financing–Choose Your Poison.

    Operations–Implementation Is the Difference.

    Stopping the Mistake Sequence in Smaller Companies.

10. Making M3 Part of Your Culture for Success.

    Learning to Evaluate and Believe Early Warnings.

    Learning to Detect Dangerous Patterns and Strategic Blunders.

    The Need for Mistakes.

Appendix A: Summary of Insights.

    From Part 1:

    From Part 2:

    From Part 3:

    From Part 4:

    From Part 5:

    From Part 6:

    From Part 7:

    From Part 8:

    From Part 9:

    From Part 10:

References.

Index.

 

Editorial Reviews

We all make mistakes. It is the magnitude of these mistakes and how we handle them that Mittelstaedt (management, Wharton Sch. of Business) considers here. Mittelstaedt has devised a system he calls M3 for "Managing Multiple Mistakes." He argues that most large-scale errors or disasters are the result of many smaller mistakes multiplied together, a point he illustrates throughout by looking at various events in business and military history. He includes both physical disasters, such as the sinking of the submarine Thresher in 1963, and various airline crashes, as well as corporate failures such as Enron and ongoing problems at Kodak and Xerox. Following each of these cases are summaries of what went wrong and "insights" that identify key ways the original mistakes could have been prevented. All in all, this is a highly readable book full of cautionary tales and advice on how to avoid making similar mistakes in one's own life and business. Recommended for public libraries and academic libraries with large business collections.-Susan Hurst, Miami Univ. Lib., Oxford, OH Copyright 2004 Reed Business Information.

Library Journal

To help businesspeople do things right and avoid the deadly mistakes that can lead to disasters such as those experienced by Enron, the Titanic, and the Space Shuttle Columbia, business professor Robert E. Mittelstaedt Jr. offers advice on building internal systems that trigger alarms before mistakes spiral out of control. In Will Your Next Mistake Be Fatal? he presents 38 insights that can prevent disasters, as well as techniques for identifying and training for worst-case scenarios. He also introduces a systematic approach to managing multiple mistakes. Copyright © 2006 Soundview Executive Book Summaries

Soundview Executive Book Summaries