Learning from Mistakes

At 10.06am on July 22 2005, Jean Charles de Menezes was shot seven times in the head and once in the shoulder by police officers who had followed him on to a tube train at Stockwell, south London.

It was Scotland Yard’s first use of a shoot-to-kill policy designed to tackle suicide bombers, and came the day after four unsuccessful attempts to detonate devices on London’s transport system. Let’s remind ourselves of the context. Two weeks earlier there were a series of coordinated bomb blasts that hit London’s public transport system during the morning rush hour. The bombings killed 52 commuters and the four suicide bombers, injured 700, and caused disruption of the city’s transport system and creating fear and panic amongst those who lived and worked in London, and beyond.

Just two weeks later with the security forces on high alert, four attempted bomb attacks again disrupted part of London’s public transport system.  Fortunately only the detonators of the bombs exploded and the bombers escaped. There followed an intense manhunt for the bombers believing them capable of striking again at any moment.

Police were hunting the four men, and they thought they may have found one of them. They were stalking a block of flats because the address was written on a piece of paper found in one of the rucksacks holding a failed bomb.  Menezes happened to live in another flat in the block and was followed as soon as he left the building that morning.

It is horrific that someone innocent died, a tragedy for the family and traumatic for the policemen involved. It is a pity that we cannot focus on the lessons to learn in preparation for when it might happen again rather than trying to assign blame. The current inquest is designed to get at what happened, but the press seemed more concerned with witch-hunts and forcing resignations.  I am sure the intent that day was to protect the lives of the public and the police were very conscious their own lives were at risk.

But have we learned the lessons of past experiences?  Unfortunately it is not the first time that an innocent man has been killed by the police.  Malcolm Gladwell author of The Tipping Point had months earlier published another book called “Blink.” 

In it he explores moments when we know something without knowing why, when we make snap judgements by blocking out the irrelevant and focusing on narrow slices of experience. It can be powerful when it works but it can be disastrous when it goes awry.  When stress levels rise we narrow our focus, time slows down and in Gladwell’s view we become temporarily autistic.

Chapter 6 is entitled “Seven Seconds in the Bronx.” In it he recounts a real incident in which four police officers end up killing an innocent man, Amaddou Diallo, who was an immigrant from Guinea. He had stepped outside his apartment at half past midnight to get some air. The cops, on patrol in a Street Crime Unit were travelling together in one vehicle, decided he looked suspicious as they drove past. They backed the car up for another look.  He stayed where he was, a behaviour the police decided was brazen. He was simply curious.  When two of the cops got out of the car and moved towards him he turned slightly to his side and went for something in his pocket. They decided he was dangerous.  He was not. He was reaching for his wallet to show ID. The cops between them fired 41 bullets into him, killing him instantly.

There is no evidence that the police were bad people, or racists or out to get Diallo. On the other hand it was not a simple accident, because the policemen made a series of a catastrophic misjudgements, and an innocent man who was outside his home for a breath of fresh air was gunned down.

The parallels with the Stockwell shooting are apparent.  What can we do to prepare our police to cope with those high stress situations and still make the correct judgements?

How do we create the right conditions to learn from mistakes, rather than identify who is to blame and make them suffer?  Think about your own organisation.  What can you do to encourage learning from mistakes?  What do you need to do differently to enable the right conditions?

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