How Could This Happen?

The first comprehensive reference work on error management, blending the latest thinking with state of the art industry practice on how organizations can learn from mistakes.

Even today the reality of error management in some organizations is simple: “Don’t make mistakes. And if you do, you’re on your own unless you can blame someone else.” In most, it has moved on but it is still often centered around quality control, with Six Sigma Black Belts seeking to eradicate errors with an unattainable goal of zero.

But the best organizations have gone further. They understand that mistakes happen, be they systemic or human. They have realized that rather than being stigmatized, errors have to be openly discussed, analyzed, and used as a source for learning.

In How Could This Happen? Jan Hagen collects insights from the leading academics in this field – covering the prerequisites for error reporting, such as psychological safety, organizational learning and innovation, safety management systems, and the influence of senior leadership behavior on the reporting climate.

This research is complemented by contributions from practitioners who write about their professional experiences of error management. They provide not only ideas for implementation but also offer an inside view of highly demanding work environments, such as flight operations in the military and operating nuclear submarines.

Every organization makes mistakes. Not every organization learns from them. It’s the job of leaders to create the culture and processes that enable that to happen. Hagen and his team show you how.

Jan Hagen is Associate Professor at ESMT, Germany. His research and teaching focus is on leadership. He is particularly interested in understanding how teams and organizations deal with errors. As well as journal articles, he published the book Confronting Mistakes – Lessons from the Aviation Industry when Dealing with Error (Palgrave Macmillan) in 2013. His research has received media coverage from outlets such as the BBC, The Economist, The Financial Times, Frankfurter Allgemeine Zeitung, The Guardian, Forbes, Handelsblatt, Harvard Business Manager, The Irish Times, Manager Magazin, Spiegel Online, and The Sunday Times. Jan runs the ESMT open programme Leadership under Pressure, and teaches in customized executive education programs and the human factor training of the German Federal Armed Forces. In addition to his academic work, he has more than 15 years of management and consulting experience.

“This is a very important book for the analysis of safety, quality, and employee engagement by focusing in detail on the many explanations for why individual and organizational errors occur, how they consistently create major accidents and organizational failures, and why organizations do not learn effectively from them. The multiple perspectives of the different authors provide a variety of explanations and apply these to many important cases.” (Edgar H. Schein, Professor Emeritus, MIT Sloan School of Management, author of Organizational Culture and Leadership, 5th Ed. (2017))

“Stories of error after the fact inevitably are simple and straightforward. But this conception belies what everyone knows to be true. Underneath simple, linear, obvious stories of error is a more complex reality, a sorrowful reality of actions going wrong. Errors have consequences for organizations, and they have consequences for the humans involved in them. Jan Hagen’s comprehensive volume of essays by a renowned set of scholars could not be timelier or more important for enhancing our understanding of errors and their management. This book is a blessing for scholars looking for new theoretical footholds in what some think has become a moribund domain of research inquiry. And, perhaps more importantly, it is an elemental book for leaders and others trying to manage complex organizational systems.” (Kathleen M. Sutcliffe, Bloomberg Distinguished Professor of Business and Medicine, Johns Hopkins University)