Why you can't learn from failure: How overconfidence hinders learning

By the fifth episode, there were signs of overconfidence. observe from outside I developed the technology. This time, we will expand the timeline ── Why is the judgment framework not updated after experiencing failure?. Experience is not a sufficient condition for learning. Organizations that repeatedly make the same mistakes, workplaces where the learnings are not retained in the organization despite review meetings, and experts whose judgment habits become more entrenched as they become more experienced -- these are not individual phenomena, but structural phenomena in which overconfidence impedes learning itself. This time,Baruch Fischhof (1946–) Hindsight Bias Research,Chris Argyris (1923–2013) and donald shawn (1930–1997)'s double-loop learning theory,Peter Senge (1947–) Learning Organizations;Karl Wijk (1936–) and Kathleen Sutcliffe High-reliability organization research, Morbidity & Mortality conference in medicine, Just Culture in aviation,james reason (1938–)'s Swiss cheese model, Confucius's ``Make a mistake and don't change it'' -- by weaving together eight perspectives, we depict the structure in which learning does not occur and the manner in which it can be restarted.

01Why doesn't "experience" produce learning?

The phrase "learning from failure" is so widely used that we often don't realize how difficult it is. The findings that have been made through empirical research seem counterintuitive at first glance.Experience is a necessary but not sufficient condition for learning.. No matter how many times we repeat the same mistake, our decision framework often remains the same.

This article deals with the reason. The structures of overconfidence mentioned in Parts 1 to 5 -- defense mechanisms, self-serving bias, confirmation bias, and groupthink -- are all From the experience of failure to updating the framework It works as a mechanism to block this route. Further covered in this article hindsight bias and Confinement to single-loop learning が、その遮断を二重に強化します。学習が起きないのは、意志や能力の問題ではなく、構造の問題です。

"It is one of modern management's most persistent illusions that learning automatically emerges from experience. In reality, unless there are explicit structures within an organization to transform experience into learning, experience often only reinforces existing judgment frameworks." - Peter Senge, The Fifth Discipline (1990)

The structure of this episode is as follows. The first half (sections 2 to 5) traces the four theoretical structures that impede individual and organizational learning, and the second half (sections 6 to 10) unpacks the institutional countermeasures accumulated in the medical and aviation industries, the Eastern ethics of failure, and the on-the-ground practices of materials examiners.

02Hindsight bias -- Fischhoff's findings

An American judgment researcher showed the cognitive psychological basis of why we cannot learn from failure. Baruch Fischhof is. In his 1975 paper “Hindsight is not equal to foresight” he Hindsight Bias has been demonstrated. This is a systematic distortion that makes us feel that an event was "predictable" after it has happened.

"Experimental research has consistently shown that after being informed of an outcome, people systematically estimate the probability of predicting that outcome higher than before knowing the outcome. 'I knew it would happen' is an illusion that is often constructed after the outcome is known, without the individual being consciously aware of it." - From Baruch Fischhoff, Journal of Experimental Psychology: Human Perception and Performance (1975)

The pathway by which hindsight bias impedes learning from failure operates in two stages. First, after a failure occurs, it feels like it was "predictable." This is the true meaning of the feeling when you look back on a decision and say, ``I should have realized that at that time.'' Secondly, therefore Failure is not a problem of judgment framework, but a problem of lack of attention at the time. will be processed as Questions about the judgment framework itself are not raised.

The implications are practical. When you look back on a materials review and end up saying, ``Let's be careful'' or ``Let's be careful next time,'' hindsight bias is almost certainly at work. For learning to persist in organizations, the question of reflection itself needs to shift from a question of attention to a question of framing. This is the starting point for Argyris' double-loop learning, which we will discuss in the next section.

03Single-loop learning and double-loop learning - Argyris' discovery

The person who most acutely articulated the structure of learning in organizations was a Harvard business scientist. Chris Argyris and a philosopher at MIT donald shawn It was. In their 1978 co-authored book, Organizational Learning, they two fundamentally different levels We differentiated into

"Single-loop learning is learning that modifies behavior based on an existing framework of judgment. ``It didn't work, let's try something different next time.'' Double-loop learning is learning that modifies the very framework that caused the outcome of the behavior. ``It didn't work, maybe we should question this premise.'' Most learning in organizations remains in a single loop." -- Chris Argyris & Donald Purpose from Schön's "Organizational Learning" (1978)

Argyris' most provocative discovery was thatOrganizational defensive routines systematically impede double-loop learning That's what it means. Organizations talk about learning, but their actual behavior is to avoid questioning their decision-making frameworks. When people say, ``The problem is deeper,'' in a meeting, organizations avoid questioning the framework by translating it into a superficial problem. This is an organized version of the groupthink mentioned in Part 1 and the collective defense mechanism mentioned in Part 3.

The implications for materials auditors are profound.When failure reflection remains in a single loop of learning, the judgment framework is not updated.. Checklists and warnings may function as superficial countermeasures, but they do not act as resistance to overconfidence itself. The institutional countermeasures and etiquette that will be discussed in the second half of this article are all mechanisms for systematically forcing double-loop learning.

04Absence of a "learning organization" -- Senge's prescription

A management scholar at MIT developed Argyris and Schön's theory as a practical theory of organizational change. Peter Senge is. His 1990 book The Fifth Discipline remains one of the most influential books on business management in the second half of the 20th century.

Senge identified five "disciplines" for learning organizations.personal mastery、mental models、shared vision、team learning, and integrate the whole systems thinking. He argues that if an organization does not have these five elements, no matter how much experience is gained, learning will not remain in the organization.

"Mental models are deep patterns of assumptions that define how we understand the world. Most problems in organizations stem from people not being able to see that their mental models are outdated. The core of a learning organization is having the discipline to be aware of their mental models, examine them, and modify them as necessary." - Peter Senge, The Fifth Discipline (1990), Chapter 10

Senge's mental model connects Argyris' judgment framework and Moore & Healy's three types of "overprecision" from the first part of this series in the same place.Overconfidence is a condition in which mental models are not updated even though they are becoming outdated.. Senge's prescription is to improve mental models. something that can be discussed The idea was to put it in the organization as a personal belief, and put it in a shared space as an object of consideration. This is a perspective that has decisive significance when considering the meeting culture of material review teams.

05Highly reliable organizations - Weick & Sutcliffe's discoveries

An organizational theorist at the University of Michigan demonstrated through empirical research a concrete structure for preserving learning in organizations. Karl Wijk and Kathleen Sutcliffe is. Their 2001 book, Managing the Unexpected, explored why some organizations maintain sustained high reliability in nuclear power plants, aircraft carriers, emergency medical services, and firefighting—in areas where failure is not an option. These organizations are High Reliability Organizations (HRO) It is called.

Weick and Sutcliffe identify five common characteristics of HROs: Practicing Mindfulness It has been systematized as

Among the characteristics of HRO, the most important in the context of this article is the first. obsession with failure is. HRO systematically accumulates and examines past small failures, near-misses, and discomfort. This is a system that forces the updating of the judgment framework as a system. Weick and Sutcliffe observed that in these organizations "A culture in which small failures are reported" is the biggest factor in preventing major failures. That is. The subject of the second half of this article will be how the culture of auditing and quality control in materials review interacts with HRO etiquette.

06Medical M&M conference ─ Institutionalization of learning

One of the industries that has institutionalized HRO theory for the longest time is healthcare. In American surgery, since the early 20th century Morbidity and Mortality Conference (M&M conference, mortality and complication case review meeting) There is a system called. sociologist charles bosk (1948–2020) analyzed this system in detail in their 1979 study Forgive and Remember: Managing Medical Failure.

"The M&M conference is more than just a case review meeting. It is a ritual in which doctors publicly consider their own failures in judgment in front of their colleagues. The important question is not ``who was at fault?'' but ``Where in the judgment could there have been another path?'' The separation between ownership of failure and blame makes this conference function as a place for learning.'' - Charles Bosk, Forgive and Remember (1979) Purpose

If we reread the essence of the M&M conference in the context of this episode, it would look like this.Institutional rituals that transform the experience of failure into a forum for consideration of judgmental frameworks.. Hindsight bias is strong in individual reflection, but a ritual in which multiple experts come together and specifically enumerate the possibilities of different judgments on the spot functions as a collective resistance to hindsight bias.

Of note is the cultural premise of the M&M conference.A safe place to talk about failures、separation from blame、Sharing vocabulary for examining judgment frameworks ── If these things are not in place, even if we introduce the M&M conference just for the sake of appearance, it will not work. This is the difference between a meeting to review failure cases in materials audits that ends up being just a superficial addition to a checklist, or a true double-loop learning experience.

07Just Culture and Reason's Swiss Cheese Model for Aviation

Along with healthcare, aviation is the industry that has most developed organizational learning from failure. british psychologist james reason The theory he developed in 1990's Human Error and 1997's Managing the Risks of Organizational Accidents has become the standard framework for modern safety engineering.

Reason's most influential concept isSwiss Cheese Model is. This model states that serious accidents do not result from a single failure, but when holes (potential failures) in all multiple layers of defense overlap at the same time. In order to prevent accidents, it is necessary to systematically understand where the holes are in the organization, rather than looking for individual "culprits."

"Most organizational accidents are not caused by poor judgment on the part of front-line personnel; they are just the result. The cause is the organizational conditions that allow for poor judgment: poor training, poor communication, production pressures, cultural acceptance. Making these latent failures visible is at the heart of organizational learning." - From James Reason, Managing the Risks of Organizational Accidents (1997)

Derived from Reason's theory, the airline industry's institutionalized culture Just Culture is. This is an institutional agreement that distinguishes between "reporting without blame" and "punishing intentional violations." Intentional violations will be punished. However, the organization guarantees that those who report errors in judgment, near-misses, or discomfort will not be punished.

When considering the culture of quality control and material review in the pharmaceutical industry, Just Culture's etiquette is crucial. A culture where people can talk about their failures, a place where they can share their near-misses, and an atmosphere where they can talk about their poor judgment -- if these things don't exist, the organization's learning mechanism will not work. Section 9 brings this down to the field scene.

08Confucius's "Make mistakes and don't change them" and Buddhist etiquette for repentance

The difficulty of learning from failure is not something modern management discovered.Confucius (551–479 BC) speaks many times in the Analects about how to deal with mistakes. The most famous verse is found in the Eireiko Hen.

“If you make a mistake and cannot change it, it is called a mistake.” - Confucius, Analects, Wei Ling Gong edition

This proposition of Confucius can be paraphrased in the language of modern learning theory.The problem is not the mistake itself, but the real mistake is not correcting the mistake.. Failure is universal, but learning from failure is not. Failure without learning leads to repeated failure. Confucius had already formulated Argyris' confinement into single-loop learning 2,500 years ago.

It should be noted that Confucius did not mean "amend". superficial behavior modification This is something I haven't talked about yet. Elsewhere in the Analects, Confucius repeatedly preaches the habits of self-reflection and renewal. Zeng Zi's ``Three times in a day I reflect on myself (san sho wa shi)'' and Confucius's own ``Do not be afraid to change your mistakes and correct them (exchanges and changes)'' -- these all demonstrate the habit of considering the framework of judgment itself.

Another Eastern tradition: Buddhism regret (regret) Etiquette also resonates with the theme of this episode. Regret is not just regret, it is a manner of observing what was at the root of one's decisions and actions. In Buddhism 慚 (zàn) and 愧 (kuì) are arranged. Hui is being ashamed of one's own ideals, and hatred is being ashamed of others and society. When both are present, genuine learning is said to occur. This is an ancient prescription that rereads Argyris's double-loop learning from an ethical dimension.

09In the pharmaceutical field ─ 4 situations where learning stops

Bringing abstract theory to the field. Here are four typical situations in a materials auditor's day where learning is locked into a single loop. Observe each of them and ask where there is a way out of the double loop.

The structure common to the four scenes isThe experience of failure disappears without being converted into a place for considering a judgment framework. That's it. Organizations gain experience but do not accumulate learning. This is not a matter of individual ability or will, but of the organization. ritual and culture It's a problem. The next section deals with that.

104 ways to restart your learning

Creating an organization that learns from failure is a topic that goes beyond the scope of this series. However, there are ways to restart learning on an individual and small team basis. As the final practice of this article, we will propose four manners.

The common principles of the four manners are:Consciously transform the experience of failure into a place for considering a judgment framework That's it. This cannot be continued by individual will alone. It should become a small ritual and become part of your team's shared etiquette. Think of the M&M conference or Just Culture as an experiment within your own team.

Why is the decision-making framework not updated even after experiencing failure? This article explores that structure. Fischhoff's hindsight bias, Argyris and Schön's single/double-loop learning, Senge's mental models, Weick and Sutcliffe's HRO, healthcare's M&M conference, aviation's Just Culture and Reason's Swiss cheese model, and Confucius's "erring and unchanging"—eight perspectives have pointed to the same place with different words.経験は学習の必要条件だが、十分条件ではない。経験を学習に変換する儀式と文化が、組織には必要である。

Parts 1 to 4 of this series were about "Why overconfidence occurs," and Parts 5 to 6 were about "How to notice it." From the remaining four episodes, we will move on to the chapter "How to live with it." The next installment (Part 7) deals with the middle ground between overconfidence and humility. The Aristotelian proposition that reducing overconfidence does not mean losing self-confidence will be explored through three traditions: Confucius' moderation, Aristotle's virtue ethics, and Schein's humble inquiry. This is the episode that gets closer to the ethical core of this series.