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were more likely to identify and write off problem loans when they had high rates of executive turnover. If you’re not the person who greenlit the initial loan, you have every incentive to rethink the previous assessment of that customer. If they’ve defaulted on the past nineteen loans, it’s probably time to adjust. Rethinking is more likely when we separate the initial decision makers from the later decision evaluators.

© Hayley Lewis, Sketchnote summary of A Spectrum of Reasons for Failure. Illustration drawn May 2020. London, United Kingdom. Copyright © 2020 by HALO Psychology Limited.

For years, NASA had failed to create that separation. Ellen Ochoa recalls that traditionally “the same managers who were responsible for cost and schedule were the ones who also had the authority to waive technical requirements. It’s easy to talk yourself into something on a launch day.”

The Columbia disaster reinforced the need for NASA to develop a stronger learning culture. On the next space shuttle flight, a problem surfaced with the sensors in an external engine tank. It reoccurred several more times over the next year and a half, but it didn’t create any observable problems. In 2006, on the day of a countdown in Houston, the whole mission management team held a vote. There was overwhelming consensus that the launch should go forward. Only one outlier had voted no: Ellen Ochoa.

In the old performance culture, Ellen might’ve been afraid to vote against the launch. In the emerging learning culture, “it’s not just that we’re encouraged to speak up. It’s our responsibility to speak up,” she explains. “Inclusion at NASA is not only a way to increase innovation and engage employees; it directly affects safety since people need to feel valued and respected in order to be comfortable speaking up.” In the past, the onus would’ve been on her to prove it was not safe to launch. Now the onus was on the team to prove it was safe to launch. That meant approaching their expertise with more humility, their decision with more doubt, and their analysis with more curiosity about the causes and potential consequences of the problem.

After the vote, Ellen received a call from the NASA administrator in Florida, who expressed surprising interest in rethinking the majority opinion in the room. “I’d like to understand your thinking,” he told her. They went on to delay the launch. “Some people weren’t happy we didn’t launch that day,” Ellen reflects. “But people did not come up to me and berate me in any way or make me feel bad. They didn’t take it out on me personally.” The following day all the sensors worked properly, but NASA ended up delaying three more launches over the next few months due to intermittent sensor malfunctions. At that point, the manager of the shuttle program called for the team to stand down until they identified the root cause. Eventually they figured out that the sensors were working fine; it was the cryogenic environment that was causing a faulty connection between the sensors and computers.

Ellen became the deputy director and then the director of the Johnson Space Center, and NASA went on to execute nineteen consecutive successful space shuttle missions before retiring the program. In 2018, when Ellen retired from NASA, a senior leader approached her to tell her how her vote to delay the launch in 2006 had affected him. “I never said anything to you twelve years ago,” he said, but “it made me rethink how I approached launch days and whether I’m doing the right thing.”

We can’t run experiments in the past; we can only imagine the counterfactual in the present. We can wonder whether the lives of fourteen astronauts would have been saved if NASA had gone back to rethink the risks of O-ring failures and foam loss before it was too late. We can wonder why those events didn’t make them as careful in reevaluating problems with spacesuits as they had become with space shuttles. In cultures of learning, we’re not weighed down with as many of these questions—which means we can live with fewer regrets.

PART IV

Conclusion

CHAPTER 11 Escaping Tunnel Vision Reconsidering Our Best-Laid Career and Life Plans

A malaise set in within a couple hours of my arriving. I thought getting a job might help. It turns out I have a lot of relatives in Hell, and, using connections, I became the assistant to a demon who pulls people’s teeth out. It wasn’t actually a job, more of an internship. But I was eager. And at first it was kind of interesting. After a while, though, you start asking yourself: Is this what I came to Hell for, to hand different kinds of pliers to a demon?

—Jack Handey

What do you want to be when you grow up? As a kid, that was my least favorite question. I dreaded conversations with adults because they always asked it—and no matter how I replied, they never liked my answer. When I said I wanted to be a superhero, they laughed. My next goal was to make the NBA, but despite countless hours of shooting hoops on my driveway, I was cut from middle school basketball tryouts three years in a row. I was clearly aiming too high.

In high school, I became obsessed with springboard diving and decided I wanted to become a diving coach. Adults scoffed at that plan: they told me I was aiming too low. In my first semester of college, I decided to major in psychology, but that didn’t open any doors—it just gave me a few to close. I knew I didn’t want to be a therapist (not patient enough) or a psychiatrist (too squeamish for med school). I was still aimless, and I envied people who had a clear career plan.

From the time he was in kindergarten, my cousin Ryan knew exactly what he wanted to be when he grew up.

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