Be Angry Be Sad Then Change The System

Whenever a tragedy strikes—whether in the UK, the US, or Europe—there is always a wave of public outrage, followed by politicians and bosses promising: “This will never happen again.”

But in the airline industry, that promise actually means something. Aviation has built a remarkable culture. When a plane crashes, they don’t waste time looking for a human scapegoat to protect corporate reputations. Instead, they thoroughly investigate the root cause. Everyone works together to ask one question: What can we change in the system so this never happens again? Because of that open, blame-free culture, flying has become incredibly safe.

Sadly, most other industries do the exact opposite.

Matthew Syed wrote a brilliant book about this called Black Box Thinking. The core message is incredibly simple: rather than hunting for someone to blame, look at fixing the system. Sometimes that means changing the training, rewriting instructions, or even just redesigning the shape of a lever or a knob so a human can’t accidentally pull the wrong one. It is common sense, and it’s an easy read for anyone. It isn’t a secret, and it isn’t complicated.

Yet, people completely ignore it.

What should shock everyone is that in many sectors—especially healthcare, and as we see too often, our transport networks—this culture of learning simply doesn’t exist. Instead, the instinct is institutional self-preservation. People work incredibly hard to protect their reputations, their careers, and their futures. But the downside of covering up mistakes is that the underlying problem never gets fixed. The same fatal errors keep rearing their heads, year in and year out.

No one should be happy with this. The fact that we allow it to continue is a slur on our society.

My wish is that more people in power would actually read Black Box Thinking and—crucially—act on it. We don’t need to paralyze industries with bureaucracy; we just need to apply basic common sense. If we can use data and systemic thinking to safely guide airplanes across the sky and track a piece of luggage in an airport, we can use it to keep people safe everywhere else.
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