May 6, 2004 (Ira Pilgrim)


An incompetent person is someone who is always making mistakes.

A competent person has already made them all.

At the tender age of 20, I was a laboratory technician in an army hospital in Europe. One day, I was cross-matching some blood for a transfusion. I switched the numbers of two bottles of blood. Fortunately, the pathologist caught the mistake before the blood left the lab. If he hadn't, I probably would have killed one of those patients. I was shattered. The pathologist, an older man, wasn't. From then on, all blood for transfusion had to be approved by him, Major Tolstoy, or by me, Private Pilgrim, before the blood left the lab. Why me? He figured that I had made the mistake and would not be likely to make it again. What's more, I would know what kinds of mistakes to look for. He was a lot wiser than I ever gave him credit for.

For most of my life, I was very intolerant of mistakes. My favorite expressions were "He should have known better! and "He doesn't know what he's doing!" I don't feel that way any more. I now know that even the best make mistakes. The greatest performers muff lines and crack notes. Of course, parachutists make fewer mistakes than most of us; their motto is "If at first you don't succeed, never mind!"

Perfection is an unusual occurrence. The only way to avoid mistakes is to do nothing but the simplest tasks. Even then, people make mistakes because they might be tired or distracted.

I still have little tolerance for people who make mistakes and deny that they made them. I expect a mechanic who makes a mistake on my car to fix it free. I also try to find experienced people who make fewer mistakes, rather than beginners; but that's not always possible. The best mechanics no longer lube cars, change tires or fix flats.

I heard a professor of surgery say, at a staff meeting, "We killed that man. If we had done things differently, he would still be alive." I was so impressed that, when I needed surgery, he was the man I went to. In contrast, I knew a surgeon who never made mistakes. His patients died, but it was never his fault.

Making mistakes is simply human. We all make them and we have to make them in order to learn. The reason that older people make fewer mistakes than younger ones is because they attempt fewer new things and have already made most of the mistakes in those things that they know how to do.

The space ship Voyager 1, which left Earth in 1977 and is still traveling in space, was almost error free, not because the people who designed and built it didn't make mistakes, but because they checked everything many many many times, and caught most of those mistakes before that incredible machine took off. They also expected failures and built in lots of redundancy; duplicate systems and systems that had lots of overlap.

I once dated a woman who was a professional musician. One day I was picking out a tune on her piano and it occurred to me that the noise that I was making might be bothering her. I asked her if it did. She answered that she had a different ear for children, amateurs and professionals. In fact she had many different ears for people with varying degrees of competence. Now I also think that way, and my expectations for a grandchild who pounds nails into a board is different from my expectations for an apprentice carpenter, which is different from what I expect of a journeyman. And I always expect people to make mistakes. Only computers don't make mistakes. They have glitches.

My current attitude about mistakes doesn't just apply to automobile mechanics and carpenters. It applies to everyone including presidents, physicians, journalists, editors, teachers, school board members, school superintendents and heads of corporations.

In fact, usually the bigger the person, the bigger the mistake.

It would be nice, wouldn't it, if the people who make errors that kill lots of people didn't make them? It sure would!

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