• Randy Swaim

Leadership: The Error Chain & Root Causes.

When a leader leads their team in a changing environment, not everything will go perfectly all the time. 



It is also possible in a rapidly changing environment, factors will change in ways that could not have been predicted and our team may not have deduced the critical success factors correctly at the beginning.  Also, however, we may have made assumptions that were not valid.  In our last blog, we pointed out that a leader must avoid “Assumptions and Making Excuses”.


Leaders often fall into a key problem when a problem or unexpected challenge arises in the initiative.  This problem area can also be a factor that connects assumptions with excuses.  It is simply this…..Leaders often focus on that point of attack and consequently, they focus on symptoms rather than Root Causes.


It highlights the concept of “The Error Chain”.  The idea is that problems are not points in time but every challenge that arises is the current revelation of a series of  decisions and actions along the way; in other words, it is the current link at the end of a series of links in the chain.  The links of the chain lead to the outcome at this point.  The key point is that if at any point in the chain, we break one link in the chain, the chain does not result.  So how does this relate to leadership?


As I work with pilots and flight crews, I point out that when something arises, if you want to understand the root cause go back 5-10 minutes and look at the decision making and you will see the root cause.   The fact that such and such happened is likely a symptom.  The root cause could be a decision that was made some links back or a factor that has been “coming on stage”; or the root cause could be that our Situational Awareness was not what it should have been and the leader did not see it developing.


A quick example in my journey as a Learjet Captain was at a time when I was taxiing out as the 6th Learjet as part of a “Red Force package” at Tyndall AFB, Fla participating in a Southwest Strategic Air Defense Exercise.  As I taxied out I noticed the infield grass doing some strange things that could suggest the possibility of  Windshear.  My co-pilot saw the same and I told him that “…regardless of what the 1st five aircraft did, we were going to wait out the weather for a few moments“.  Halfway down the parallel taxiway the lead Learjet called Air Traffic Control Tower and said they were going to wait and watch the weather as well and my co-pilot and I gave each other a High 5.  We were aware of the subtle signs that something was changing and it could possibly be bad.


In the same way, a leader must be aware of the concept of Error Chain and how Situational Awareness applies.  A leader must be aware of the concept and also to lead their teams to maximize their Situational Awareness and to break the links in the Error Chain.  Whether pilots or team leaders, Small adjustments Early are much better, and less stressful, than drastic changes at the last second.


As a pilot, I always said that when the last 5 minutes of this flight began to read like the first paragraph of an accident report, I changed something.  How many times in my career have I broken the Error Chain and didn’t even realize it.  Leaders must understand the Error Chain and address ROOT Causes and break the links before it becomes prohibitive.


Coach Randy Swaim, Coaching for Relevance, LLC