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Palgrave Macmillan

Confronting Mistakes

Lessons from the Aviation Industry when Dealing with Error

ISBN 9781137276179
Publication Date September 2013
Formats Hardcover Ebook (EPUB) Ebook (PDF) 
Publisher Palgrave Macmillan

Mistakes are unavoidable. Yet in most organizations, they are rarely thoroughly examined. An exception is the high-risk aviation industry, where experts have established an open and democratic culture for dealing with error.
Confronting Mistakes draws on this expertise to initiate a new framework for active error management relevant to wider industry. By analyzing dramatic aviation accidents, Jan Hagen presents a new approach to error management in business to reveal how diagnostic, error-permissive behaviour is the first step towards turning mistakes into learning opportunities.

JAN U. Hagen is a member of the faculty and director of Open Enrolment Programs at ESMT European School of Management and Technology, Berlin, Germany. His research and teaching focus on leadership, error management, and crisis management; he is particularly interested in the way teams and organizations deal with errors. A pilot himself, he has been studying the interaction of flight crews in the cockpits of airline and military aircraft for several years as part of his research. In addition to his academic work, Jan has more than 15 years of management experience in the European financial services industry. He received his doctoral degree in business administration from Freie Universität Berlin.

Introduction: Why Errors Matter
Case 1: New England Air (NE) 248
Too Scared to Ask
Case 2: Japan Airlines (JAL) 8054
Hope Replaces Action
Case 3: Birgenair 301
Authority and Mental Framing
Case 4: KLM 4805
The Pressure of the Captain's Mood
Case 5: United Airlines 173
Silent Power
Case 6: Avianca 052
Encouragement is not Empowerment
Crew Resource Management
Transforming the Captain's Position – but Preserving the Hierarchical Structure
Surprising Side Effects Led to a Breakthrough
Case 7: United Airlines 811
Copilot Takes Charge
Case 8: United Airlines 232
Flexible Team Enhancement
Case 9: Successful Error Detection and Correction
Copilot Overrules Captain
Case 10: Czar 52
Limits of CRM


'A riveting, at times thriller-like, read…reading this book, and talking about how it could work in your field, might be the beginning of the change you need' - Michael Skapinker, Financial Times
'Confronting Mistakes is a remarkable book. Its gripping case studies of airline disasters will keep readers on the edge of their chairs, and its penetrating analysis is deep and sophisticated. Hagen's writing is highly accessible and engaging and will enlighten everyone from error experts to curious readers in other industries. The book is destined to be a classic in the error field.' Amy C. Edmondson, Novartis Professor of Leadership and Management, Harvard Business School
'Human behavior is a complex ecosystem, but that is no excuse to wave a white flag of surrender. Hagen has done a masterful job of capturing the salient lessons from the high risk field of aviation and made them available to the world. A tip of the hat to a fellow warrior in the battle against human error and their often tragic consequences.'Tony Kern, CEO, Convergent Performance, former B-1B command pilot and Chair of the US Air Force Human Factors Steering Group
'It is a truly excellent work. Everyone who reads it will take something positive away from it.'Captain Robert L. Bragg, First Officer of PanAm 1736, 1977
'Compelling' Andrew Hall, FT
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