Outside magazine, September 1996

Into Thin Air
Everest deals with trespassers harshly: the dead vanish beneath the snows. While the living struggle to explain
what happened. And why. A survivor of the mountain’s worst disaster examines the business of Mount Everest
and the steep price of ambition.

By Jon Krakauer

Straddling the top of the world, one foot in Tibet and the other in Nepal, I cleared the
ice from my oxygen mask, hunched a shoulder against the wind, and stared absently at
the vast sweep of earth below. I understood on some dim, detached level that it was a
spectacular sight. I’d been fantasizing about this moment, and the release of emotion
that would accompany it, for many months. But now that I was finally here, standing
on the summit of Mount Everest, I just couldn’t summon the energy to care.

It was the afternoon of May 10. I hadn’t slept in 57 hours. The only food I’d been able to force down over the
preceding three days was a bowl of Ramen soup and a handful of peanut M&M’s. Weeks of violent coughing had left
me with two separated ribs, making it excruciatingly painful to breathe. Twenty-nine thousand twenty-eight feet up in
the troposphere, there was so little oxygen reaching my brain that my mental capacity was that of a slow child. Under
the circumstances, I was incapable of feeling much of anything except cold and tired.

I’d arrived on the summit a few minutes after Anatoli Boukreev, a Russian guide with an American expedition, and
just ahead of Andy Harris, a guide with the New Zealand-based commercial team that I was a part of and someone
with whom I’d grown to be friends during the last six weeks. I snapped four quick photos of Harris and Boukreev
striking summit poses, and then turned and started down. My watch read 1:17 P.M. All told, I’d spent less than five
minutes on the roof of the world.

After a few steps, I paused to take another photo, this one looking down the Southeast Ridge, the route we had
ascended. Training my lens on a pair of climbers approaching the summit, I saw something that until that moment had
escaped my attention. To the south, where the sky had been perfectly clear just an hour earlier, a blanket of clouds
now hid Pumori, Ama Dablam, and the other lesser peaks surrounding Everest.

Days later–after six bodies had been found, after a search for two others had been abandoned, after surgeons had
amputated the gangrenous right hand of my teammate Beck Weathers–people would ask why, if the weather had
begun to deteriorate, had climbers on the upper mountain not heeded the signs? Why did veteran Himalayan guides
keep moving upward, leading a gaggle of amateurs, each of whom had paid as much as $65,000 to be ushered safely
up Everest, into an apparent death trap?

Nobody can speak for the leaders of the two guided groups involved, for both men are now dead. But I can attest that
nothing I saw early on the afternoon of May 10 suggested that a murderous storm was about to bear down on us. To
my oxygen-depleted mind, the clouds drifting up the grand valley of ice known as the Western Cwm looked
innocuous, wispy, insubstantial. Gleaming in the brilliant midday sun, they appeared no different than the harmless
puffs of convection condensation that rose from the valley almost daily. As I began my descent, I was indeed anxious,
but my concern had little to do with the weather. A check of the gauge on my oxygen tank hadrevealed that it was
almost empty. I needed to get down, fast.

The uppermost shank of the Southeast Ridge is a slender, heavily corniced fin of rock and
wind-scoured snow that snakes for a quarter-mile toward a secondary pinnacle known as the
South Summit. Negotiating the serrated ridge presents few great technical hurdles, but the route
is dreadfully exposed. After 15 minutes of cautious shuffling over a 7,000-foot abyss, I arrived
at the notorious Hillary Step, a pronounced notch in the ridge named after Sir Edmund Hillary,
the first Westerner to climb the mountain, and a spot that does require a fair amount of
technical maneuvering. As I clipped into a fixed rope and prepared to rappel over the lip, I was
greeted by an alarming sight.

Thirty feet below, some 20 people were queued up at the base of the Step, and three climbers
were hauling themselves up the rope that I was attempting to descend. I had no choice but to

unclip from the line and step aside.

The traffic jam comprised climbers from three separate expeditions: the team I belonged to, a group of paying clients
under the leadership of the celebrated New Zealand guide Rob Hall; another guided party headed by American Scott
Fischer; and a nonguided team from Taiwan. Moving at the snail’s pace that is the norm above 8,000 meters, the
throng labored up the Hillary Step one by one, while I nervously bided my time.

Harris, who left the summit shortly after I did, soon pulled up behind me. Wanting to
conserve whatever oxygen remained in my tank, I asked him to reach inside my backpack
and turn off the valve on my regulator, which he did. For the next ten minutes I felt
surprisingly good. My head cleared. I actually seemed less tired than with the gas turned on.
Then, abruptly, I felt like I was suffocating. My vision dimmed and my head began to spin. I
was on the brink of losing consciousness.

Instead of turning my oxygen off, Harris, in his hypoxically impaired state, had mistakenly
cranked the valve open to full flow, draining the tank. I’d just squandered the last of my gas
going nowhere. There was another tank waiting for me at the South Summit, 250 feet below,
but to get there I would have to descend the most exposed terrain on the entire route without
benefit of supplemental oxygen.

But first I had to wait for the crowd to thin. I removed my now useless mask, planted my ice ax into the mountain’s
frozen hide, and hunkered on the ridge crest. As I exchanged banal congratulations with the climbers filing past,
inwardly I was frantic: “Hurry it up, hurry it up!” I silently pleaded. “While you guys are screwing around here, I’m
losing brain cells by the millions!”

Most of the passing crowd belonged to Fischer’s group, but near the back of the parade two of my teammates
eventually appeared: Hall and Yasuko Namba. Girlish and reserved, the 47-year-old Namba was 40 minutes away
from becoming the oldest woman to climb Everest and the second Japanese woman to reach the highest point on each
continent, the so-called Seven Summits.

Later still, Doug Hansen-another member of our expedition, a postal worker from Seattle who had become my closest
friend on the mountain-arrived atop the Step. “It’s in the bag!” I yelled over the wind, trying to sound more upbeat than
I felt. Plainly exhausted, Doug mumbled something from behind his oxygen mask that I didn’t catch, shook my hand
weakly, and continued plodding upward.

The last climber up the rope was Fischer, whom I knew casually from Seattle, where we both lived. His strength and
drive were legendary-in 1994 he’d climbed Everest without using bottled oxygen-so I was surprised at how slowly he
was moving and how hammered he looked when he pulled his mask aside to say hello. “Bruuuuuuce!” he wheezed
with forced cheer, employing his trademark, fratboyish greeting. When I asked how he was doing, Fischer insisted he
was feeling fine: “Just dragging ass a little today for some reason. No big deal.” With the Hillary Step finally clear, I
clipped into the strand of orange rope, swung quickly around Fischer as he slumped over his ice ax, and rappelled over
the edge.

It was after 2:30 when I made it down to the South Summit. By now tendrils of mist were wrapping across the top of
27,890-foot Lhotse and lapping at Everest’s summit pyramid. No longer did the weather look so benign. I grabbed a
fresh oxygen cylinder, jammed it onto my regulator, and hurried down into the gathering cloud. Moments after I
dropped below the South Summit, it began to snow lightly and the visibility went to hell.

Four hundred vertical feet above, where the summit was still washed in bright sunlight under an immaculate cobalt
sky, my compadres were dallying, memorializing their arrival at the apex of the planet with photos and high-fives-and
using up precious ticks of the clock. None of them imagined that a horrible ordeal was drawing nigh. None of them
suspected that by the end of that long day, every minute would matter.

In May of 1963, when I was nine years old, Tom Hornbein and Willi Unsoeld made the first ascent of Everest’s
daunting West Ridge, one of the great feats in the annals of mountaineering. Late in the day on their summit push,
they climbed a stratum of steep, crumbly limestone-the infamous Yellow Band-that they didn’t think they’d be able to
descend. Their best shot for getting off the mountain alive, they reckoned, was to go over the top and down the
Southeast Ridge, an extremely audacious plan, given the late hour and the unknown terrain. Reaching the summit at
sunset, they were forced to spend the night in the open above 28,000 feet-at the time, the highest bivouac in history-
and to descend the Southeast Ridge the next morning. That night cost Unsoeld his toes, but the two survived to tell
their tale.

Unsoeld, who hailed from my hometown in Oregon, was a close friend of my father’s. I climbed my first mountain in
the company of my dad, Unsoeld, and his oldest son, Regon, a few months before Unsoeld departed for Nepal. Not
surprisingly, accounts of the 1963 Everest epic resonated loud and long in my preadolescent imagination. While my
friends idolized John Glenn, Sandy Koufax, and Johnny Unitas, my heroes were Hornbein and Unsoeld.

Secretly, I dreamed of climbing Everest myself one day; for more than a decade it remained a burning ambition. It
wasn’t until my midtwenties that I abandoned the dream as a preposterous boyhood fantasy. Soon thereafter I began to
look down my nose at the world’s tallest mountain. It had become fashionable among alpine cognoscenti to denigrate
Everest as a “slag heap,” a peak lacking sufficient technical challenge or aesthetic appeal to be a worthy objective for a
“serious” climber, which I desperately aspired to be.

Such snobbery was rooted in the fact that by the early 1980s, Everest’s easiest line-the South Col/Southeast Ridge, or
the so-called Yak Route-had been climbed more than a hundred times. Then, in 1985, the floodgates were flung wide
open when Dick Bass, a wealthy 55-year-old Texan with limited climbing experience, was ushered to the top of
Everest by an extraordinary young climber named David Breashears. In bagging Everest, Bass became the first person
to ascend all of the so-called Seven Summits, a feat that earned him worldwide renown and spurred a swarm of other
amateur climbers to follow in his guided bootprints.

“To aging Walter Mitty types like myself, Dick Bass was an inspiration,” Seaborn Beck Weathers explained during the
trek to Everest Base Camp last April. A 49-year-old Dallas pathologist, Weathers was one of eight paying clients on
my expedition. “Bass showed that Everest was within the realm of possibility for regular guys. Assuming you’re
reasonably fit and have some disposable income, I think the biggest obstacle is probably taking time off from your job
and leaving your family for two months.”

For a great many climbers, the record shows, stealing time away from the daily grind has not been an insurmountable
obstacle, nor has the hefty outlay of cash. Over the past half-decade, the traffic on all of the Seven Summits, and
especially Everest, has grown at an astonishing rate. And to meet demand, the number of commercial enterprises
peddling guided ascents of these mountains has multiplied correspondingly. In the spring of 1996, 30 separate
expeditions were on the flanks of Everest, at least eight of them organized as moneymaking ventures.

Even before last season’s calamitous outcome, the proliferation of commercial expeditions was a touchy issue.
Traditionalists were offended that the world’s highest summit was being sold to rich parvenus who, if denied the
services of guides, would have difficulty making it to the top of a peak as modest as Mount Rainier. Everest, the
purists sniffed, had been debased and profaned.

Such critics also point out that, thanks to the commercialization of Everest, the once hallowed peak has now even been
dragged into the swamp of American jurisprudence. Having paid princely sums to be escorted up Everest, some
climbers have then sued their guides after the summit eluded them. “Occasionally you’ll get a client who thinks he’s
bought a guaranteed ticket to the summit,” laments Peter Athans, a highly respected guide who’s made 11 trips to
Everest and reached the top four times. “Some people don’t understand that an Everest expedition can’t be run like a
Swiss train.”

Sadly, not every Everest lawsuit is unwarranted. Inept or disreputable companies have on more than one occasion
failed to deliver crucial logistical support-oxygen, for instance-as promised. On some expeditions guides have gone to
the summit without any of their clients, prompting the bitter clients to conclude that they were brought along simply to
pick up the tab. In 1995, the leader of one commercial expedition absconded with tens of thousands of dollars of his
clients’ money before the trip even got off the ground.

To a certain degree, climbers shopping for an Everest expedition get what they pay for. Expeditions on the northern,
Tibetan side of the mountain are considerably cheaper-the going rate there is $20,000 to $40,000 per person-than those
on the south, in part because China charges much less for climbing permits than does Nepal. But there’s a trade-off:
Until 1995, no guided client had ever reached the summit from Tibet.

This year, Hall charged $65,000 a head, not including airfare or personal equipment, to take people up the South
Col/Southeast Ridge route. Although no commercial guide service charged more, Hall, a lanky 35-year-old with a
biting Kiwi wit, had no difficulty booking clients, thanks to his phenomenal success rate: He’d put 39 climbers on the
summit between 1990 and 1995, which meant that he was responsible for three more ascents than had been made in
the first 20 years after Hillary’s inaugural climb. Despite the disdain I’d expressed for Everest over the years, when the
call came to join Hall’s expedition, I said yes without even hesitating to catch my breath. Boyhood dreams die hard, I
discovered, and good sense be damned.

On April 10, after ten days of hiking through the steep, walled canyons and rhododendron forests of northern Nepal, I
walked into Everest Base Camp. My altimeter read 17,600 feet.

Situated at the entrance to a magnificent natural amphitheater formed by Everest and its two sisters, Lhotse and
Nuptse, was a small city of tents sheltering 240 climbers and Sherpas from 14 expeditions, all of it sprawled across a
bend in the Khumbu Glacier. The escarpments above camp were draped with hanging glaciers, from which calved
immense serac avalanches that thundered down at all hours of the day and night. Hard to the east, pinched between the
Nuptse wall and the West Shoulder of Everest, the Khumbu Icefall spilled to within a quarter-mile of the tents in a
chaos of pale blue shards.

In stark contrast to the harsh qualities of the environment stood our campsite and all its creature comforts, including a
19-person staff. Our mess tent, a cavernous canvas structure, was wired with a stereo system and solar-powered
electric lights; an adjacent communications tent housed a satellite phone and fax. There was a hot shower. A cook boy
came to each client’s tent in the mornings to serve us steaming mugs of tea in our sleeping bags. Fresh bread and
vegetables arrived every few days on the backs of yaks.

In many ways, Rob Hall’s Adventure Consultants site served as a sort of town hall for Base Camp, largely because
nobody on the mountain was more respected than Hall, who was on Everest for his eighth time. Whenever there was a
problem-a labor dispute with the Sherpas, a medical emergency, a critical decision about climbing strategy-people
came to him for advice. And Hall, always generous, dispensed his accumulated wisdom freely to the very rivals who
were competing with him for clients, most notably Fischer.

Fischer’s Mountain Madness camp, distinguished by a huge Starbucks Coffee banner that hung from a chunk of
granite, was a mere five minutes’ walk down the glacier. Fischer and Hall were competitors, but they were also
friends, and there was a good deal of socializing between the two teams. His mess tent wasn’t as well appointed as
ours, but Fischer was always quick to offer a cup of fresh-brewed coffee to any climber or trekker who poked a head
inside the door.

The 40-year-old Fischer was a strapping, gregarious man with a blond ponytail and manic energy. He’d grown up in
New Jersey and had fallen in love with climbing after taking a NOLS course as a 14-year-old. In his formative years,
during which he became known for a damn-the-torpedoes style, he’d survived a number of climbing accidents,
including twice cratering into the ground from a height of more than 70 feet. Fischer’s infectious, seat-of-the-pants
approach to his own life was reflected in his improvisational approach to guiding Everest. In striking contrast to Hall-
who insisted that his clients climb as a group at all times, under the close watch of his guides-Fischer encouraged his
clients to be independent, to move at their own pace, to go wherever they wanted, whenever they wanted.

Both men were under considerable pressure this season. The previous year, Hall had for the first time failed to get
anybody to the top. Another dry spell would be very bad for business. Meanwhile Fischer, who had climbed the peak
without oxygen but had never guided the mountain, was still trying to get established in the Everest business. He
needed to get clients to the summit, especially a high-profile one like Sandy Hill Pittman, the Manhattan boulevardier-
cum-writer who was filing daily diaries on an NBC World Wide Web site.

Despite the many trappings of civilization at Base Camp, there was no forgetting that we were more than three miles
above sea level. Walking to the mess tent at mealtime left me wheezing to catch my breath. If I sat up too quickly, my
head reeled and vertigo set in. I developed a dry, hacking cough that would steadily worsen over the next six weeks.
Cuts and scrapes refused to heal. I was rarely hungry, a sign that my oxygen-deprived stomach had shut down and my
body had begun to consume itself for sustenance. My arms and legs gradually began to wither to toothpicks, and by
expedition’s end I would weigh 25 pounds less than when I left Seattle.

Some of my teammates fared even worse than I in the meager air. At least half of them suffered from various intestinal
ailments that kept them racing to the latrine. Hansen, 46, who’d paid for the expedition by working at a Seattle-area
post office by night and on construction jobs by day, was plagued by an unceasing headache for most of his first week
at Base Camp. It felt, as he put it, “like somebody’s driven a nail between my eyes.” This was Hansen’s second time on
Everest with Hall. The year before, he’d been forced to turn around 330 vertical feet below the summit because of deep
snow and the late hour. “The summit looked sooooo close,” Hansen recalled with a painful laugh. “Believe me, there
hasn’t been a day since that I haven’t thought about it.” Hansen had been talked into returning this year by Hall, who
felt sorry that Hansen had been denied the summit and who had significantly discounted Hansen’s fee to entice him to
give it another try.

A rail-thin man with a leathery, prematurely furrowed face, Hansen was a single father who spent a lot of time in Base
Camp writing faxes to his two kids, ages 19 and 27, and to an elementary school in Kent, Washington, that had sold T-
shirts to help fund his climb. Hansen bunked in the tent next to mine, and every time a fax would arrive from his
daughter, Angie, he’d read it to me, beaming. “Jeez,” he’d announce, “how do you suppose a screw-up like me could
have raised such a great kid?”

As a newcomer to altitude-I’d never been above 17,000 feet-I brooded about how I’d perform higher on the mountain,
especially in the so-called Death Zone above 25,000 feet. I’d done some fairly extreme climbs over the years in
Alaska, Patagonia, Canada, and the Alps. I’d logged considerably more time on technical rock and ice than most of the
other clients and many of the guides. But technical expertise counted for very little on Everest, and I’d spent less time
at high altitude-none, to be precise-than virtually every other climber here. By any rational assessment, I was
singularly unqualified to attempt the highest mountain in the world.

This didn’t seem to worry Hall. After seven Everest expeditions he’d fine-tuned a remarkably effective method of
acclimatization. In the next six weeks, we would make three trips above Base Camp, climbing about 2,000 feet higher
each time. After that, he insisted, our bodies would be sufficiently adapted to the altitude to permit safe passage to the
29,028-foot summit. “It’s worked 39 times so far, pal,” Hall assured me with a wry grin.

Three days after our arrival in Base Camp, we headed out on our first acclimatization sortie, a one-day round-trip to
Camp One, perched at the upper lip of the Icefall, 2,000 vertical feet above. No part of the South Col route is more
feared than the Icefall, a slowly moving jumble of huge, unstable ice blocks: We were all well aware that it had
already killed 19 climbers. As I strapped on my crampons in the frigid predawn gloom, I winced with each creak and
rumble from the glacier’s shifting depths.

Long before we’d even got to Base Camp, our trail had been blazed by Sherpas, who had fixed more than a mile of
rope and installed about 60 aluminum ladders over the crevasses that crisscross the shattered glacier. As we shuffled
forth, three-quarters of the way to Camp One, Hall remarked glibly that the Icefall was in better shape than he’d ever
seen it: “The route’s like a bloody freeway this season.”

But only slightly higher, at about 19,000 feet, the fixed ropes led us beneath and then over a 12-story chunk of ice that
leaned precariously off kilter. I hurried to get out from beneath its wobbly tonnage and reach its crest, but my fastest
pace was no better than a crawl. Every four or five steps I’d stop, lean against the rope, and suck desperately at the
thin, bitter air, searing my lungs.

We reached the end of the icefall about four hours after setting out, but the relative safety of Camp One didn’t supply
much peace of mind: I couldn’t stop thinking about the ominously tilted slab and the fact that I would have to pass
beneath its frozen bulk at least seven more times if I was going to make it to the top of Everest.

Most of the recent debate about Everest has focused on the safety of commercial expeditions. But the least
experienced, least qualified climbers on the mountain this past season were not guided clients; rather, they were
members of traditionally structured, noncommercial expeditions.

While descending the lower Icefall on April 13, I overtook a pair of slower climbers outfitted with unorthodox
clothing and gear. Almost immediately it became apparent that they weren’t very familiar with the standard tools and
techniques of glacier travel. The climber in back repeatedly snagged his crampons and stumbled. Waiting for them to
cross a gaping crevasse bridged by two rickety ladders lashed end to end, I was shocked to see them go across
together, almost in lockstep, a needlessly dangerous act. An awkward attempt at conversation revealed that they were
members of a Taiwanese expedition.

The reputation of the Taiwanese had preceded them to Everest. In the spring of 1995, the team had traveled to Alaska
to climb Mount McKinley as a shakedown for their attempt on Everest in 1996. Nine climbers reached the summit of
McKinley, but seven of them were caught by a storm on the descent, became disoriented, and spent a night in the open
at 19,400 feet, initiating a costly, hazardous rescue by the National Park Service.

Five of the climbers-two of them with severe frostbite and one dead-were plucked from high on the peak by
helicopter. “If we hadn’t arrived right when we did, two others would have died, too,” says American Conrad Anker,
who with his partner Alex Lowe climbed to 19,400 feet to help rescue the Taiwanese. “Earlier, we’d noticed the
Taiwanese group because they looked so incompetent. It really wasn’t any big surprise when they got into trouble.”

The leader of the expedition, Ming Ho Gau-a jovial photographer who answers to “Makalu”-had to be assisted down
the upper mountain. “As they were bringing him down,” Anker recalls, “Makalu was yelling, ‘Victory! Victory! We
made summit!’ to everyone he passed, as if the disaster hadn’t even happened.” When the survivors of the McKinley
debacle showed up on Everest in 1996, Makalu Gau was again their leader.

In truth, their presence was a matter of grave concern to just about everyone on the mountain. The fear was that the
Taiwanese would suffer a calamity that would compel other expeditions to come to their aid, risking further lives and
possibly costing climbers a shot at the summit. Of course, the Taiwanese were by no means the only group that
seemed egregiously unqualified. Camped beside us at Base Camp was a 25-year-old Norwegian climber named Petter
Neby, who announced his intention to make a solo ascent of the Southwest Face, an outrageously difficult route,
despite the fact that his Himalayan experience consisted of two easy ascents of neighboring Island Peak, a 20,270-foot

And then there were the South Africans. Lavishly funded, sponsored by a major newspaper, the source of effusive
national pride, their team had received a personal blessing from Nelson Mandela prior to their departure. The first
South African expedition ever to be granted a permit to climb Everest, they were a mixed-race group that hoped to put
the first black person on the summit. They were led by a smooth-talking former military officer named Ian Woodall.
When the team arrived in Nepal it included three very strong members, most notably a brilliant climber named Andy
de Klerk, who happened to be a good friend of mine.

But almost immediately, four members, including de Klerk, defected. “Woodall turned out to be a total control freak,”
said de Klerk. “And you couldn’t trust him. We never knew when he was talking bullshit or telling the truth. We didn’t
want to put our lives in the hands of a guy like that. So we left.”

Later de Klerk would learn that Woodall had lied about his climbing record. He’d never climbed anywhere near 8,000
meters, as he claimed. In fact, he hadn’t climbed much of anything. Woodall had also allegedly lied about expedition
finances and even lied about who was named on the official climbing permit.

After Woodall’s deceit was made public, it became an international scandal, reported on the front pages of newspapers
throughout the Commonwealth. When the editor of the Johannesburg Sunday Times, the expedition’s primary sponsor,
confronted Woodall in Nepal, Woodall allegedly tried to physically intimidate him and, according to de Klerk,
threatened, “I’m going to rip your fucking head off!”

In the end, Woodall refused to relinquish leadership and insisted that the climb would proceed as planned. By this
point none of the four climbers left on the team had more than minimal alpine experience. At least two of them, says
de Klerk, “didn’t even know how to put their crampons on.”

The solo Norwegian, the Taiwanese, and especially the South Africans were frequent topics of discussion around the
dinner table in our mess tent. “With so many incompetent people on the mountain,” Hall frowned one evening in late
April, “I think it’s pretty unlikely that we’ll get through this without something bad happening.”

For our third and final acclimatization excursion, we spent four nights at 21,300-foot Camp Two and a night at
24,000-foot Camp Three. Then on May 1 our whole team descended to Base Camp to recoup our strength for the
summit push. Much to my surprise, Hall’s acclimatization plan seemed to be working: After three weeks, I felt like I
was finally adapting to the altitude. The air at Base Camp now seemed deliciously thick.

From the beginning, Hall had planned that May 10 would be our summit day. “Of the four times I’ve summited,” he
explained, “twice it was on the tenth of May. As the Sherps would put it, the tenth is an ‘auspicious’ date for me.” But
there was also a more down-to-earth reason for selecting this date: The annual ebb and flow of the monsoon made it

likely that the most favorable weather of the year would fall on or near May 10.

For all of April, the jet stream had been trained on Everest like a fire hose, blasting the summit
pyramid with nonstop hurricane-force winds. Even on days when Base Camp was perfectly
calm and flooded with sunshine, an immense plume of wind-driven snow was visible over the
summit. But if all went well, in early May the monsoon approaching from the Bay of Bengal
would force the jet stream north into Tibet. If this year was like past years, between the
departure of the wind and the arrival of the monsoon storms we would be presented with a brief
window of clear, calm weather during which a summit assault would be possible.

Unfortunately, the annual weather patterns were no secret, and every expedition had its sights
set on the same window. Hoping to avoid dangerous gridlock on the summit ridge, Hall held a
powwow in the mess tent with leaders of the expeditions in Base Camp. The council, as it
were, determined that Göran Kropp, a young Swede who had ridden a bicycle all the way to

Nepal from Stockholm, would make the first attempt, alone, on May 3. Next would be a team from Montenegro. Then,
on May 8 or 9, it would be the turn of the IMAX expedition, headed by David Breashears, which hoped to wrap up a
large-format film about Everest with footage from the top.

Our team, it was decided, would share a summit date of May 10 with Fischer’s group. An American commercial team
and two British-led commercial groups promised to steer clear of the top of the mountain on the tenth, as did the
Taiwanese. Woodall, however, declared that the South Africans would go to the top whenever they pleased, probably
on the tenth, and anyone who didn’t like it could “bugger off.”

Hall, ordinarily extremely slow to rile, flew into a rage over Woodall’s refusal to cooperate. “I don’t want to be

anywhere near the upper mountain when those punters are up there,” he seethed.

“It feels good to be on our way to the summit, yeah?” Harris inquired as we pulled into Camp Two. The midday sun
was reflecting off the walls of Nuptse, Lhotse, and Everest, and the entire ice-coated valley seemed to have been
transformed into a huge solar oven. We were finally ascending for real, headed straight toward the top, Harris and me
and everybody else.

Harris-Harold to his friends-was the junior guide on the expedition and the only one who’d never been to Everest
(indeed, he’d never been above 23,000 feet). Built like an NFL quarterback and preternaturally good-natured, he was
usually assigned to the slower clients at the back of the pack. For much of the expedition, he had been laid low with
intestinal ailments, but he was finally getting his strength back, and he was eager to prove himself to his seasoned
colleagues. “I think we’re actually gonna knock this big bastard off,” he confided to me with a huge smile, staring up at
the summit.

Harris worked as a much-in-demand heli-skiing guide in the antipodal winter. Summers he guided climbers in New
Zealand’s Southern Alps and had just launched a promising heli-hiking business. Sipping tea in the mess tent back at
Base Camp, he’d shown me a photograph of Fiona McPherson, the pretty, athletic doctor with whom he lived, and
described the house they were building together in the hills outside Queenstown. “Yeah,” he’d marveled, “it’s kind of
amazing, really. My life seems to be working out pretty well.”

Later that day, Kropp, the Swedish soloist, passed Camp Two on his way down the mountain, looking utterly worked.
Three days earlier, under clear skies, he’d made it to just below the South Summit and was no more than an hour from
the top when he decided to turn around. He had been climbing without supplemental oxygen, the hour had been late-2
P.M., to be exact-and he’d believed that if he’d kept going, he’d have been too tired to descend safely.

“To turn around that close to the summit,” Hall mused, shaking his head. “That showed incredibly good judgment on
young Göran’s part. I’m impressed.” Sticking to your predetermined turn-around time-that was the most important rule
on the mountain. Over the previous month, Rob had lectured us repeatedly on this point. Our turn-around time, he
said, would probably be 1 P.M., and no matter how close we were to the top, we were to abide by it. “With enough
determination, any bloody idiot can get up this hill,” Hall said. “The trick is to get back down alive.”

Cheerful and unflappable, Hall’s easygoing facade masked an intense desire to succeed-which to him was defined in
the fairly simple terms of getting as many clients as possible to the summit. But he also paid careful attention to the
details: the health of the Sherpas, the efficiency of the solar-powered electrical system, the sharpness of his clients’
crampons. He loved being a guide, and it pained him that some celebrated climbers didn’t give his profession the
respect he felt it deserved.

On May 8 our team and Fischer’s team left Camp Two and started climbing the Lhotse Face, a vast sweep of steel-hard
ice rising from the head of the Western Cwm. Hall’s Camp Three, two-thirds of the way up this wall, was set on a
narrow ledge that had been chopped into the face by our Sherpas. It was a spectacularly perilous perch. A hundred feet
below, no less exposed, were the tents of most of the other teams, including Fischer’s, the South Africans, and the

It was here that we had our first encounter with death on the mountain. At 7:30 A.M. on May 9, as we were pulling on
our boots to ascend to Camp Four, a 36-year-old steelworker from Taipei named Chen Yu-Nan crawled out of his tent
to relieve himself, with only the smooth-soled liners of his mountaineering boots on his feet-a rather serious lapse of
judgment. As he squatted, he lost his footing on the slick ice and went hurtling down the Lhotse Face, coming to rest,
head-first, in a crevasse. Sherpas who had seen the incident lowered a rope, pulled him out of the slot, and carried him
back to his tent. He was bruised and badly rattled, but otherwise he seemed unharmed. Chen’s teammates left him in a
tent to recover and departed for Camp Four. That afternoon, as Chen tried to descend to Camp Two with the help of
Sherpas, he keeled over and died.

Over the preceding six weeks there had been several serious accidents: Tenzing Sherpa, from our team, fell 150 feet
into a crevasse and injured a leg seriously enough to require helicopter evacuation from Base Camp. One of Fischer’s

Sherpas nearly died of a mysterious illness at Camp Two. A young, apparently fit British climber had a serious heart
attack near the top of the Icefall. A Dane was struck by a falling serac and broke several ribs. Until now, however,
none of the mishaps had been fatal.

Chen’s death cast a momentary pall over the mountain. But 33 climbers at the South Col would be departing for the
summit in a few short hours, and the gloom was quickly shoved aside by nervous anticipation of the challenge to
come. Most of us were simply wrapped too tightly in the grip of summit fever to engage in thoughtful reflection about
the death of someone in our midst. There would be plenty of time for reflection later, we assumed, after we all had
summited-and got back down.

Climbing with oxygen for the first time, I had reached the South Col, our launching pad for the
summit assault, at one o’clock that afternoon. A barren plateau of bulletproof ice and
windswept boulders, the Col sits at 26,000 feet above sea level, tucked between the upper
ramparts of Lhotse, the world’s fourth-highest mountain, and Everest. Roughly rectangular,
about four football fields long by two across, the Col is bounded on the east by the Kangshung
Face, a 7,000-foot drop-off, and on the west by the 4,000-foot Lhotse Face. It is one of the
coldest, most inhospitable places I have ever been.

I was the first Western climber to arrive. When I got there, four Sherpas were struggling to
erect our tents in a 50-mph wind. I helped them put up my shelter, anchoring it to some
discarded oxygen canisters wedged beneath the largest rocks I could lift. Then I dove inside to
wait for my teammates.

It was nearly 5 P.M. when the last of the group made camp. The final stragglers in Fischer’s group came in even later,
which didn’t augur well for the summit bid, scheduled to begin in six hours. Everyone retreated to their nylon domes
the moment they reached the Col and did their best to nap, but the machine-gun rattle of the flapping tents and the
anxiety over what was to come made sleep out of the question for most of us.

Surrounding me on the plateau were some three dozen people, huddled in tents pitched side by side. Yet an odd sense
of isolation hung over the camp. Up here, in this godforsaken place, I felt distressingly disconnected from everyone
around me-emotionally, spiritually, physically. We were a team in name only, I’d sadly come to realize. Although we
would leave camp in a few hours as a group, we would ascend as individuals, linked to one another by neither rope nor
any deep sense of loyalty. Each client was in it for himself or herself, pretty much. And I was no different: I really
hoped Doug Hansen would get to the top, for instance, yet if he were to turn around, I knew I would do everything in
my power to keep pushing on. In another context this insight would have been depressing, but I was too preoccupied
with the weather to dwell on it. If the wind didn’t abate, the summit would be out of the question for all of us.

At 7 P.M. the gale abruptly ceased. The temperature was 15 below zero, but there was almost no wind. Conditions
were excellent; Hall, it appeared, had timed our summit bid perfectly. The tension was palpable as we sipped tea,
delivered to us in our tents by Sherpas, and readied our gear. Nobody said much. All of us had suffered greatly to get
to this moment. I had eaten little and slept not at all since leaving Camp Two two days earlier. Damage to my thoracic
cartilage made each cough feel like a stiff kick between the ribs and brought tears to my eyes. But if I wanted a crack
at the summit, I had no choice but to ignore my infirmities as much as possible and climb.

Finally, at 11:35, we were away from the tents. I strapped on my oxygen mask and ascended into the darkness. There
were 15 of us in Hall’s team: guides Hall, Harris, and Mike Groom, an Australian with impressive Himalayan
experience; Sherpas Ang Dorje, Lhakpa Chhiri, Nawang Norbu, and Kami; and clients Hansen, Namba, Weathers,
Stuart Hutchison (a Canadian doctor), John Taske (an Australian doctor), Lou Kasischke (a lawyer from Michigan),
Frank Fischbeck (a publisher from Hong Kong), and me.

Fischer’s group-guides Fischer, Boukreev, and Neal Beidleman; five Sherpas; and clients Charlotte Fox, Tim Madsen,
Klev Schoening, Sandy Pittman, Lene Gammelgaard, and Martin Adams-left the South Col at midnight. Shortly after
that, Makalu Gau started up with three Sherpas, ignoring his promise that no Taiwanese would make a summit attempt
on May 10. Thankfully, the South Africans had failed to make it to Camp Four and were nowhere in sight.

The night had a cold, phantasmal beauty that intensified as we ascended. More stars than I had ever seen smeared the
frozen sky. Far to the southeast, enormous thunderheads drifted over Nepal, illuminating the heavens with surreal
bursts of orange and blue lightning. A gibbous moon rose over the shoulder of 27,824-foot Makalu, washing the slope
beneath my boots in ghostly light, obviating the need for a headlamp. I broke trail throughout the night with Ang
Dorje-our sirdar, or head Sherpa-and at 5:30, just as the sun was edging over the horizon, I reached the crest of the
Southeast Ridge. Three of the world’s five highest peaks stood out in jagged relief against the pastel dawn. My
altimeter read 27,500 feet.

Hall had instructed us to climb no higher until the whole group gathered at this level roost known as the Balcony, so I
sat down on my pack to wait. When Hall and Weathers finally arrived at the back of the herd, I’d been sitting for more
than 90 minutes. By now Fischer’s group and the Taiwanese team had caught and passed us. I was peeved over
wasting so much time and at falling behind everybody else. But I understood Hall’s rationale, so I kept quiet and
played the part of the obedient client. To my mind, the rewards of climbing come from its emphasis on self-reliance,
on making critical decisions and dealing with the consequences, on personal responsibility. When you become a
client, I discovered, you give up all that. For safety’s sake, the guide always calls the shots.

Passivity on the part of the clients had thus been encouraged throughout our expedition. Sherpas put in the route, set
up the camps, did the cooking, hauled the loads; we clients seldom carried more than daypacks stuffed with our
personal gear. This system conserved our energy and vastly increased our chances of getting to the top, but I found it
hugely unsatisfying. I felt at times as if I wasn’t really climbing the mountain-that surrogates were doing it for me.
Although I had willingly accepted this role in order to climb Everest, I never got used to it. And I was happy as hell
when, at 7:10 A.M., Hall gave me the OK to continue climbing.

One of the first people I passed when I started moving again was Fischer’s sirdar, Lobsang Jangbu, kneeling in the
snow over a pile of vomit. Both Lobsang and Boukreev had asked and been granted permission by Fischer to climb
without supplemental oxygen, a highly questionable decision that significantly affected the performance of both men,
but especially Lobsang. His feeble state, moreover, had been compounded by his insistence on “short-roping” Pittman
on summit day.

Lobsang, 25, was a gifted high-altitude climber who’d summited Everest twice before without oxygen. Sporting a long
black ponytail and a gold tooth, he was flashy, self-assured, and very appealing to the clients, not to mention crucial to
their summit hopes. As Fischer’s head Sherpa, he was expected to be at the front of the group this morning, putting in
the route. But just before daybreak, I’d looked down to see Lobsang hitched to Pittman by her three-foot safety tether;
the Sherpa, huffing and puffing loudly, was hauling the assertive New Yorker up the steep slope like a horse pulling a
plow. Pittman was on a widely publicized quest to ascend Everest and thereby complete the Seven Summits. She’d
failed to make it to the top on two previous expeditions; this time she was determined to succeed.

Fischer knew that Lobsang was short-roping Pittman, yet did nothing to stop it; some people have thus concluded that
Fischer ordered Lobsang to do it, because Pittman had been moving slowly when she started out on summit day, and
Fischer worried that if Pittman failed to reach the summit, he would be denied a marketing bonanza. But two other
clients on Fischer’s team speculate that Lobsang was short-roping her because she’d promised him a hefty cash bonus
if she reached the top. Pittman has denied this and insists that she was hauled up against her wishes. Which begs a
question: Why didn’t she unfasten the tether, which would have required nothing more than reaching up and
unclipping a single carabiner?

“I have no idea why Lobsang was short-roping Sandy,” confesses Beidleman. “He lost sight of what he was supposed
to be doing up there, what the priorities were.” It didn’t seem like a particularly serious mistake at the time. A little
thing. But it was one of many little things-accruing slowly, compounding imperceptibly, building steadily toward
critical mass.

A human plucked from sea level and dropped on the summit of Everest would lose consciousness within minutes and
quickly die. A well-acclimatized climber can function at that altitude with supplemental oxygen-but not well, and not
for long. The body becomes far more vulnerable to pulmonary and cerebral edema, hypothermia, frostbite. Each
member of our team was carrying two orange, seven-pound oxygen bottles. A third bottle would be waiting for each

of us at the South Summit on our descent, stashed there by Sherpas. At a conservative flow rate of two liters per
minute, each bottle would last between five and six hours. By 4 or 5 P.M., about 18 hours after starting to climb,
everyone’s gas would be gone.

Hall understood this well. The fact that nobody had summited this season prior to our attempt concerned him, because
it meant that no fixed ropes had been installed on the upper Southeast Ridge, the most exposed part of the climb. To
solve this problem, Hall and Fischer had agreed before leaving Base Camp that on summit day the two sirdars-Ang
Dorje from Hall’s team and Lobsang from Fischer’s-would leave Camp Four 90 minutes ahead of everybody else and
put in the fixed lines before any clients reached the upper mountain. “Rob made it very clear how important it was to
do this,” recalls Beidleman. “He wanted to avoid a bottleneck at all costs.”

For some reason, however, the Sherpas hadn’t set out ahead of us on the night of May 9. When Ang Dorje and I
reached the Balcony, we were an hour in front of the rest of the group, and we could have easily moved on and
installed the ropes. But Hall had explicitly forbidden me to go ahead, and Lobsang was still far below, short-roping
Pittman. There was nobody to accompany Ang Dorje.

A quiet, moody young man who regarded Lobsang as a showboat and a goldbrick, Ang Dorje had been working
extremely hard, well beyond the call of duty, for six long weeks. Now he was tired of doing more than his share. If
Lobsang wasn’t going to fix ropes, neither was he. Looking sullen, Ang Dorje sat down with me to wait.

Sure enough, not long after everybody caught up with us and we continued climbing up, a bottleneck occurred when
our group encountered a series of giant rock steps at 28,000 feet. Clients huddled at the base of this obstacle for nearly
an hour while Beidleman, standing in for the absent Lobsang, laboriously ran the rope out.

Here, the impatience and technical inexperience of Namba nearly caused a disaster. A businesswoman who liked to
joke that her husband did all the cooking and cleaning, Namba had become famous back in Japan for her Seven
Summits globe-trotting, and her quest for Everest had turned into a minor cause célèbre. She was usually a slow,
tentative climber, but today, with the summit squarely in her sights, she seemed energized as never before. She’d been
pushing hard all morning, jostling her way toward the front of the line. Now, as Beidleman clung precariously to the
rock 100 feet above, the overeager Namba clamped her ascender onto the dangling rope before the guide had anchored
his end of it. Just as she was about to put her full body weight on the rope-which would have pulled Beidleman off-
guide Mike Groom intervened and gently scolded her.

The line continued to grow longer, and so did the delay. By 11:30 A.M., three of Hall’s clients-Hutchison, Taske, and
Kasischke-had become worried about the lagging pace. Stuck behind the sluggish Taiwanese team, Hutchison now
says, “It seemed increasingly unlikely that we would have any chance of summiting before the 1 P.M. turn-around
time dictated by Rob.”

After a brief discussion, they turned their back on the summit and headed down with Kami and Lhakpa Chhiri. Earlier,
Fischbeck, one of Hall’s strongest clients, had also turned around. The decision must have been supremely difficult for
at least some of these men, especially Fischbeck, for whom this was a fourth attempt on Everest. They’d each spent as
much as $70,000 to be up here and had endured weeks of misery. All were driven, unaccustomed to losing and even
less to quitting. And yet, faced with a tough decision, they were among the few who made the right one that day.

There was a second, even worse, bottleneck at the South Summit, which I reached at about 11 A.M. The Hillary Step
was just a stone’s throw away, and slightly beyond that was the summit itself. Rendered dumb with awe and
exhaustion, I took some photos and sat down with Harris, Beidleman, and Boukreev to wait for the Sherpas to fix
ropes along the spectacularly corniced summit ridge.

A stiff breeze raked the ridge crest, blowing a plume of spindrift into Tibet, but overhead the sky was an achingly
brilliant blue. Lounging in the sun at 28,700 feet inside my thick down suit, gazing across the Himalayas in a hypoxic
stupor, I completely lost track of time. Nobody paid much attention to the fact that Ang Dorje and Nawang Norbu
were sharing a thermos of tea beside us and seemed to be in no hurry to go higher. Around noon, Beidleman finally
asked, “Hey, Ang Dorje, are you going to fix the ropes, or what?”

Ang Dorje’s reply was a quick, unequivocal “No”–perhaps because neither Lobsang nor any of Fischer’s other Sherpas
was there to share the work. Shocked into doing the job ourselves, Beidleman, Boukreev, Harris, and I collected all the
remaining rope, and Beidleman and Boukreev started stringing it along the most dangerous sections of the summit
ridge. But by then more than an hour had trickled away.

Bottled oxygen does not make the top of Everest feel like sea level. Ascending above the South Summit with my
regulator delivering two liters of oxygen per minute, I had to stop and draw three or four heaving lungfuls of air after
each ponderous step. The systems we were using delivered a lean mix of compressed oxygen and ambient air that
made 29,000 feet feel like 26,000 feet. But they did confer other benefits that weren’t so easily quantified, not the least
of which was keeping hypothermia and frostbite at bay.

Climbing along the blade of the summit ridge, sucking gas into my ragged lungs, I enjoyed a strange, unwarranted
sense of calm. The world beyond the rubber mask was stupendously vivid but seemed not quite real, as if a movie
were being projected in slow motion across the front of my goggles. I felt drugged, disengaged, thoroughly insulated
from external stimuli. I had to remind myself over and over that there was 7,000 feet of sky on either side, that
everything was at stake here, that I would pay for a single bungled step with my life.

Plodding slowly up the last few steps to the summit, I had the sensation of being underwater, of moving at quarter-
speed. And then I found myself atop a slender wedge of ice adorned with a discarded oxygen cylinder and a battered
aluminum survey pole, with nowhere higher to climb. A string of Buddhist prayer flags snapped furiously in the wind.
To the north, down a side of the mountain I had never seen, the desiccated Tibetan plateau stretched to the horizon.

Reaching the top of Everest is supposed to trigger a surge of intense elation; against long odds, after all, I had just
attained a goal I’d coveted since childhood. But the summit was really only the halfway point. Any impulse I might
have felt toward self-congratulation was immediately extinguished by apprehension about the long, dangerous descent
that lay ahead. As I turned to go down, I experienced a moment of alarm when a glance at my regulator showed that
my oxygen was almost gone. I started down the ridge as fast as I could move but soon hit the traffic jam at the Hillary
Step, which was when my gas ran out. When Hall came by, I masked my rising panic and thanked him for getting me
to the top of Everest. “Yeah, it’s turned out to be a pretty good expedition,” he replied. “I only wish we could have
gotten more clients to the top.” Hall was clearly disappointed that five of his eight clients had turned back earlier in the
day, while all six of Fischer’s clients were still plugging toward the summit.

Soon after Hall passed, the Hillary Step finally cleared. Dizzy, fearing that I would black out, I made my way
tenuously down the fixed lines. Then, 50 feet above the South Summit, the rope ended, and I balked at going farther
without gas.

Over at the South Summit I could see Harris sorting through a pile of oxygen bottles. “Yo, Andy!” I yelled. “Could
you bring me a fresh bottle?”

“There’s no oxygen here!” the guide shouted back. “These bottles are all empty!” I nearly lost it. I had no idea what to
do. Just then, Groom came past on his way down from the summit. He had climbed Everest in 1993 without
supplemental oxygen and wasn’t overly concerned about going without. He gave me his bottle, and we quickly
scrambled over to the South Summit.

When we got there, an examination of the oxygen cache revealed right away that there were six full bottles. Harris,
however, refused to believe it. He kept insisting that they were all empty, and nothing Groom or I said could convince
him otherwise. Right then it should have been obvious that Harris was acting irrationally and had slipped well beyond
routine hypoxia, but I was so impeded myself that it simply didn’t register. Harris was the invincible guide, there to
look after me and the other clients; the thought never entered my own crippled mind that he might in fact be in dire
straits-that a guide might urgently need help from me.

As Harris continued to assert that there were no full bottles, Groom looked at me quizzically. I looked back and
shrugged. Turning to Harris, I said, “No big deal, Andy. Much ado about nothing.” Then I grabbed a new oxygen
canister, screwed it onto my regulator, and headed down the mountain. Given what unfolded over the next three hours,

my failure to see that Harris was in serious trouble was a lapse that’s likely to haunt me for the rest of my life.

At 3 P.M., within minutes of leaving the South Summit, I descended into clouds ahead of the others. Snow started to
fall. In the flat, diminishing light, it became hard to tell where the mountain ended and where the sky began. It would
have been very easy to blunder off the edge of the ridge and never be heard from again. The lower I went, the worse
the weather became.

When I reached the Balcony again, about 4 P.M., I encountered Beck Weathers standing alone, shivering violently.
Years earlier, Weathers had undergone radial keratotomy to correct his vision. A side effect, which he discovered on
Everest and consequently hid from Hall, was that in the low barometric pressure at high altitude, his eyesight failed.
Nearly blind when he’d left Camp Four in the middle of the night but hopeful that his vision would improve at
daybreak, he stuck close to the person in front of him and kept climbing.

Upon reaching the Southeast Ridge shortly after sunrise, Weathers had confessed to Hall that he was having trouble
seeing, at which point Hall declared, “Sorry, pal, you’re going down. I’ll send one of the Sherpas with you.” Weathers
countered that his vision was likely to improve as soon as the sun crept higher in the sky; Hall said he’d give Weathers
30 minutes to find out-after that, he’d have to wait there at 27,500 feet for Hall and the rest of the group to come back
down. Hall didn’t want Weathers descending alone. “I’m dead serious about this,” Hall admonished his client.
“Promise me that you’ll sit right here until I return.”

“I crossed my heart and hoped to die,” Weathers recalls now, “and promised I wouldn’t go anywhere.” Shortly after
noon, Hutchison, Taske, and Kasischke passed by with their Sherpa escorts, but Weathers elected not to accompany
them. “The weather was still good,” he explains, “and I saw no reason to break my promise to Rob.”

By the time I encountered Weathers, however, conditions were turning ugly. “Come down with me,” I implored. “I’ll
get you down, no problem.” He was nearly convinced, until I made the mistake of mentioning that Groom was on his
way down, too. In a day of many mistakes, this would turn out to be a crucial one. “Thanks anyway,” Weathers said.
“I’ll just wait for Mike. He’s got a rope; he’ll be able to short-rope me.” Secretly relieved, I hurried toward the South
Col, 1,500 feet below.

These lower slopes proved to be the most difficult part of the descent. Six inches of powder snow blanketed
outcroppings of loose shale. Climbing down them demanded unceasing concentration, an all but impossible feat in my
current state. By 5:30, however, I was finally within 200 vertical feet of Camp Four, and only one obstacle stood
between me and safety: a steep bulge of rock-hard ice that I’d have to descend without a rope. But the weather had
deteriorated into a full-scale blizzard. Snow pellets born on 70-mph winds stung my face; any exposed skin was
instantly frozen. The tents, no more than 200 horizontal yards away, were only intermittently visible through the
whiteout. There was zero margin for error. Worried about making a critical blunder, I sat down to marshal my energy.

Suddenly, Harris appeared out of the gloom and sat beside me. At this point there was no mistaking that he was in
appalling shape. His cheeks were coated with an armor of frost, one eye was frozen shut, and his speech was slurred.
He was frantic to reach the tents. After briefly discussing the best way to negotiate the ice, Harris started scooting
down on his butt, facing forward. “Andy,” I yelled after him, “it’s crazy to try it like that!” He yelled something back,
but the words were carried off by the screaming wind. A second later he lost his purchase and was rocketing down on
his back.

Two hundred feet below, I could make out Harris’s motionless form. I was sure he’d broken at least a leg, maybe his
neck. But then he stood up, waved that he was OK, and started stumbling toward camp, which was for the moment in
plain sight, 150 yards beyond.

I could see three or four people shining lights outside the tents. I watched Harris walk across the flats to the edge of
camp, a distance he covered in less than ten minutes. When the clouds closed in a moment later, cutting off my view,
he was within 30 yards of the tents. I didn’t see him again after that, but I was certain that he’d reached the security of
camp, where Sherpas would be waiting with hot tea. Sitting out in the storm, with the ice bulge still standing between
me and the tents, I felt a pang of envy. I was angry that my guide hadn’t waited for me.

Twenty minutes later I was in camp. I fell into my tent with my crampons still on, zipped the door tight, and sprawled
across the frost-covered floor. I was drained, more exhausted than I’d ever been in my life. But I was safe. Andy was
safe. The others would be coming into camp soon. We’d done it. We’d climbed Mount Everest.

It would be many hours before I learned that everyone had in fact not made it back to camp–that one teammate was
already dead and that 23 other men and women were caught in a desperate struggle for their lives.

Neal Beidleman waited on the summit from 1:25 until 3:10 as Fischer’s clients appeared over the last rise, one by one.
The lateness of the hour worried him. After Gammelgaard, the last of them, arrived with Lobsang, “I decided it was
time to get the hell out of there,” Beidleman says, “even though Scott hadn’t shown yet.” Twenty minutes down the
ridge, Beidleman-with Gammelgaard, Pittman, Madsen, and Fox in tow-passed Fischer, still on his way up. “I didn’t
really say anything to him,” Beidleman recalls. “He just sort of raised his hand. He looked like he was having a hard
time, but he was Scott, so I wasn’t particularly worried. I figured he’d tag the summit and catch up to us pretty quick to
help bring the clients down. But he never showed up.”

When Beidleman’s group got down to the South Summit, Pittman collapsed. Fox, the most experienced client on the
peak, gave her an injection of a powerful steroid, dexamethasone, which temporarily negates the symptoms of altitude
sickness. Beidleman grabbed Pittman by her harness and started dragging her down behind him.

“Once I got her sliding,” he explains, “I’d let go and glissade down in front of her. Every 50 meters I’d stop, wrap my
hands around the fixed rope, and brace myself to arrest her slide with a body block. The first time Sandy came
barreling into me, the points of her crampons sliced into my down suit. Feathers went flying everywhere.” Fortunately,
after about 20 minutes the injection revived Pittman, and she was able to resume the descent under her own power.

As darkness fell and the storm intensified, Beidleman and five of Fischer’s clients overtook Groom, who was bringing
down Weathers, on a short rope, and Namba. “Beck was so hopelessly blind,” Groom reports, “that every ten meters
he’d take a step into thin air and I’d have to catch him with the rope. It was bloody nerve-racking.”

Five hundred feet above the South Col, where the steep shale gave way to a gentler slope of snow, Namba’s oxygen
ran out and the diminutive Japanese woman sat down, refusing to move. “When I tried to take her oxygen mask off so
she could breathe more easily,” says Groom, “she’d insist on putting it right back on. No amount of persuasion could
convince her that she was out of oxygen, that the mask was actually suffocating her.”

Beidleman, realizing that Groom had his hands full with Weathers, started dragging Namba down toward Camp Four.
They reached the broad, rolling expanse of the South Col around 8 P.M., but by then it was pitch black, and the storm
had grown into a hurricane. The windchill was in excess of 70 below. Only three or four headlamps were working, and
everyone’s oxygen was long gone. Visibility was down to a few meters. No one had a clue how to find the tents. Two
Sherpas materialized out of the darkness, but they were lost as well.

For the next two hours, Beidleman, Groom, the two Sherpas, and seven clients staggered blindly around in the storm,
growing ever more exhausted and hypothermic, hoping to blunder across the camp. “It was total chaos,” says
Beidleman. “People are wandering all over the place; I’m yelling at everyone, trying to get them to follow a single
leader. Finally, probably around ten o’clock, I walked over this little rise, and it felt like I was standing on the edge of
the earth. I could sense a huge void just beyond.”

The group had unwittingly strayed to the easternmost edge of the Col, the opposite side from Camp Four, right at the
lip of the 7,000-foot Kangshung Face. “I knew that if we kept wandering in the storm, pretty soon we were going to
lose somebody,” says Beidleman. “I was exhausted from dragging Yasuko. Charlotte and Sandy were barely able to
stand. So I screamed at everyone to huddle up right there and wait for a break in the storm.”

The climbers hunkered in a pathetic cluster on a windswept patch of ice. “By then the cold had about finished me off,”
says Fox. “My eyes were frozen. The cold was so painful, I just curled up in a ball and hoped death would come

Three hundred and fifty yards to the west, while this was going on, I was shivering uncontrollably in my tent, even
though I was zipped into my sleeping bag and wearing my down suit and every other stitch of clothing I had. The gale
was threatening to blow the tent apart. Oblivious to the tragedy unfolding outside and completely out of bottled
oxygen, I drifted in and out of fitful sleep, delirious from exhaustion, dehydration, and the cumulative effects of
oxygen depletion.

At some point, Hutchison shook me and asked if I would go outside with him to bang on pots and shine lights, in the
hope of guiding any lost climbers in, but I was too weak and incoherent to respond. Hutchison, who had got back to
camp at 2 P.M. and was less debilitated than those of us who’d gone to the summit, then tried to rouse clients and
Sherpas in the other tents. Everybody was too cold, too exhausted. So Hutchison went out into the storm alone.

He left six times that night to look for the missing climbers, but the blizzard was so fierce that he never dared to
venture more than a few yards from the tents. “The winds were ballistically strong,” says Hutchison. “The blowing
spindrift felt like a sandblaster or something.”

Just before midnight, out among the climbers hunkered on the Col, Beidleman noticed a few stars overhead. The wind
was still whipping up a furious ground blizzard, but far above, the sky began to clear, revealing the hulking silhouettes
of Everest and Lhotse. From these reference points, Klev Schoening, a client of Fischer’s, thought he’d figured out
where the group was in relation to the tents. After a shouting match with Beidleman, Schoening convinced the guide
that he knew the way.

Beidleman tried to coax everyone to their feet and get them moving in the direction indicated by Schoening, but Fox,
Namba, Pittman, and Weathers were too feeble to walk. So Beidleman assembled those who were ambulatory, and
together with Groom they stumbled off into the storm to get help, leaving behind the four incapacitated clients and
Tim Madsen. Madsen, unwilling to abandon Fox, his girlfriend, volunteered to look after everybody until a rescue
party arrived.

The tents lay about 350 yards to the west. When Beidleman, Groom, and the clients got there, they were met by
Boukreev. Beidleman told the Russian where to find the five clients who’d been left out in the elements, and then all
four climbers collapsed in their tents.

Boukreev had returned to Camp Four at 4:30 P.M., before the brunt of the storm, having rushed down from the
summit without waiting for clients-extremely questionable behavior for a guide. A number of Everest veterans have
speculated that if Boukreev had been present to help Beidleman and Groom bring their clients down, the group might
not have got lost on the Col in the first place. One of the clients from that group has nothing but contempt for
Boukreev, insisting that when it mattered most, the guide “cut and ran.”

Boukreev argues that he hurried down ahead of everybody else because “it is much better for me to be at South Col,
ready to carry up oxygen if clients run out.” This is a difficult rationale to understand. In fact, Boukreev’s impatience
on the descent more plausibly resulted from the fact that he wasn’t using bottled oxygen and was relatively lightly
dressed and therefore hadto get down quickly: Without gas, he was much more susceptible to the dreadful cold. If this
was indeed the case, Fischer was as much to blame as Boukreev, because he gave the Russian permission to climb
without gas in the first place.

Whatever Boukreev’s culpability, however, he redeemed himself that night after Beidleman staggered in. Plunging
repeatedly into the maw of the hurricane, he single-handedly brought back Fox, Pittman, and Madsen. But Namba and
Weathers, he reported, were dead. When Beidleman was informed that Namba hadn’t made it, he broke down in his
tent and wept for 45 minutes.

Stuart Hutchison shook me awake at 6:00 A.M. on May 11. “Andy’s not in his tent,” he told me somberly, “and he
doesn’t seem to be in any of the other tents, either. I don’t think he ever made it in.”

“Andy’s missing?” I asked. “No way. I saw him walk to the edge of camp with my own eyes.” Shocked, horrified, I

pulled on my boots and rushed out to look for Harris. The wind was still fierce, knocking me down several times, but
it was a bright, clear dawn, and visibility was perfect. I searched the entire western half of the Col for more than an
hour, peering behind boulders and poking under shredded, long-abandoned tents, but found no trace of Harris. A surge
of adrenaline seared my brain. Tears welled in my eyes, instantly freezing my eyelids shut. How could Andy be gone?
It couldn’t be so.

I went to the place where Harris had slid down the ice bulge and methodically retraced the route he’d taken toward
camp, which followed a broad, almost flat ice gully. At the point where I last saw him when the clouds came down, a
sharp left turn would have taken Harris 40 or 50 feet up a rocky rise to the tents.

I saw, however, that if he hadn’t turned left but instead had continued straight down the gully-which would have been
easy to do in a whiteout, even if one wasn’t exhausted and stupid with altitude sickness-he would have quickly come to
the westernmost edge of the Col and a 4,000-foot drop to the floor of the Western Cwm. Standing there, afraid to
move any closer to the edge, I noticed a single set of faint crampon tracks leading past me toward the abyss. Those
tracks, I feared, were Harris’s.

After getting into camp the previous evening, I’d told Hutchison that I’d seen Harris arrive safely in camp. Hutchison
had radioed this news to Base Camp, and from there it was passed along via satellite phone to the woman with whom
Harris shared his life in New Zealand, Fiona McPherson. Now Hall’s wife back in New Zealand, Jan Arnold, had to do
the unthinkable: call McPherson back to inform her that there had been a horrible mistake, that Andy was in fact
missing and presumed dead. Imagining this conversation and my role in the events leading up to it, I fell to my knees
with dry heaves, retching as the icy wind blasted my back.

I returned to my tent just in time to overhear a radio call between Base Camp and Hall–who, I learned to my horror,
was up on the summit ridge and calling for help. Beidleman then told me that Weathers and Namba were dead and that
Fischer was missing somewhere on the peak above. An aura of unreality had descended over the mountain, casting the
morning in a nightmarish hue.

Then our radio batteries died, cutting us off from the rest of the mountain. Alarmed that they had lost contact with us,
climbers at Camp Two called the South African team, which had arrived on the South Col the previous day. When Ian
Woodall was asked if he would loan his radio to us, he refused.

After reaching the summit around 3:30 P.M. on May 10, Scott Fischer had headed down with Lobsang, who had
waited for Fischer on the summit while Beidleman and their clients descended. They got no farther than the South
Summit before Fischer began to have difficulty standing and showed symptoms of severe hypothermia and cerebral
edema. According to Lobsang, Fischer began “acting like crazy man. Scott is saying to me, ‘I want to jump down to
Camp Two.’ He is saying many times.” Pleading with him not to jump, Lobsang started short-roping Fischer, who
outweighed him by some 70 pounds, down the Southeast Ridge. A few hours after dark, they got into some difficult
mixed terrain 1,200 feet above the South Col, and Lobsang was unable to drag Fischer any farther.

Lobsang anchored Fischer to a snow-covered ledge and was preparing to leave him there when three tired Sherpas
showed up. They were struggling to bring down Makalu Gau, who was as debilitated as Fischer. The Sherpas sat the
Taiwanese leader beside the American leader, tied the two semiconscious men together, and around 10 P.M.
descended into the night to get help.

Meanwhile, Hall and Hansen were still on the frightfully exposed summit ridge, engaged in a grim struggle of their
own. The 46-year-old Hansen, whom Hall had turned back just below this spot exactly a year ago, had been
determined to bag the summit this time around. “I want to get this thing done and out of my life,” he’d told me a
couple of days earlier. “I don’t want to have to come back here.”

Indeed, Hansen had reached the top this time, though not until after 3 P.M., well after Hall’s pre-determined turn-
around time. Given Hall’s conservative, systematic nature, many people wonder why he didn’t turn Hansen around
when it became obvious that he was running late. It’s not far-fetched to speculate that because Hall had talked Hansen
into coming back to Everest this year, it would have been especially hard for him to deny Hansen the summit a second

time–especially when all of Fischer’s clients were still marching blithely toward the top.

“It’s very difficult to turn someone around high on the mountain,” cautions Guy Cotter, a New Zealand guide who
summited Everest with Hall in 1992 and was guiding the peak for him in 1995 when Hansen made his first attempt. “If
a client sees that the summit is close and they’re dead-set on getting there, they’re going to laugh in your face and keep
going up.”

In any case, for whatever reason, Hall did not turn Hansen around. Instead, after reaching the summit at 2:10 P.M.,
Hall waited for more than an hour for Hansen to arrive and then headed down with him. Soon after they began their
descent, just below the top, Hansen apparently ran out of oxygen and collapsed. “Pretty much the same thing happened
to Doug in ’95,” says Ed Viesturs, an American who guided the peak for Hall that year. “He was fine during the ascent,
but as soon as he started down he lost it mentally and physically. He turned into a real zombie, like he’d used
everything up.”

At 4:31 P.M., Hall radioed Base Camp to say that he and Hansen were above the Hillary Step and urgently needed
oxygen. Two full bottles were waiting for them at the South Summit; if Hall had known this he could have retrieved
the gas fairly quickly and then climbed back up to give Hansen a fresh tank. But Harris, in the throes of his oxygen–
starved dementia, overheard the 4:31 radio call while descending the Southeast Ridge and broke in to tell Hall–
incorrectly, just as he’d told Groom and me–that all the bottles at the South Summit were empty. So Hall stayed with
Hansen and tried to bring the helpless client down without oxygen, but could get him no farther than the top of the
Hillary Step.

Cotter, a very close friend of both Hall and Harris, happened to be a few miles from Everest Base Camp at the time,
guiding an expedition on Pumori. Overhearing the radio conversations between Hall and Base Camp, he called Hall at
5:36 and again at 5:57, urging his mate to leave Hansen and come down alone. “I know I sound like the bastard for
telling Rob to abandon his client,” confesses Cotter, “but by then it was obvious that leaving Doug was his only
choice.” Hall, however, wouldn’t consider going down without Hansen.

There was no further word from Hall until the middle of the night. At 2:46 A.M. on May 11, Cotter woke up to hear a
long, broken transmission, probably unintended: Hall was wearing a remote microphone clipped to the shoulder strap
of his backpack, which was occasionally keyed on by mistake. In this instance, says Cotter, “I suspect Rob didn’t even
know he was transmitting. I could hear someone yelling-it might have been Rob, but I couldn’t be sure because the
wind was so loud in the background. He was saying something like ‘Keep moving! Keep going!’ presumably to Doug,
urging him on.”

If that was indeed the case, it meant that in the wee hours of the morning Hall and Hansen were still struggling from
the Hillary Step toward the South Summit, taking more than 12 hours to traverse a stretch of ridge typically covered
by descending climbers in half an hour.

Hall’s next call to Base Camp was at 4:43 A.M. He’d finally reached the South Summit but was unable to descend
farther, and in a series of transmissions over the next two hours he sounded confused and irrational. “Harold was with
me last night,” Hall insisted, when in fact Harris had reached the South Col at sunset. “But he doesn’t seem to be with
me now. He was very weak.”

Mackenzie asked him how Hansen was doing. “Doug,” Hall replied, “is gone.” That was all he said, and it was the last
mention he ever made of Hansen.

On May 23, when Breashears and Viesturs, of the IMAX team, reached the summit, they found no sign of Hansen’s
body but they did find an ice ax planted about 50 feet below the Hillary Step, along a highly exposed section of ridge
where the fixed ropes came to an end. It is quite possible that Hall managed to get Hansen down the ropes to this
point, only to have him lose his footing and fall 7,000 feet down the sheer Southwest Face, leaving his ice ax jammed
into the ridge crest where he slipped.

During the radio calls to Base Camp early on May 11, Hall revealed that something was wrong with his legs, that he
was no longer able to walk and was shaking uncontrollably. This was very disturbing news to the people down below,
but it was amazing that Hall was even alive after spending a night without shelter or oxygen at 28,700 feet in
hurricane-force wind and minus-100-degree windchill.

At 5 A.M., Base Camp patched through a call on the satellite telephone to Jan Arnold, Hall’s wife, seven months
pregnant with their first child in Christchurch, New Zealand. Arnold, a respected physician, had summited Everest
with Hall in 1993 and entertained no illusions about the gravity of her husband’s predicament. “My heart really sank
when I heard his voice,” she recalls. “He was slurring his words markedly. He sounded like Major Tom or something,
like he was just floating away. I’d been up there; I knew what it could be like in bad weather. Rob and I had talked
about the impossibility of being rescued from the summit ridge. As he himself had put it, ‘You might as well be on the

By that time, Hall had located two full oxygen bottles, and after struggling for four hours trying to deice his mask,
around 8:30 A.M. he finally started breathing the life-sustaining gas. Several times he announced that he was
preparing to descend, only to change his mind and remain at the South Summit. The day had started out sunny and
clear, but the wind remained fierce, and by late morning the upper mountain was wrapped with thick clouds. Climbers
at Camp Two reported that the wind over the summit sounded like a squadron of 747s, even from 8,000 feet below.

About 9:30 A.M., Ang Dorje and Lhakpa Chhiri ascended from Camp Four in a brave attempt to bring Hall down. At
the same time, four other Sherpas went to rescue Fischer and Gau. When they reached Fischer, the Sherpas tried to
give him oxygen and hot tea, but he was unresponsive. Though he was breathing-barely-his eyes were fixed and his
teeth were clenched. Believing he was as good as dead, they left him tied to the ledge and started descending with
Gau, who after receiving tea and oxygen, and with considerable assistance, was able to move to the South Col.

Higher on the peak, Ang Dorje and Lhakpa Chhiri climbed to 28,000 feet, but the murderous wind forced them to turn
around there, still 700 feet below Hall.

Throughout that day, Hall’s friends begged him to make an effort to descend from the South Summit under his own
power. At 3:20 P.M., after one such transmission from Cotter, Hall began to sound annoyed. “Look,” he said, “if I
thought I could manage the knots on the fixed ropes with me frostbitten hands, I would have gone down six hours ago,
pal. Just send a couple of the boys up with a big thermos of something hot-then I’ll be fine.”

At 6:20 P.M., Hall was patched through a second time to Arnold in Christchurch. “Hi, my sweetheart,” he said in a
slow, painfully distorted voice. “I hope you’re tucked up in a nice warm bed. How are you doing?”

“I can’t tell you how much I’m thinking about you!” Arnold replied. “You sound so much better than I expected…. Are
you warm, my darling?”

“In the context of the altitude, the setting, I’m reasonably comfortable,” Hall answered, doing his best not to alarm her.
“How are your feet?”

“I haven’t taken me boots off to check, but I think I may have a bit of frostbite.”

“I’m looking forward to making you completely better when you come home,” said Arnold. “I just know you’re going
to be rescued. Don’t feel that you’re alone. I’m sending all my positive energy your way!” Before signing off, Hall told
his wife, “I love you. Sleep well, my sweetheart. Please don’t worry too much.”

These would be the last words anyone would hear him utter. Attempts to make radio contact with Hall later that night
and the next day went unanswered. Twelve days later, when Breashears and Viesturs climbed over the South Summit
on their way to the top, they found Hall lying on his right side in a shallow ice-hollow, his upper body buried beneath
a drift of snow.

Early on the morning of May 11, when I returned to Camp Four after searching in vain for Harris, Hutchison, standing
in for Groom, who was unconscious in his tent, organized a team of four Sherpas to locate the bodies of our
teammates Weathers and Namba. The Sherpa search party, headed by Lhakpa Chhiri, departed ahead of Hutchison,
who was so exhausted and befuddled that he forgot to put his boots on and left camp in his light, smooth-soled liners.
Only when Lhakpa Chhiri pointed out the blunder did Hutchison return for his boots. Following Boukreev’s directions,
the Sherpas had no trouble locating the two bodies at the edge of the Kangshung Face.

The first body turned out to be Namba, but Hutchison couldn’t tell who it was until he knelt in the howling wind and
chipped a three-inch-thick carapace of ice from her face. To his shock, he discovered that she was still breathing. Both
her gloves were gone, and her bare hands appeared to be frozen solid. Her eyes were dilated. The skin on her face was
the color of porcelain. “It was terrible,” Hutchison recalls. “I was overwhelmed. She was very near death. I didn’t
know what to do.”

He turned his attention to Weathers, who lay 20 feet away. His face was also caked with a thick armor of frost. Balls
of ice the size of grapes were matted to his hair and eyelids. After clearing the frozen detritus from his face, Hutchison
discovered that he, too, was still alive: “Beck was mumbling something, I think, but I couldn’t tell what he was trying
to say. His right glove was missing and he had terrible frostbite. He was as close to death as a person can be and still
be breathing.”

Badly shaken, Hutchison went over to the Sherpas and asked Lhakpa Chhiri’s advice. Lhakpa Chhiri, an Everest
veteran respected by Sherpas and sahibs alike for his mountain savvy, urged Hutchison to leave Weathers and Namba
where they lay. Even if they survived long enough to be dragged back to Camp Four, they would certainly die before
they could be carried down to Base Camp, and attempting a rescue would needlessly jeopardize the lives of the other
climbers on the Col, most of whom were going to have enough trouble getting themselves down safely.

Hutchison decided that Chhiri was right. There was only one choice, however difficult: Let nature take its inevitable
course with Weathers and Namba, and save the group’s resources for those who could actually be helped. It was a
classic act of triage. When Hutchison returned to camp at 8:30 A.M. and told the rest of us of his decision, nobody
doubted that it was the correct thing to do.

Later that day a rescue team headed by two of Everest’s most experienced guides, Pete Athans and Todd Burleson,
who were on the mountain with their own clients, arrived at Camp Four. Burleson was standing outside the tents about
4:30 P.M. when he noticed someone lurching slowly toward camp. The person’s bare right hand, naked to the wind
and horribly frostbitten, was outstretched in a weird, frozen salute. Whoever it was reminded Athans of a mummy in a
low-budget horror film. The mummy turned out to be none other than Beck Weathers, somehow risen from the dead.

A couple of hours earlier, a light must have gone on in the reptilian core of Weathers’s comatose brain, and he
regained consciousness. “Initially I thought I was in a dream,” he recalls. “Then I saw how badly frozen my right hand
was, and that helped bring me around to reality. Finally I woke up enough to recognize that I was in deep shit and the
cavalry wasn’t coming so I better do something about it myself.”

Although Weathers was blind in his right eye and able to focus his left eye within a radius of only three or four feet, he
started walking into the teeth of the wind, deducing correctly that camp lay in that direction. If he’d been wrong he
would have stumbled immediately down the Kangshung Face, the edge of which was a few yards in the opposite
direction. Ninety minutes later he encountered “some unnaturally smooth, bluish-looking rocks,” which turned out to
be the tents of Camp Four.

The next morning, May 12, Athans, Burleson, and climbers from the IMAX team short-roped Weathers down to
Camp Two. On the morning of May 13, in a hazardous helicopter rescue, Weathers and Gau were evacuated from the
top of the icefall by Lieutenant Colonel Madan Khatri Chhetri of the Nepalese army. A month later, a team of Dallas
surgeons would amputate Weathers’s dead right hand just below the wrist and use skin grafts to reconstruct his left

After helping to load Weathers and Gau into the rescue chopper, I sat in the snow for a long while, staring at my boots,

trying to get some grip, however tenuous, on what had happened over the preceding 72 hours. Then, nervous as a cat, I
headed down into the Icefall for one last trip through the maze of decaying seracs.

I’d always known, in the abstract, that climbing mountains was a dangerous pursuit. But until I climbed in the
Himalayas this spring, I’d never actually seen death at close range. And there was so much of it: Including three
members of an Indo-Tibetan team who died on the north side just below the summit in the same May 10 storm and an
Austrian killed some days later, 11 men and women lost their lives on Everest in May 1996, a tie with 1982 for the
worst single-season death toll in the peak’s history.

Of the six people on my team who reached the summit, four are now dead–people with whom I’d laughed and
vomited and held long, intimate conversations. My actions–or failure to act–played a direct role in the death of Andy
Harris. And while Yasuko Namba lay dying on the South Col, I was a mere 350 yards away, lying inside a tent, doing
absolutely nothing. The stain this has left on my psyche is not the sort of thing that washes off after a month or two of
grief and guilt-ridden self-reproach.

Five days after Namba died, three Japanese men approached me in the village of Syangboche and introduced
themselves. One was an interpreter, the other was Namba’s husband, the third was her brother. They had many
questions, few of which I could answer adequately. I flew back to the States with Doug Hansen’s belongings and was
met at the Seattle airport by his two children, Angie and Jaime. I felt stupid and utterly impotent when confronted by
their tears.

Stewing over my culpability, I put off calling Andy Harris’s partner, Fiona McPherson, and Rob Hall’s wife, Jan
Arnold, so long that they finally phoned me from New Zealand. When Fiona called, I was able to say nothing to
diminish her anger or bewilderment. During my conversation with Jan, she spent more time comforting me than vice

With so many marginally qualified climbers flocking to Everest these days, a lot of people believe that a tragedy of
this magnitude was overdue. But nobody imagined that an expedition led by Hall would be at the center of it. Hall ran
the tightest, safest operation on the mountain, bar none. So what happened? How can it be explained, not only to the
loved ones left behind, but to a censorious public?

Hubris surely had something to do with it. Hall had become so adept at running climbers of varying abilities up and
down Everest that he may have become a little cocky. He’d bragged on more than one occasion that he could get
almost any reasonably fit person to the summit, and his record seemed to support this. He’d also demonstrated a
remarkable ability to manage adversity.

In 1995, for instance, Hall and his guides not only had to cope with Hansen’s problems high on the peak, but they also
had to deal with the complete collapse of another client, the celebrated French alpinist Chantal Mauduit, who was
making her seventh stab at Everest without oxygen. Mauduit passed out stone cold at 28,700 feet and had to be
dragged and carried all the way from the South Summit to the South Col “like a sack of spuds,” as Guy Cotter put it.
After everybody came out of that summit attempt alive, Hall may well have thought there was little he couldn’t handle.

Before this year, however, Hall had had uncommonly good luck with the weather, and one wonders whether it might
have skewed his judgment. “Season after season,” says David Breashears, who has climbed Everest three times, “Rob
had brilliant weather on summit day. He’d never been caught by a storm high on the mountain.” In fact, the gale of
May 10, though violent, was nothing extraordinary; it was a fairly typical Everest squall. If it had hit two hours later,
it’s likely that nobody would have died. Conversely, if it had arrived even one hour earlier, the storm could easily have
killed 18 or 20 climbers–me among them.

Indeed, the clock had as much to do with the tragedy as the weather, and ignoring the clock can’t be passed off as an
act of God. Delays at the fixed lines could easily have been avoided. Predetermined turn-around times were
egregiously and willfully ignored. The latter may have been influenced to some degree by the rivalry between Fischer
and Hall. Fischer had a charismatic personality, and that charisma had been brilliantly marketed. Fischer was trying
very hard to eat Hall’s lunch, and Hall knew it. In a certain sense, they may have been playing chicken up there, each

guide plowing ahead with one eye on the clock, waiting to see who was going to blink first and turn around.

Shocked by the death toll, people have been quick to suggest policies and procedures intended to ensure that the
catastrophes of this season won’t be repeated. But guiding Everest is a very loosely regulated business, administered
by a byzantine Third World bureaucracy that is spectacularly ill-equipped to assess qualifications of guides or clients,
in a nation that has a vested interest in issuing as many climbing permits as the market will support.

Truth be told, a little education is probably the most that can be hoped for. Everest would without question be safer if
prospective clients truly understood the gravity of the risks they face–the thinness of the margin by which human life
is sustained above 25,000 feet. Walter Mittys with Everest dreams need to keep in mind that when things go wrong up
in the Death Zone–and sooner or later they always do–the strongest guides in the world may be powerless to save
their clients’ lives. Indeed, as the events of 1996 demonstrated, the strongest guides in the world are sometimes
powerless to save even their own lives.

Climbing mountains will never be a safe, predictable, rule-bound enterprise. It is an activity that idealizes risk-taking;
its most celebrated figures have always been those who stuck their necks out the farthest and managed to get away
with it. Climbers, as a species, are simply not distinguished by an excess of common sense. And that holds especially
true for Everest climbers: When presented with a chance to reach the planet’s highest summit, people are surprisingly
quick to abandon prudence altogether. “Eventually,” warns Tom Hornbein, 33 years after his ascent of the West Ridge,
“what happened on Everest this season is certain to happen again.”

For evidence that few lessons were learned from the mistakes of May 10, one need look no farther than what happened
on Everest two weeks later. On the night of May 24, by which date every other expedition had left Base Camp or was
on its way down the mountain, the South Africans finally launched their summit bid. At 9:30 the following morning,
Ian Woodall radioed that he was on the summit, that teammate Cathy O’Dowd would be on top in 15 minutes, and that
his close friend Bruce Herrod was some unknown distance below. Herrod, whom I’d met several times on the
mountain, was an amiable 37-year-old with little climbing experience. A freelance photographer, he hoped that
making the summit of Everest would give his career a badly needed boost.

As it turned out, Herrod was more than seven hours behind the others and didn’t reach the summit until 5 P.M., by
which time the upper mountain had clouded over. It had taken him 21 hours to climb from the South Col to the top.
With darkness fast approaching, he was out of oxygen, physically drained, and completely alone on the roof of the
world. “That he was up there that late, with nobody else around, was crazy,” says his former teammate, Andy de Klerk
“It’s absolutely boggling.”

Herrod had been on the South Col from the evening of May 10 through May 12. He’d felt the ferocity of that storm,
heard the desperate radio calls for help, seen Beck Weathers crippled with horrible frostbite. Early on his ascent of
May 24-25, Herrod had climbed right past the frozen body of Scott Fischer. Yet none of that apparently made much of
an impression on him. There was another radio transmission from Herrod at 7 P.M., but nothing was heard from him

after that, and he never appeared at Camp Four. He is presumed to be dead–the 11th casualty
of the season.

As I write this, 54 days have passed since I stood on top of Everest, and there hasn’t been more
than an hour or two on any given day in which the loss of my companions hasn’t monopolized
my thoughts. Not even in sleep is there respite: Imagery from the climb and its sad aftermath
permeates my dreams.

There is some comfort, I suppose, in knowing that I’m not the only survivor of Everest to be so
affected. A teammate of mine from Hall’s expedition tells me that since he returned, his
marriage has gone bad, he can’t concentrate at work, his life has been in turmoil. In another
case, Neal Beidleman helped save the lives of five clients by guiding them down the mountain,
yet he is haunted by a death he was unable to prevent, of a client who wasn’t on his team and
thus wasn’t really his responsibility.

When I spoke to Beidleman recently, he recalled what it felt like to be out on the South Col, huddling with his group
in the awful wind, trying desperately to keep everyone alive. He’d told and retold the story a hundred times, but it was
still as vivid as the initial telling. “As soon as the sky cleared enough to give us an idea of where camp was,” he
recounted, “I remember shouting, ‘Hey, this break in the storm may not last long, so let’s go!’ I was screaming at
everyone to get moving, but it became clear that some of them didn’t have enough strength to walk or even stand.

“People were crying. I heard someone yell, ‘Don’t let me die here!’ It was obvious that it was now or never. I tried to
get Yasuko on her feet. She grabbed my arm, but she was too weak to get up past her knees. I started walking and
dragged her for a step or two. Then her grip loosened and she fell away. I had to keep going. Somebody had to make it
to the tents and get help, or everybody was going to die.”

Beidleman paused. “But I can’t help thinking about Yasuko,” he said when he resumed, his voice hushed. “She was so
little. I can still feel her fingers sliding across my biceps and then letting go. I never even turned to look back.”

Contributing editor Jon Krakauer has been writing for this magazine for 15 years. He is the author of Into the Wild
and Eiger Dreams.

Copyright 1996, Outside magazine

Everest Revelation:
A clarification

In my article “Into Thin Air” I speculated that Andy Harris, a guide on Rob Hall’s expedition, walked off the edge of the South Col and fell to
his death after becoming disoriented in the rogue storm of May 10. Only minutes before Harris disappeared, I’d encountered him in the
blizzard. I spoke with him briefly and then watched him walk to within 30 yards of camp, where he became enveloped in clouds.

Two weeks after the magazine went to press, I discovered compelling evidence that Harris did not walk off the Col to his death and that the
person I had met in the storm just above Camp Four was in fact not Harris. In a telephone conversation, Martin Adams, a client on Scott
Fischer’s expedition, revealed that he, too, had encountered a climber sitting just above the South Col at about the same time I had
encountered Harris. In the stormy darkness, Adams couldn’t tell who the other climber was, but their conversation, he says, was very similar to
the conversation I reported having with Harris. Both Adams and I are now certain that, in my own hypoxic condition, I confused him with

On July 25, in a four-hour, face-to-face discussion, Lobsang Jangbu, Fischer’s head sherpa revealed something that hadn’t come up in previous
discussions: that he had spoken with Harris on the South Summit at 5:30 p.m. on May 10 approximately the same time I thought I saw Harris
near the South Col. By this late hour Rob Hall had been repeatedly calling for help on the radio, saying that Doug Hansen had collapsed on
the Hillary Step and that both Hall and Hansen desperately needed oxygen. As Lobsang began descending from the South Summit, he saw
Harris, who was himself ailing, plodding slowly up the summit ridge to assist Hall and Hansen. It was an extremely heroic act for which
Harris deserves to be remembered.

As I reported, when radio contact between Hall and Base Camp was reestablished the next morning, a distraught, severely debilitated Hall said
that Harris “was with me last night. But he doesn’t seem to be with me now. He was very weak.” From this snippet, which I originally
interpreted as being the incoherent babble of a severely hypoxic man, it is impossible to say exactly what became of Harris. But the awful
truth that he is gone remains.

For two months after returning from Everest, I was haunted by the fact that Harris, who’d become a close friend during the expedition,
appeared to have been so near the safety of Camp Four and yet never made it. Unable to let the matter rest, I obsessively mulled the
circumstances of his death even after my article went to press which is how I made the belated discovery of my error.

That I confused Harris for Adams is perhaps not surprising, given the poor visibility, my profound exhaustion, and the confused, oxygen-
starved state I was in. But my mistake greatly compounded the pain of Andy Harris’s partner, Fiona McPherson; his parents, Ron and Mary
Harris; and his many friends. For that I am inexpressibly sorry.

Jon Krakauer
Seattle, Washington

Product 4279



Delusions of

How Optimism Undermines
Executives’ Decisions

by Dan Lovallo and Daniel Kahneman

Included with this full-text

Harvard Business Review



Article Summary

The Idea in Brief—

the core idea

The Idea in Practice—

putting the idea to work


Delusions of Success


Further Reading

A list of related material, with annotations to guide further
exploration of the article’s ideas and applications



page 1 of 10

Delusions of Success

How Optimism Undermines Executives’ Decisions






















. A









The Idea in Brief

Three-quarters of business initiatives floun-

der—new manufacturing plants close pre-

maturely, mergers and acquisitions don’t

pay off, start-ups fail to gain market share.


Delusional optimism

: We overem-

phasize projects’ potential benefits and un-

derestimate likely costs, spinning success

scenarios while ignoring the possibility of


The culprits? Cognitive biases and orga-

nizational pressures to accentuate the posi-

tive. We can’t eradicate either, but we


take a more objective view of an initiative’s

likely outcome. How?

Reference forecast-


: comparing a project’s potential out-

comes with those of similar, past projects—

to produce more accurate predictions.

The Idea in Practice

R O S E – C O L O R E D G L A S S E S

We’re subject to numerous

cognitive biases



Competing for limited funding, we create

project proposals accentuating the positive.

These initial forecasts skew subsequent analy-

ses of market and financial information toward

overoptimism: We don’t adjust our original esti-

mates enough to account for inevitable prob-


Competitor neglect.

We ignore competitors’ capabilities and plans.

Rushing to secure a new market, for example,

we forget that rivals will follow suit. As compet-

itors ramp up production and marketing, sup-

ply outstrips demand—rendering the market


Exaggerating our abilities and control.

We take credit for positive outcomes while at-

tributing negative outcomes to external factors

and deny the role of chance in our plans’ out-

comes. Result? We assume we can avoid or over-

come all project problems.

We also fall victim to

organizational pressures


We approve proposals with the highest
probability of failure.

Since only the most promising proposals attract

investment dollars, we make overoptimistic



overoptimistic proposals are


We reward optimism and interpret pessi-
mism as disloyalty.

Reinforcing one another’s unrealistic views of

the future, we undermine our company’s criti-

cal thinking.


How to counteract cognitive biases and organi-

zational pressures? Awareness


a more ob-

jective forecasting method—especially with

never-before-attempted initiatives. These steps

can give us an “outside view” to augment our

intuitive “inside view”:

Select a set of past projects to serve as
your reference class.

A studio executive forecasting sales of a new

film selects recent films in the same genre, fea-

turing similar actors and comparable budgets.

Assess the distribution of outcomes.

Identify the average and extremes in the refer-

ence-class projects’ outcomes. The studio execu-

tive’s reference-class movies sold $40 million in

tickets on average. But 10% sold less than $2 mil-

lion and 5% sold more than $120 million.

Predict your project’s position in the dis-

Intuitively estimate where your project would

fall along the reference class’s distribution. The

studio executive predicted $95 million as his

new film’s sales.

Assess your prediction’s reliability.

Counteract your biased prediction from Step 3.

Based on how well your past predictions

matched actual outcomes, estimate the correla-

tion between your


prediction and the


outcome. Express your estimate as a coef-

ficient between 0 and 1 (0 = no correlation; 1 =

complete correlation). The studio executive ex-

pressed his correlation coefficient as 0.6.

Correct your intuitive estimate.

Adjust your intuitive prediction based on your

predictability analysis. The studio executive’s


estimate was $62 million: $95M + [0.6

($40M – $95M)].

harvard business review • july 2003 page 2 of 10






















. A









In planning major initiatives, executives routinely exaggerate the

bene�ts and discount the costs, setting themselves up for failure. Here’s

how to inject more reality into forecasting.

Delusions of

How Optimism Undermines
Executives’ Decisions

by Dan Lovallo and Daniel Kahneman

In 1992, Oxford Health Plans started to build a
complex new computer system for processing
claims and payments. From the start, the
project was hampered by unforeseen prob-
lems and delays. As the company fell further
behind schedule and budget, it struggled,
vainly, to stem an ever rising flood of paper-
work. When, on October 27, 1997, Oxford dis-
closed that its system and its accounts were in
disarray, the company’s stock price dropped
63%, destroying more than $3 billion in share-
holder value in a single day.

Early in the 1980s, the United Kingdom,
Germany, Italy, and Spain announced that
they would work together to build the Euro-
fighter, an advanced military jet. The project
was expected to cost $20 billion, and the jet
was slated to go into service in 1997. Today,
after nearly two decades of technical glitches
and unexpected expenses, the aircraft has yet
to be deployed, and projected costs have more
than doubled, to approximately $45 billion.

In 1996, the Union Pacific railroad bought
its competitor Southern Pacific for $3.9 bil-

lion, creating the largest rail carrier in North
America. Almost immediately, the two compa-
nies began to have serious difficulties merging
their operations, leading to snarled traffic, lost
cargo, and massive delays. As the situation got
worse, and the company’s stock price tum-
bled, customers and shareholders sued the
railroad, and it had to cut its dividend and
raise new capital to address the problems.

Debacles like these are all too common in
business. Most large capital investment
projects come in late and over budget, never
living up to expectations. More than 70% of
new manufacturing plants in North America,
for example, close within their first decade of
operation. Approximately three-quarters of
mergers and acquisitions never pay off—the
acquiring firm’s shareholders lose more than
the acquired firm’s shareholders gain. And ef-
forts to enter new markets fare no better; the
vast majority end up being abandoned within
a few years.

According to standard economic theory, the
high failure rates are simple to explain: The

Delusions of Success

harvard business review • july 2003 page 3 of 10

frequency of poor outcomes is an unavoidable
result of companies taking rational risks in un-
certain situations. Entrepreneurs and manag-
ers know and accept the odds because the re-
wards of success are sufficiently enticing. In
the long run, the gains from a few successes
will outweigh the losses from many failures.

This is, to be sure, an attractive argument
from the perspective of executives. It effec-
tively relieves them of blame for failed
projects—after all, they were just taking rea-
sonable risks. But having examined this phe-
nomenon from two very different points of
view—a business scholar’s and a psycholo-
gist’s—we have come to a different conclu-
sion. We don’t believe that the high number of
business failures is best explained as the result
of rational choices gone wrong. Rather, we see
it as a consequence of flawed decision making.
When forecasting the outcomes of risky
projects, executives all too easily fall victim to
what psychologists call the planning fallacy. In
its grip, managers make decisions based on de-
lusional optimism rather than on a rational
weighting of gains, losses, and probabilities.
They overestimate benefits and underestimate
costs. They spin scenarios of success while
overlooking the potential for mistakes and
miscalculations. As a result, managers pursue
initiatives that are unlikely to come in on bud-
get or on time—or to ever deliver the expected

Executives’ overoptimism can be traced
both to cognitive biases—to errors in the way
the mind processes information—and to orga-
nizational pressures. These biases and pres-
sures are ubiquitous, but their effects can be
tempered. By supplementing traditional fore-
casting processes, which tend to focus on a
company’s own capabilities, experiences, and
expectations, with a simple statistical analysis
of analogous efforts completed earlier, execu-
tives can gain a much more accurate under-
standing of a project’s likely outcome. Such an

outside view

, as we call it, provides a reality
check on the more intuitive

inside view

, reduc-
ing the odds that a company will rush blindly
into a disastrous investment of money and

Rose-Colored Glasses

Most people are highly optimistic most of the
time. Research into human cognition has
traced this overoptimism to many sources.

One of the most powerful is the tendency of
individuals to exaggerate their own talents—
to believe they are above average in their en-
dowment of positive traits and abilities. Con-
sider a survey of 1 million students conducted
by the College Board in the 1970s. When asked
to rate themselves in comparison to their
peers, 70% of the students said they were
above average in leadership ability, while only
2% rated themselves below average. For ath-
letic prowess, 60% saw themselves above the
median, 6% below. When assessing their abil-
ity to get along with others, 60% of the stu-
dents judged themselves to be in the top
decile, and fully 25% considered themselves to
be in the top 1%.

The inclination to exaggerate our talents is
amplified by our tendency to misperceive the
causes of certain events. The typical pattern of
such attribution errors, as psychologists call
them, is for people to take credit for positive
outcomes and to attribute negative outcomes
to external factors, no matter what their true
cause. One study of letters to shareholders in
annual reports, for example, found that execu-
tives tend to attribute favorable outcomes to
factors under their control, such as their cor-
porate strategy or their R&D programs. Unfa-
vorable outcomes, by contrast, were more
likely to be attributed to uncontrollable exter-
nal factors such as weather or inflation. Simi-
lar self-serving attributions have been found
in other studies of annual reports and execu-
tive speeches.

We also tend to exaggerate the degree of
control we have over events, discounting the
role of luck. In one series of studies, partici-
pants were asked to press a button that could
illuminate a red light. The people were told
that whether the light flashed was determined
by a combination of their action and random
chance. Afterward, they were asked to assess
what they experienced. Most people grossly
overstated the influence of their action in de-
termining whether the light flashed.

Executives and entrepreneurs seem to be
highly susceptible to these biases. Studies that
compare the actual outcomes of capital invest-
ment projects, mergers and acquisitions, and
market entries with managers’ original expec-
tations for those ventures show a strong ten-
dency toward overoptimism. An analysis of
start-up ventures in a wide range of industries
found, for example, that more than 80% failed

No matter how detailed, the

business scenarios used in

planning are generally


Dan Lovallo

is a senior lecturer at the
Australian Graduate School of Manage-
ment at the University of New South
Wales and a former strategy specialist
at McKinsey & Company.

Daniel Kahne-

is the Eugene Higgins Professor of
Psychology at Princeton University in
New Jersey and a professor of public af-
fairs at Princeton’s Woodrow Wilson
School; he received the Nobel Prize in
economic sciences in 2002.

Delusions of Success

harvard business review • july 2003 page 4 of 10

to achieve their market-share target. The stud-
ies are backed up by observations of execu-
tives. Like other people, business leaders rou-
tinely exaggerate their personal abilities,
particularly for ambiguous, hard-to-measure
traits like managerial skill. Their self-confi-
dence can lead them to assume that they’ll be
able to avoid or easily overcome potential
problems in executing a project. This misap-
prehension is further exaggerated by manag-
ers’ tendency to take personal credit for lucky
breaks. Think of mergers and acquisitions, for
instance. Mergers tend to come in waves, dur-
ing periods of economic expansion. At such
times, executives can overattribute their com-
pany’s strong performance to their own ac-
tions and abilities rather than to the buoyant
economy. This can, in turn, lead them to an
inflated belief in their own talents. Conse-
quently, many M&A decisions may be the re-
sult of hubris, as the executives evaluating an
acquisition candidate come to believe that,
with proper planning and superior manage-
ment skills, they could make it more valuable.
Research on postmerger performance sug-
gests that, on average, they are mistaken.

Managers are also prone to the illusion that
they are in control. Sometimes, in fact, they
will explicitly deny the role of chance in the
outcome of their plans. They see risk as a chal-
lenge to be met by the exercise of skill, and
they believe results are determined purely by
their own actions and those of their organiza-
tions. In their idealized self-image, these exec-
utives are not gamblers but prudent and deter-
mined agents, who are in control of both
people and events. When it comes to making
forecasts, therefore, they tend to ignore or
downplay the possibility of random or uncon-
trollable occurrences that may impede their
progress toward a goal.

The cognitive biases that produce overopti-
mism are compounded by the limits of human
imagination. No matter how detailed, the
business scenarios used in planning are gener-
ally inadequate. The reason is simple: Any
complex project is subject to myriad prob-
lems—from technology failures to shifts in ex-
change rates to bad weather—and it is beyond
the reach of the human imagination to foresee
all of them at the outset. As a result, scenario
planning can seriously understate the proba-
bility of things going awry. Often, for instance,
managers will establish a “most likely” sce-

nario and then assume that its outcome is in
fact the most likely outcome. But that assump-
tion can be wrong. Because the managers have
not fully considered all the possible sequences
of events that might delay or otherwise dis-
rupt the project, they are likely to understate
the overall probability of unfavorable out-
comes. Even though any one of those out-
comes may have only a small chance of occur-
ring, in combination they may actually be far
more likely to happen than the so-called most
likely scenario.

Accentuating the Positive

In business situations, people’s native opti-
mism is further magnified by two other kinds
of cognitive bias—anchoring and competitor
neglect—as well as political pressures to em-
phasize the positive and downplay the nega-
tive. Let’s look briefly at each of these three


When executives and their sub-
ordinates make forecasts about a project, they
typically have, as a starting point, a prelimi-
nary plan drawn up by the person or team pro-
posing the initiative. They adjust this original
plan based on market research, financial anal-
ysis, or their own professional judgment be-
fore arriving at decisions about whether and
how to proceed. This intuitive and seemingly
unobjectionable process has serious pitfalls,
however. Because the initial plan will tend to
accentuate the positive—as a proposal, it’s de-
signed to make the case for the project—it will
skew the subsequent analysis toward overopti-
mism. This phenomenon is the result of an-
choring, one of the strongest and most preva-
lent of cognitive biases.

In one experiment that revealed the power
of anchoring, people were asked for the last
four digits of their Social Security number.
They were then asked whether the number of
physicians in Manhattan is larger or smaller
than the number formed by those four digits.
Finally, they were asked to estimate what the
number of Manhattan physicians actually is.
The correlation between the Social Security
number and the estimate was significantly
positive. The subjects started from a random
series of digits and then insufficiently adjusted
their estimate away from it.

Anchoring can be especially pernicious
when it comes to forecasting the cost of major
capital projects. When executives set budgets

When pessimistic opinions

are suppressed, while

optimistic ones are

rewarded, an

organization’s ability to

think critically is


Delusions of Success

harvard business review • july 2003 page 5 of 10

for such initiatives, they build in contingency
funds to cover overruns. Often, however, they
fail to put in enough. That’s because they’re
anchored to their original cost estimates and
don’t adjust them sufficiently to account for
the likelihood of problems and delays, not to
mention expansions in the scope of the
projects. One Rand Corporation study of 44
chemical-processing plants owned by major
companies like 3M, DuPont, and Texaco found
that, on average, the factories’ actual construc-
tion costs were more than double the initial
estimates. Furthermore, even a year after
start-up, about half the plants produced at less
than 75% of their design capacity, with a quar-
ter producing at less than 50%. Many of the
plants had their performance expectations
permanently lowered, and the owners never
realized a return on their investments.

Competitor Neglect.

One of the key factors
influencing the outcome of a business initia-
tive is competitors’ behavior. In making fore-
casts, however, executives tend to focus on
their own company’s capabilities and plans
and are thus prone to neglect the potential
abilities and actions of rivals. Here, again, the
result is an underestimation of the potential
for negative events—in this case, price wars,
overcapacity, and the like. Joe Roth, the
former chairman of Walt Disney Studios, ex-
pressed the problem well in a 1996 interview
with the

Los Angeles Times

: “If you only think
about your own business, you think, ‘I’ve got a
good story department, I’ve got a good mar-
keting department, we’re going to go out and
do this.’ And you don’t think that everybody
else is thinking the same way.”

Neglecting competitors can be particularly
destructive in efforts to enter new markets.
When a company identifies a rapidly growing
market well suited to its products and capabil-
ities, it will often rush to gain a beachhead in
it, investing heavily in production capacity
and marketing. The effort is often justified by
the creation of attractive pro forma forecasts
of financial results. But such forecasts rarely
account for the fact that many other competi-
tors will also target the market, convinced that
they, too, have what it takes to succeed. As all
these companies invest, supply outstrips de-
mand, quickly rendering the new market un-
profitable. Even savvy venture capitalists fell
into this trap during the recent ill-fated Inter-
net boom.

Organizational Pressure.

Every company
has only a limited amount of money and time
to devote to new projects. Competition for this
time and money is intense, as individuals and
units jockey to present their own proposals as
being the most attractive for investment. Be-
cause forecasts are critical weapons in these
battles, individuals and units have big incen-
tives to accentuate the positive in laying out
prospective outcomes. This has two ill effects.
First, it ensures that the forecasts used for
planning are overoptimistic, which, as we de-
scribed in our discussion of anchoring, distorts
all further analysis. Second, it raises the odds
that the projects chosen for investment will be
those with the most overoptimistic forecasts—
and hence the highest probability of disap-

Other organizational practices also encour-
age optimism. Senior executives tend, for in-
stance, to stress the importance of stretch
goals for their business units. This can have
the salutary effect of increasing motivation,
but it can also lead unit managers to further
skew their forecasts toward unrealistically rosy
outcomes. (And when these forecasts become
the basis for compensation targets, the prac-
tice can push employees to behave in danger-
ously risky ways.) Organizations also actively
discourage pessimism, which is often inter-
preted as disloyalty. The bearers of bad news
tend to become pariahs, shunned and ignored
by other employees. When pessimistic opin-
ions are suppressed, while optimistic ones are
rewarded, an organization’s ability to think
critically is undermined. The optimistic biases
of individual employees become mutually re-
inforcing, and unrealistic views of the future
are validated by the group.

The Outside View

For most of us, the tendency toward optimism
is unavoidable. And it’s unlikely that compa-
nies can, or would even want to, remove the
organizational pressures that promote opti-
mism. Still, optimism can, and should, be tem-
pered. Simply understanding the sources of
overoptimism can help planners challenge as-
sumptions, bring in alternative perspectives,
and in general take a balanced view of the fu-

But there’s also a more formal way to im-
prove the reliability of forecasts. Companies
can introduce into their planning processes an

Delusions of Success

harvard business review • july 2003 page 6 of 10

objective forecasting method that counteracts
the personal and organizational sources of op-
timism. We’ll begin our exploration of this ap-
proach with an anecdote that illustrates both
the traditional mode of forecasting and the
suggested alternative.

In 1976, one of us was involved in a project
to develop a curriculum for a new subject area
for high schools in Israel. The project was con-
ducted by a small team of academics and
teachers. When the team had been operating
for about a year and had some significant
achievements under its belt, its discussions
turned to the question of how long the project
would take. Everyone on the team was asked
to write on a slip of paper the number of
months that would be needed to finish the
project—defined as having a complete report
ready for submission to the Ministry of Educa-
tion. The estimates ranged from 18 to 30

One of the team members—a distinguished
expert in curriculum development—was then
posed a challenge by another team member:
“Surely, we’re not the only team to have tried
to develop a curriculum where none existed
before. Try to recall as many such projects as
you can. Think of them as they were in a stage
comparable to ours at present. How long did it
take them at that point to reach completion?”
After a long silence, the curriculum expert
said, with some discomfort, “First, I should say
that not all the teams that I can think of, that
were at a comparable stage, ever did complete
their task. About 40% of them eventually gave
up. Of the remaining, I cannot think of any
that completed their task in less than seven
years, nor of any that took more than ten.” He
was then asked if he had reason to believe that
the present team was more skilled in curricu-
lum development than the earlier ones had
been. “No,” he replied, “I cannot think of any
relevant factor that distinguishes us favorably
from the teams I have been thinking about. In-
deed, my impression is that we are slightly
below average in terms of resources and po-
tential.” The wise decision at this point would
probably have been for the team to disband.
Instead, the members ignored the pessimistic
information and proceeded with the project.
They finally completed the initiative eight
years later, and their efforts went largely for
naught—the resulting curriculum was rarely

In this example, the curriculum expert made
two forecasts for the same problem and arrived
at very different answers. We call these two dis-
tinct modes of forecasting the inside view and
the outside view. The inside view is the one that
the expert and all the other team members
spontaneously adopted. They made forecasts
by focusing tightly on the case at hand—consid-
ering its objective, the resources they brought
to it, and the obstacles to its completion; con-
structing in their minds scenarios of their com-
ing progress; and extrapolating current trends
into the future. Not surprisingly, the resulting
forecasts, even the most conservative ones,
were exceedingly optimistic.

The outside view, also known as reference-
class forecasting, is the one that the curricu-
lum expert was encouraged to adopt. It com-
pletely ignored the details of the project at
hand, and it involved no attempt at forecast-
ing the events that would influence the
project’s future course. Instead, it examined
the experiences of a class of similar projects,
laid out a rough distribution of outcomes for
this reference class, and then positioned the
current project in that distribution. The result-
ing forecast, as it turned out, was much more

The contrast between inside and outside
views has been confirmed in systematic re-
search. Recent studies have shown that when
people are asked simple questions requiring
them to take an outside view, their forecasts
become significantly more objective and reli-
able. For example, a group of students enroll-
ing at a college were asked to rate their future
academic performance relative to their peers
in their major. On average, these students ex-
pected to perform better than 84% of their
peers, which is logically impossible. Another
group of incoming students from the same
major were asked about their entrance scores
and their peers’ scores before being asked
about their expected performance. This sim-
ple detour into pertinent outside-view infor-
mation, which both groups of subjects were
aware of, reduced the second group’s average
expected performance ratings by 20%. That’s
still overconfident, but it’s much more realistic
than the forecast made by the first group.

Most individuals and organizations are in-
clined to adopt the inside view in planning
major initiatives. It’s not only the traditional
approach; it’s also the intuitive one. The natu-

Delusions of Success

harvard business review • july 2003 page 7 of 10

ral way to think about a complex project is to
focus on the project itself—to bring to bear all
one knows about it, paying special attention to
its unique or unusual features. The thought of
going out and gathering statistics about related
cases seldom enters a planner’s mind. The cur-
riculum expert, for example, did not take the
outside view until prompted—even though he
already had all the information he needed.
Even when companies bring in independent
consultants to assist in forecasting, they often
remain stuck in the inside view. If the consult-
ants provide comparative data on other compa-
nies or projects, they can spur useful outside-
view thinking. But if they concentrate on the
project itself, their analysis will also tend to be
distorted by cognitive biases.

While understandable, managers’ prefer-
ence for the inside view over the outside view
is unfortunate. When both forecasting meth-
ods are applied with equal intelligence and
skill, the outside view is much more likely to
yield a realistic estimate. That’s because it by-
passes cognitive and organizational biases. In
the outside view, managers aren’t required to
weave scenarios, imagine events, or gauge
their own levels of ability and control—so they
can’t get all those things wrong. And it doesn’t
matter if managers aren’t good at assessing
competitors’ abilities and actions; the impact
of those abilities and actions is already re-
flected in the outcomes of the earlier projects
within the reference class. It’s true that the
outside view, being based on historical prece-
dent, may fail to predict extreme outcomes—
those that lie outside all historical precedents.
But for most projects, the outside view will
produce superior results.

The outside view’s advantage is most pro-
nounced for initiatives that companies have
never attempted before—like building a plant
with a new manufacturing technology or en-
tering an entirely new market. It is in the plan-
ning of such de novo efforts that the biases to-
ward optimism are likely to be great.
Ironically, however, such cases are precisely
where the organizational and personal pres-
sures to apply the inside view are most in-
tense. Managers feel that if they don’t fully ac-
count for the intricacies of the proposed
project, they would be derelict in their duties.
Indeed, the preference for the inside view over
the outside view can feel almost like a moral
imperative. The inside view is embraced as a

serious attempt to come to grips with the com-
plexities of a unique challenge, while the out-
side view is rejected as relying on a crude anal-
ogy to superficially similar instances. Yet the
fact remains: The outside view is more likely
to produce accurate forecasts and much less
likely to deliver highly unrealistic ones.

Of course, choosing the right class of analo-
gous cases becomes more difficult when exec-
utives are forecasting initiatives for which pre-
cedents are not easily found. It’s not like in the
curriculum example, where many similar ef-
forts had already been undertaken. Imagine
that planners have to forecast the results of an
investment in a new and unfamiliar technol-
ogy. Should they look at their company’s ear-
lier investments in new technologies? Or
should they look at how other companies car-
ried out projects involving similar technolo-
gies? Neither is perfect, but each will provide
useful insights—so the planners should ana-
lyze both sets of analogous cases. We provide a
fuller explanation of how to identify and ana-
lyze a reference class in the sidebar “How to
Take the Outside View.”

Putting Optimism in Its Place

We are not suggesting that optimism is bad, or
that managers should try to root it out of
themselves or their organizations. Optimism
generates much more enthusiasm than does
realism (not to mention pessimism), and it en-
ables people to be resilient when confronting
difficult situations or challenging goals. Com-
panies have to promote optimism to keep em-
ployees motivated and focused. At the same
time, though, they have to generate realistic
forecasts, especially when large sums of
money are at stake. There needs to be a bal-
ance between optimism and realism—be-
tween goals and forecasts. Aggressive goals
can motivate the troops and improve the
chances of success, but outside-view forecasts
should be used to decide whether or not to
make a commitment in the first place.

The ideal is to draw a clear distinction be-
tween those functions and positions that in-
volve or support decision making and those
that promote or guide action. The former
should be imbued with a realistic outlook,
while the latter will often benefit from a sense
of optimism. An optimistic CFO, for example,
could mean disaster for a company, just as a
lack of optimism would undermine the vision-

The outside view is more

likely to produce accurate

forecasts and much less

likely to deliver highly

unrealistic ones.

Delusions of Success

harvard business review • july 2003 page 8 of 10

How to Take the Outside View
Making a forecast using the outside view requires planners to
identify a reference class of analogous past initiatives, deter-
mine the distribution of outcomes for those initiatives, and
place the project at hand at an appropriate point along that
distribution. This effort is best organized into five steps:1

1. Select a reference class. Identifying the right reference
class involves both art and science. You usually have to weigh sim-
ilarities and differences on many variables and determine which
are the most meaningful in judging how your own initiative will
play out. Sometimes that’s easy. If you’re a studio executive trying
to forecast sales of a new film, you’ll formulate a reference class
based on recent films in the same genre, starring similar actors,
with comparable budgets, and so on. In other cases, it’s much
trickier. If you’re a manager at a chemical company that is consid-
ering building an olefin plant incorporating a new processing
technology, you may instinctively think that your reference class
would include olefin plants now in operation. But you may actu-
ally get better results by looking at other chemical plants built
with new processing technologies. The plant’s outcome, in other
words, may be more influenced by the newness of its technology
than by what it produces. In forecasting an outcome in a compet-
itive situation, such as the market share for a new venture, you
need to consider industrial structure and market factors in de-
signing a reference class. The key is to choose a class that is broad
enough to be statistically meaningful but narrow enough to be
truly comparable to the project at hand.

2. Assess the distribution of outcomes. Once the refer-
ence class is chosen, you have to document the outcomes of
the prior projects and arrange them as a distribution, showing
the extremes, the median, and any clusters. Sometimes you
won’t be able to precisely document the outcomes of every
member of the class. But you can still arrive at a rough distri-
bution by calculating the average outcome as well as a mea-
sure of variability. In the film example, for instance, you may
find that the reference-class movies sold $40 million worth of
tickets on average, but that 10% sold less than $2 million worth
of tickets and 5% sold more than $120 million worth.

3. Make an intuitive prediction of your project’s position
in the distribution. Based on your own understanding of the
project at hand and how it compares with the projects in the
reference class, predict where it would fall along the distribu-
tion. Because your intuitive estimate will likely be biased, the
final two steps are intended to adjust the estimate in order to
arrive at a more accurate forecast.

4. Assess the reliability of your prediction. Some events
are easier to foresee than others. A meteorologist’s forecast

of temperatures two days from now, for example, will be
more reliable than a sportscaster’s prediction of the score of
next year’s Super Bowl. This step is intended to gauge the
reliability of the forecast you made in Step 3. The goal is to
estimate the correlation between the forecast and the actual
outcome, expressed as a coefficient between 0 and 1, where 0
indicates no correlation and 1 indicates complete correlation.
In the best case, information will be available on how well
your past predictions matched the actual outcomes. You can
then estimate the correlation based on historical precedent.
In the absence of such information, assessments of predict-
ability become more subjective. You may, for instance, be
able to arrive at an estimate of predictability based on how
the situation at hand compares with other forecasting situa-
tions. To return to the movie example, say that you are fairly
confident that your ability to predict the sales of films ex-
ceeds the ability of sportscasters to predict point spreads in
football games but is not as good as the ability of weather
forecasters to predict temperatures two days out. Through a
diligent statistical analysis, you could construct a rough scale
of predictability based on computed correlations between
predictions and outcomes for football scores and tempera-
tures. You can then estimate where your ability to predict
film scores lies on this scale. When the calculations are com-
plex, it may help to bring in a skilled statistician.

5. Correct the intuitive estimate. Due to bias, the intuitive
estimate made in Step 3 will likely be optimistic—deviating
too far from the average outcome of the reference class. In this
final step, you adjust the estimate toward the average based on
your analysis of predictability in Step 4. The less reliable the
prediction, the more the estimate needs to be regressed to-
ward the mean. Suppose that your intuitive prediction of a
film’s sales is $95 million and that, on average, films in the
reference class do $40 million worth of business. Suppose fur-
ther that you have estimated the correlation coefficient to be
0.6. The regressed estimate of ticket sales would be:

$95M + [0.6 ($40M–$95M)] = $62M
As you see, the adjustment for optimism will often be sub-

stantial, particularly in highly uncertain situations where pre-
dictions are unreliable.

1. This discussion builds on “Intuitive Predictions: Biases and Corrective
Procedures,” a 1979 article by Daniel Kahneman and Amos Tversky that ap-
peared in TIMS Studies in Management Science, volume 12 (Elsevier/North

Delusions of Success

harvard business review • july 2003 page 9 of 10

ary qualities essential for superior R&D and
the esprit de corps central to a successful sales
force. Indeed, those charged with implement-
ing a plan should probably not even see the
outside-view forecasts, which might reduce
their incentive to perform at their best.

Of course, clean distinctions between deci-
sion making and action break down at the top.
CEOs, unit managers, and project champions
need to be optimistic and realistic at the same
time. If you happen to be in one of these posi-
tions, you should make sure that you and your
planners adopt an outside view in deciding
where to invest among competing initiatives.
More objective forecasts will help you choose

your goals wisely and your means prudently.
Once an organization is committed to a course
of action, however, constantly revising and re-
viewing the odds of success is unlikely to be
good for its morale or performance. Indeed, a
healthy dose of optimism will give you and
your subordinates an advantage in tackling
the challenges that are sure to lie ahead.

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Delusions of Success

How Optimism Undermines Executives’ Decisions

Further Reading


The High Cost of Accurate Knowledge

by Kathleen M. Sutcliffe and Klaus Weber

Harvard Business Review

May 2003

Product no. R0305E

These authors agree that senior managers’ abil-

ity to interpret information is critical to making

better decisions. Today’s complex information,

they maintain, is rarely precise—and often am-

biguous and conflicting. Therefore, companies

should think carefully about whether to invest

heavily in systems for collecting and organizing

vast amounts of competitive data. Information’s

accuracy and abundance are less important for

strategy and organizational change than the

ways in which executives


such informa-

tion—and communicate their interpretations.

In other words, executives must manage



more than they manage



Sutcliffe and Weber aren’t suggesting that accu-

rate information doesn’t matter at all. Corpo-

rate leaders must have clear knowledge of their

industries. But managers’ interpretive


determine their companies’ competitive advan-

tage more than the information itself. And the

most successful leaders interpret information

through a curious blend of optimism and pessi-

mism that the authors call “humble optimism”:

They embrace opportunities—but they’re not

overly confident in their ability to control those

opportunities. They thus manage ambiguity—

while simultaneously mobilizing action.

What Do Managers Know, Anyway?

by John M. Mezias and William H. Starbuck

Harvard Business Review

May 2003

Product no. F0305A

Mezias and Starbuck also contend that accurate

competitive information may be less important

to a company’s success than previously as-

sumed. And they add another important piece

to the decision-making puzzle: managers’ will-

ingness to seek and make wise use of feedback.

Managers, the authors maintain, often have

badly distorted pictures of their businesses and

their competitive environments. And they have

great confidence in their own distorted percep-

tions. Why? They tend to focus on what’s hap-

pening right now, in their specific jobs, in their

specific business units, operating in their very

specific competitive worlds. Busy among the

trees, they lose sight of the forest. They also base

their analyses on sources of varied reliability—

such as corporate documents they often misun-

derstand, personal experiences, and rumors.

And they also surround themselves with


This may sound like a recipe for disastrously

large errors in judgment. But when managers

get prompt feedback on the impact of their de-

cisions, their misperceptions may cause only

small errors—if they respond appropriately.

The challenge lies in overcoming managers’

fear of sanctions if they’re wrong. Companies

must accept that distorted perception is a fact of

management—and design decision processes

that work despite inaccurate perceptions. The

implications? Encourage managers to admit

their errors and modify their approaches





mailto:[email protected]




Chip Heath, Richard P. Larrick, and Joshua Klayman


The literature in cognitive psychology has described a variety of shortcomings that

prevent individuals from learning effectively. We review this literature and provide
examples of a IUimber of organizational practices that may effectively repair the cog­
nitive shortcomings of individuals. We call these practices cognitive repairs. We
then discuss six tradeoffs that affect the success of cognitive repairs. We close by
considering how a cognitive perspective might benefit those who study organiza­
tional teaming and those who manage it.

�esureh I n Organizational Behavior, Volume 10, pages 1-37.
Copyright 0 1998 by JAI Press Inc.
All rights of reproduction In any form reserved.
ISBN: 0-7613-0366-1



In a famous speech, Hamlet declares, “What a piece of work is man. How noble in
reason, how infinite in faculties” (Hamlet, II, 2). An observer who summarized the
psychology of the late twentieth century would probably choose very different
phrases to describe the human condition-perhaps, “What fools these mortals be”
(Midsummer Night’s Dream, III, 2).

Are people “infinite in faculties” and “noble in reason”? Herbert Simon won a
Nobel prize for arguing that social science must understand the ways that human
faculties are limited. Instead of being infinite in faculties, Simon’s humans could
be only “boundedly rational” because their cognitive abilities-their ability to
perceive, remember, and process information-were restricted. Well, then, if peo­
ple are not infinite in faculties, �re they “noble in reason”? Cognitive psycholo­
gists have spent 30 years examining the actual processes that people use when
they collect information, combine it, and draw inferences about their world (Nis­
bett & Ross, 1980; Kahneman, Slovic, & Tversky, 1982; .Holland, Holyoak, Nis­
bett, & Thagard, 1986). Instead of depicting people as “noble” (or magnificent) in
reason, this research has argued that people reason in ways that produce system­
atic errors. A pessimistic modem Hamlet might combine the observations of these
two research streams and describe .humans as equipped with primitive hardware
and buggy software.

However, outsiders have not always accepted the pessimistic description of
human faculties and reason that is found in the research literature. As one skeptic
put it, “If we are so stupid, how did we get to the moon?” (Nisbett & Ross, 1980).

How should we resolve the apparent discrepancy between the pessimistic liter­
ature on human shortcomings and the optimistic evidence of human accomplish­
ment? One way is to dismiss the laboratory research. Some researchers have
argued that the shortcomings that have been documented in the lab are so minor
that they do not constitute mistakes of any real consequence (Funder, 1987;
Cohen, 198 I). Others have argued that individuals are less likely to make errors in
natural environments than in contrived laboratory experiments (Anderson, 1991;
Gigerenzer, 1996; Cheng & Holyoak, 1985; Hilton, 1995).

We propose another way to resolve the discrepancy. Unlike some researchers,
we do not dismiss the examples of limitations, errors, and biases reported in the lit­
erature; we assume that individuals are limited, their decision processes are
biased, and that they often make costly mistakes on important decisions. We
resolve tho apparent discrepancy between evidence of individual shortcomings
and the empirical fact of moonwalks by observing that individuals did not make it
to the moon, NASA did.

Organizations like NASA may have discovered ways to avoid or repair the indi­
vidual shortcomings that have been documented by cognitive researchers. Orga­
nizations may develop such repairs through deliberate analysis, learn them
through trial and error, or discover them through serendipitous accident. In some

Cognitive Rryairs 3

cases, repairs may derive from formal academic disciplines like economics or sta­
tistics (e.g., Nisbett, 1992; Nisbett, Krantz, Jepson, & Kunda, 1983; Larrick, Mor­
gan, & Nisbett, 1990), but in most cases they will not: They will be ad hoc,
intuitive rules that emerge from day-to-day practice. Our thesis, then, is that indi­
viduals indeed face cognitive limitations and shortcomings, but that organizations
can provide individuals with norms and procedures that mitigate their limitations
and reduce their shortcomings.

In this paper we describe a variety of potentially serious shortcomings that have
been documented in research on human judgment and reasoning. We focus in par­
ticular on teaming and hypothesis testing, that is, how people use information to
develop and revise their mental model of the world. For each cognitive shortcom­
ing we discuss, we provide examples of organizational practices that may repair
this shortcoming. We call these practices cognitive repairs to emphasize the fact
that they correct some cognitive process that was initially flawed and in need of

We identify potential cognitive repairs to spur researchers to consider how such
repairs might look and function. Although at this point, we can make only an anec­
dotal case for interpreting certain practices as “repairs,” we hope that, by pointing
out some plausible examples of such repairs, we will prompt researchers in both
psychology and organizations to consider more systematically how such repairs
might function.

More generally, the concept of organizational cognitive repairs illustrates that
researchers may find interesting relationships between individual cognition and
organizational practice. These relationships have not received the attention they
deserve. On the one side, research in cognitive psychology has largely treated
individual learners as “rugged individualists” who face a difficult environment
alone, equipped only with their own, flawed cognitive strategies. On the other
side, organizational research has largely ignored the literature on individual cog­
nition, focusing instead on issues of motivation or incentives. By studying organi­
zational sources of cognitive repairs, we bring together two frequently disparate
literatures and demonstrate how knowledge at one level of analysis can inform the

By reviewing individual shortcomings and identifying potential cognitive
repairs, we also hope to contribute to the academic and popular literature on orga­
nizational learning (Epple, Argote, & Devadas, 1991; Deming, 1982; Senge,
1990; Cohen, I 99 I; Miner & Mezias, I 996). One important means to facilitate
learning by organizations is to develop processes that overcome the shortcomings
of individuals within the organization.

Below, we start with a brief example of the kinds of repairs that we consider in
this paper. Then we introduce a framework that describes different stages in the
learning process, and we use it to review the literature on individual shortcomings
and to suggest potential repairs. As a preliminary reply to Hamlet, we say that
even if rugged individuals are unlikely to be infinite in faculties and noble in rea-


son, individuals who have access to organizational and cultural repairs may some­
times appear so.

An Example of Our Approach

Consider one study that might be regarded as an ominous indication of ignoble
reasoning by individual experts. Hynes and Vanmarcke (1976) asked seven “inter­
nationally known” civil engineers to predict the height of a structure that would
cause a foundation to fail; they also asked the engineers to set a 50 percent confi­
dence interval around their prediction so that their confidence interval was wide
enough to have a 50 percent chance of enclosing the true failure height. The results
were quite sobering: not one engineer correctly predicted the true failure height
within his or her confidence interval.

Evidently, the civil engineers thought they knew more than they did-if they
had been aware of the limitations of their analysis, they would have set wider con­
fidence intervals and would have predicted the true failure height more correctly.
In the psychological literature this kind of finding has been labeled “overconfi­
dence,” and it is not an aberration. Similar results have been observed with a num­
ber of individual professionals (e.g., Russo & Schoemaker, 1992).1n summarizing
the evidence, Griffin and Tversky {1992) quipped that experts are “often wrong
but rarely in doubt.”

To illustrate why this study paints an ominous picture of individual reasoning,
consider that (unless you are reading this paper outside) you are sitting in a build­
ing that was constructed by civil engineers who were substantially less accom­
plished than the internationally known experts in the study. Your civil engineers
made numerous decisions to ensure the stability and safety of your building; they
decided how strong to make its roof supports and how stable to make its founda­
tion. If even expert engineers are overconfident, should you be concerned about
your safety?

The answer, we believe, is no. Fortunately, the engineering profession has
developed a particular repair, called “safety factors,” that mitigate the overconfi­
dent reasoning of individual engineers. In an actual assignment civil engineers
would precisely calculate the amount and strength of foundation materials neces­
sary to hold a structure of a particular height, then they would multiply their pre­
cise answer by a safety factor (i.e., a number between three and eight), and use the
larger figur� to build the foundation. Were the confidence intervals of the engi­
neers too narrow? Yes. Were they too narrow by a factor of three? No.

Safety factors are an example of the kind of cognitive repair we consider in this
paper. An organization (e.g., an engineering firm or the engineering profession at
large) provides its members with a repair that helps combat a systematic and
potentially serious bias in individual judgment. As a result, the organization
shields individuals within the organization from acting on their flawed decisions,



Cognitive Repairs 5

and it shields individuals inside and outside the organization from suffering the

What is a Cognitive Repair?

Organizational repairs can roughly be divided into two classes: (I) motivational
repairs increase the energy and enthusiasm with which individuals pursue a task
and (2) cognitive repairs improve the mental procedures individuals use to decide
which task to pursue and how to pursue it. 1 Organizational research on motivation
and incentives can be regarded as the study of motivational repairs (Milgrom &
Roberts, 1992; Eisenhardt, 1989). Organizations may need to repair motivational
problems in order to encourage individuals to learn (e.g., see Heath, Knez, &
Camerer, 1993). For example, individuals may not be willing to experiment with
new tasks because they have become endowed with the benefits associated with
the old task.

Although previous work has recognized the importance of motivational repairs,
it has neglected cognitive repairs. Even when individuals have the right incentives
and resources, they may not learn from their experience if they use the wrong
mental process to generate hypotheses, collect information, and draw conclusions.
The civil engineers who misestimated the stability of the clay embankment were
�dequately motivated to get the right answer. However, they did not on their own
invoke the kind of correctives (e.g., safety factors) that might have made their
guesses more appropriately cautious.


In this section we organize the literature on learning and decision making around
three different stages of the learning process. Effective learners must ( I ) generate
hypotheses that explain the causal structure of the world, (2) collect infonnation to
distinguish among their hypotheses, (3) draw conclusions that are appropriate and
cautious. The boundaries between these stages are fuzzy-they are interrelated
and interconnected (Klayman, 1995). However, we distinguish among them
because they involve different psychological processes.

Our strategy throughout the review is to consider first the individual then the
organization. For each stage of learning, we describe how an ideal individual
learner might reason, and review psychological research showing how real indi­
viduals depart from this ideal. Then, we describe potential cognitive repairs by
which organizations might correct the individual shortcoming in question.

…. I


Generating Hypotheses

In the first stage of the learning process individuals must generate hypotheses
about the relationships among events. Subject to constraints of time and informa­
tion, individuals should generate hypotheses that are deep (i.e., by considering
causes that are more general or systemic) and broad (i.e., by considering a larger
number of potential causes). However, a great deal of psychological research sug­
gests that individuals develop hypotheses that are shallow and narrow.

Individuals Generate Hypotheses that are Shallow Rather than Deep

lndivid11als Search for Explanations that Make Themselves Look Good

Individuals often conduct shallow searches when they try to explain success or
failure because they search in a self-serving way (i.e., in a way that allows them
to feel good about themselves). In a meta-analysis of 91 tests of this self-serving
bias, Mullen and Riordan ( 1988) show that individuals typically conclude that
their succe.rses resulted from stable, internal factors (e.g., ability), but that their
failures resulted from unstable, environmental factors (e.g., the difficulty of the
environment, insufficient effort, .or bad luck) (see also Fiske & Taylor, 199 1,
pp. 78-82).

How might organizations repair self-serving biases? Some repairs may be quite
simple: Traders on Wall Street are warned, “Don’t confuse brains and a bull mar­
ket” (Odean, 1996). This compact phrase prompts individual traders to consider
the base rate of success in the market, and it makes it more difficult for them to
indulge in self-serving explanations for their success.

At Florida Power and Light employees developed a new way to fight self-serv­
ing biases after an incident that prominently featured a Japanese inspector for the
Deming Prize who later became a folk hero within the company (Walton, 1990,
p. 6 1). To impress the inspector, FP&L managers took him to visit a new facility
that had been constructed faster and more economically than any facility in the
history of the industry. However, the Deming inspector did not simply accept the
results at face value and congratulate them on their “quality” project management;
instead, he asked a number of questions to determine why they were so successful.
The managers’ answers were so inadequate ttiat it soon became clear that they did
not understand enough about their success to recreate it in the future. The inspec­
tor dismjssed their “success” in his Japanese-accented English-“you were
rucky.” Later on his phrase, complete with accent, became a common repair for
self-serving interpretations of success.

The Deming inspector deflated a self-serving bias by considering alternative
hypotheses for success (e.g. , luck rather than skill or knowledge). Traditionally at
FP&L, managers were not questioned as long as they achieved good results. After
this incident managers were much more likely to be asked to explain their sue-


1 Cognitive Repairs 7

cesses. If they could not do so, the verdict would be delivered: “you were rucky”
(Walton, 1990, p. 61 ). The strategic use of the accent was designed to remind man­
agers about the earlier incident where luck produced dramatic results that were
unlikely to be repeated.

Individuals Focus on People Rather than Situations

Individuals also generate a shallow set of hypotheses because social settings
tend to highlight people as causes. In Western culture individuals typically choose
to explain events in terms of people’s actions and traits rather than situational fac­
tors (Gilbert & Malone, 1995; Ross, 1977; Ross & Nisbett, 1991). In a recent
study observers heard another student give a pro-life or pro-choice speech on
abortion. Afterward, observers assumed speakers held attitudes consistent with
their speeches even though the speeches were derived from scripts written by the
experimenters and even though the observers themselves told the speakers which
position to speak for (Gilbert & Jones, 1986). Similarly, Deming ( 1982) describes
a company that used a variety of flammable products in their production process.
After analyzing the data on fires, Deming found that the fires were a stable and
predictable outcome of the production process. However, according to Deming,
the company president focused his attentions elsewhere. He “sent a letter to every
one of the I 0,500 employees or the company to plead with them to set fewer fires”

. (p. 325).
People’s actions are frequently more obvious than their situations. Therefore,

when individuals generate hypotheses about why an event occurred, their first
hypothesis is likely to be that some person caused it (e.g., Ross & Nisbett, 1991).
This tendency to focus on people rather than situations has been documented by so
many investigators in so many situations that it has been called the fundamental
attribution error (Ross, 1977; for recent reviews see Ross & Nisbett, 199 1; Gilbert
& Malone, 1995).

Organizations might repair the fundamental attribution error by reminding indi­
viduals to consider causes other than people, especially the people who are likely
to be closest to any problem: front-line workers. For example, an old military
adage says, “There are no such things as bad troops, only bad officers” (Cohen &
Gooch, 1990, p. 228). Parallel repairs are found in total quality management
(TQM). Ishikawa says, “whenever mistakes occur, two-thirds to four-fifths of
responsibility rests with management” (Ishikawa, 1985, p. ix). Such maxims may
partially repair the fundamental attribution error because they encourage individ­
uals to look beyond the front line. On the other hand, they may simply focus the
error on people at a higher level. Thus, .a better repair may be one from Deming,
who tells managers that of the problems he has seen, “94% belong to the system”
(Deming, 1982, p. 3 15). Ishikawa and Deming both use vivid statistics to over­
come the fundamental attribution error even though it is unlikely that either has


conducted a precise empirical analysis. Deming’s “94%” is particularly notewor­
thy because of its apparent precision.

Individuals Stop Searching as Soon as They Generate One Hypothesis

Self-serving biases and the fundamental attribution error are special cases of a
much broader tendency: Individuals tend to stop searching for a cause as soon as
they locate a plausible candidate hypothesis (Gregory, Cialdini, & Carpenter,
1982; Hoch, 1984).

To counter this general tendency, organizations have developed some repairs
that are widely applicable across a number of domains. In one technique known as
the “Five W hys,” workers at Toyota learned to ask “why?” five times before they
stopped generating hypotheses. When they did so, they were more likely to find a
root cause rather than a superficial one. lmai ( 1986) illustrates the technique with
the following example:

Question 1:
Answer 1:
Question 2:
Question 3:
An.fwer 3:
Question 4:
Question 5:

Why did the machine stop?

Because the fuse blew due to an overload.

Why was there an overload?

Because the bearing lubrication was inadequate.

Why was the lubrication inadequate?

Because the lubrication pump was not fu nctioning right.

W hy wasn’t the lubricating pump working right?

Because the pump axle wore out.

Why was it worn out?
Because sludge got in.

lmai argues that by asking “why” five times, workers identified “the real cause
and therefore the real solution: attaching a strainer to the lubricating pump. If
workers had not gone through such repetitive questions, they might have settled
with an intermediate·countermeasure, such as replacing the fuse” (lmai, 1986, p.
50). Another illustration of the Five Whys deals directly with the fundamental
attribution error: “Problem: He doesn’t manage well. (1) Why? He’s not on the
floor. (2) Why? He’s in the equipment room. (3) Why? The newest equipment isn’t
working. (4) Why? Purchasing gave the supplier a short lead time. (5) Why? Poor
planning system” (Forum, 1992, p. 54). In general, when individuals ask “why”
the first time, they are likely to develop answers that invoke some salient, recent,
or proximlfl event (e.g., some person’s actions). Subsequent whys are likely to
cause individuals to think more broadly and situationally.

Although the Five Whys is an admirable cognitive repair because of its power
and simplicity, individuals may find it difficult to execute by themselves. When
individuals have one good hypothesis in mind, that hypothesis often blocks their
ability to see alternatives (Gregory, Cialdini, & Carpenter, 1982; Gnepp & Klay­
man, 1992; Mynatt, Doherty, & Dragan, 1993). For example, Hoch (1984) found

Cognitive Repairs 9

that subjects who generated pro reasons for buying a product had more difficulty
generating con reasons immediately afterward.

If individuals find it difficult to generate alternate hypo1heses on their own, th�n
organizations may repair shallow search by confronting individuals w ith others
who are expert in asking questions that reveal deep causes. At Microsoft, Bill
Gates has by personal example, encouraged a culture that relies on relentless ques­
tioning. Says one Windows manager, “you go into the meetings and you come out
just sweating because, if there is any flaw, he will land on it immediately and pick
it to bits” (Cusumano & Selby, 1995, p. 25). Employees “overuse” terms borrowed
from Gates,like “drill down” as a euphemism for “going into more detail” (“What
Bill Gates Really Wants,” 1995).

A similar cognitive repair is found in the organization that administers the Dem­
ing quality prize. Here, official Deming inspectors examine managers using a
technique called “single-case bore questions.” They begin with broad exploratory
queries and then relentlessly delve down into weaknesses and omissions in the
answers they receive. Single-case bore questions sometimes identify c auses that
are quite deep. For example, Florida Power and Light often had to deal with power
outages that occurred when a tree fell on a power line and severed it To improve
the reliability of its service, FP&L organized a unit to trim all the trees in sites
where damage had occurred, and thus prevent future outages. Managers at FP&L
congratulated themselves for creating a procedure that prevented future problems.
However, the Deming inspectors were not satisfied with the procedure since it pre­
vented problems only in areas that had already experienced a crisis. They searched
for a solution at a deeper level, and asked managers a number of questions about

· what might be considered forestry! What kind of trees grow in the region? Do
palms grow faster or slower than oaks? Managers at FP&L realized they did not
know the answers to these questions, and that they had not searched deeply
enough to solve their problems. After their experience with single-case bore ques­
tions, FP&L managers consulted with foresters and developed a regular mainte­
nance procedure to trim trees based on their growth rates and across the entire
region, not just in areas where trees had previously severed lines. After participat­
ing in sessions of this kind with the Deming inspectors, managers at the firm
learned to ask single-case bore questions in their own internal discussions, thus
institutionalizing this cognitive repair (Walton, 1990, pp. 57-63 ).

Individuals Generate Hypotheses that are Narrow Rather Than Broad

In an ideal world individual learners would not only generate deeper hypothe­
ses; they would also consider a broad rather than narrow set of potential hypothe­
ses. However, even when individuals generate alternative hypotheses, their
“alternatives” often differ only slightly from one another, and all lie within the
same general frame. For example, participants in one experiment were asked to
consider the serious parking problem faced by their university, and they were


given time to generate as many solutions as they could (Gettys et al., 1987). Com­
bined, participants generated about 300 solutions that researchers were later able
to classify into about seven major categories. One category, for example, sug­
gested ways to reduce demand for parking (e.g., by increasing parking fees) and
�nother suggested ways to use parking more efficiently (e.g., by segregating park­
mg slots according to size). The average participant proposed about II solutions
�ut these II solutions represented only about three of the seven possible catego­
nes. The authors asked an independent panel of experts to compile a complete list
of hi�h-quality s?lutions, and they used this complete list to assess how many
solutions were m1ssed by each individual. The typical participant missed from 70
to 80 percent of the high-quality solutions. However, when asked, individuals
believed they had missed only 25 percent.

Even experts fail to consider a broad range of alternative hypotheses. For exam­
ple, one group of researchers showed professional auto mechanics a “fault tree”
that �isted a number of hypotheses about why a car might not start (e.g., battery,
startmg system, fuel system, ignition). Some mechanics were presented with a
“full tree” that contained seven specific hypotheses, others were given a “pruned
tree” that omiued some important hypotheses (e.g. the ignition system). The
results indicated that when hypotheses were pruned off the tree, mechanics did not
adequately consider them (Fischhoff, Slovic, & Lichtenstein, 1978).

How might organizations repair narrow search by individuals? Individuals
might search more broadly if they are cued to think about a problem from different
perspectives. At Sharp, employees are told to be “dragonflies but not flatfish.”
Dragonflies have compound eyes and see things from multiple perspectives at
once, but flatfish have large eyes that only look in one direction (Nonaka & Takeu­
chi, 1995).

The “dragonfly” repair exhorts individuals to consider different perspectives,
but t�is may be difficult for indi�iduals to do by themselves. Organizations might
repatr narrow search more effectively by encouraging individuals to recruit others
who have different perspectives. A good example of this is provided by Bridge­
stone Tire, which conducts “kokai watches” to generate alternative hypotheses for
improving work practices. During a kokai watch a group of up to a dozen people
from different areas of a factory, gather for a few hours to watch others work. I�
one four-hour watch a dozen people identified 63 potential dangers with a new
machine (Walton, 1990, pp. 200-201).


The kokai watch has a number of features that ensure that watchers generate a
broad array of hypotheses. First, it mandates a large number of watchers (up to
12). Second, it selects watchers from a variety of different areas-in one kokai
watch that examined die and material changes, watchers included a plant visitor,
a member of the human resources staff, a chemist, and a project manager. “The
idea was that people could observe a process, even those who were strangers to it,
with fresh eyes, seeing things that closely involved workers might not” (Walton,
1990, p. 200). Third, it ensures that watchers do not discard hypotheses prema-

Cognitive Rqmirs 11

turely. The watchers are instructed to “write down anything, ‘Hey, looks like the

guy is walking too much,’ or ‘Looks like he’s not handling the knife right'” (Wal­

ton, 1990, p. 201). Only after watchers generate hypotheses independently are the

results combined and filtered.
Other organizational procedures also repair narrow individual search by ensur­

ing that individuals generate hypotheses independently. For example, when
Motorola forms cross-functional teams to evaluate new products, they do noi
allow employees who have participated in one product team to participate in
another team with a similar product. This prohibition limits the pool of potential
team members in a costly way; evaluation teams involve six to nine people and
spend two to three months to develop a business plan for the new product. How­
ever, by consciously disregarding previous experience, Motorola allows new
teams to develop recommendations independently from previous teams. At the
same time, Motorola avoids losing the knowledge of previous “veterans”-the�
serve as a “review team” that evaluates the recommendations of the newest team.
Other repairs ensure that a broad range of alternatives are considered simulta·
neously. Some companies divide a product development team into competing sub­
groups which develop separate project proposals, and only later recombine to
debate the advantages and disadvantages of the independent proposals. Again, this
strategy is costly because it is redundant. However, it may have a d vantages
because the built-in independence ensures that different subgroups will approach
a problem from different perspectives (Nonaka & Takeuchi, 1995, p. 14).

Collecting Information

In the second stage of the learning process ideal learners collect infonnation to
test and revise their hypotheses. There are two main sources of such information:
the information that individuals already have in their memory and the information
that they collect from the environment. Both kinds of information have potential
flaws, but individuals might minimize these flaws if they collected infonnation in
a rigorous way. However, learners do not always act as though they are aware of
the potential flaws in their information-they frequently collect only a small,
biased sample.

Individuals Often Collect Small Samples of Information

Individuals often collect only a limited sample of information because they are

constrained by time or attention. In a classic study, Payne (1976) asked his sub­

jects to choose one apartment out of a rrumber of alternatives, each of which was

described on several different dimensions (e.g., rent, cleanliness, landlord quality,

noise level). W hen subjects chose among only two apartments, they tended to con­

sider all of the information before they decided. However, individuals searched a
smaller and smaller percentage of information as more information became avail-



able. For example, one subject, who was deciding among 12 apartments charac­
terized on eight different dimensions, looked at only about 25 percent of the
information before making a final choice.

It would be reasonable for individual learners to collect only a small sample of
information if they performed a cost/benefit analysis and decided that collecting a
large sample was too costly. However, there is evidence that individuals collect
only a small sample of information because they systematically underestimate the
benefits of larger samples. Tversky and Kahneman (1971) argue that individuals
typically believe that small samples will be quite similar to the population from
which they are drawn. They labeled this belief the·”law of small numbers” to high­
light that it contradicts the statistical “law of large numbers,” which argues that
samples can yield an accurate picture of a population when they are sufficiently
large. When individuals believe in the law of small numbers, they assume that any
sample will be sufficient, no matter how small.

At the extreme, individuals may not collect any information from the external
environment because they believe that they already have adequate information
stored in their head. Organizations may overcome this tendency by encouraging or
requiring individuals to collect larger samples. This kind of repair is pervasive in
writings on TQM. “In promoting -statistical quality control, we have used the slo­
gan, ‘Let us talk with data'” (Ishikawa, 1985, p. 200). At many TQM companies
one of the main principles of the quality effort is “Management by Fact” (Walton,
1990, p. 37).

And TQM not only talks about data, it provides individuals with tools that help
them collect and analyze data. For example, six of the “Seven Tools” of TQM pro­
vide ways to collect data (e.g., checksheets) or to simplify and display large quan­
tities of data (e.g., histograms, scatter plots, Pareto diagrams, control charts)
(Deming, 1982; lmai, 1986; Ishikawa, 1982, 1985; Juran, 1992).

Individuals Collect Biased Samples of Information

Individual learners not only collect small samples of information, they also tend
to collect samples that are biased (i.e., that are unrepresentative of the larger
world). Consider the common claims that “the other line always moves faster” or
“it only rains after I wash my car.” Unless we want to believe that a malevolent
spirit is il) charge of such harassment, these examples demonstrate that our mem­
ories do not store a random sample of all waiting times or all rainstorms-we are
more likely to remember the rainstorms that spoil the finish on our freshly washed
car. Even when individuals collect information from the outside world (rather than
from memory), they do not always attend to the most relevant and important infor­
mation. Below, we discuss a number of factors that might lead individual learners
to collect biased samples.

Cognitive Repairs 13

Individuals Only Consider Available Information

As indicated by the car wash example, individuals oft�n collect biased sampl�s
because they collect information that is easily available in memory, for example,
because it is especially vivid or recent. The problem is that individuals typically
assume that the information that is available is also most frequent, probable, and
causally important (Tversky & Kahneman, 1973). This assumption is often
wrong. Individuals dramatically overestimate the likelihood of vivid causes of
death like accidents or homicides, and they underestimate the likelihood of less
vivid causes like disease or strokes. Individuals estimate that accidents caused as
many deaths as diseases and that homicides were as common as strokes. In fact,
diseases take 16 times more lives than accidents and strokes take II times more
lives than homicides. Individuals also overweight recent information. They
assume that the most recent flood provides an upper bound on possible flood dam­
age, and the purchase of earthquake insurance “increases sharply after a quake and
then decreases steadily as memories fade” (Siovic, Fischhoff, & Lichtenstein,
1982, p. 465).

Many organizations repair individuals’ tendency to rely on biased, available
information by instituting a process that collects information more systematically.
At a Motorola division that develops equipment for cellular phone systems, one
group realized that an availability bias was causing it to overlook certain custom- .
ers when it evaluated new products. The unit assigned account managers only to
large accounts, so when managers evaluated new products, they primarily consid­
ered the needs and requirements of only large customers. However, the unit also
served a number of smaller customers that did not have their own account man­
ager. Together, these small customers accounted for a large percentage of reve­
nues. Motorola overcame the availability bias by developing a Feature
Prioritization Process; they surveyed customers up to four times a year and then


. 3 weighted all of the inputs based on customer volume an pnonty.
Hospitals also have a variety of procedures to force individuals to collect infor­

mation more systematically. Trauma physicians are often confronted by vivid but
potentially misleading information. One doctor states that, contrary to what one
might expect, stabbings and bullet wounds are “relatively straightforward affairs”
because they leave “clear tracks on the body.” Other injuries are more difficult to
treat because they leave no visible cues. “It would be all too human to focus on a
lacerated scalp-a gory but basically insignificant injury-and miss a fractured
thighbone that had invisibly severed a major artery” ( Rosenthal, 1994, p. 48). The
medical profession has developed a series of strict protocols for trauma situations
that allow doctors to quickly collect all the relevant information, not just that
which is salient. For example, when a patient first enters the emergency room,
physicians follow the “ABCs”; they establish airway, then breathing, then circu­
lation.4 For situations that are more critical, such as cardiac emergencies, proto­
cols are even more rigorous and specific.


If individuals tend to focus on information that is highly available, it is not ter­
ribly surprising that they are frequently unaware of missing information. Even
when information is present, learners do not pay as much attention to what doesn’t
happen as what does (Agostinelli, Sherman, Fazio, & Hearst, 1986; Newman,
Wolff, & Hearst, 1980).

Certain professions and organizations have learned to repair the tendency to
ignore missing information. Homicide detectives learn to notice the absence of
items at murder scenes, since many murderers take back something that belongs to
them after committing the crime. “You look at what’s been taken and you find out
who it belonged to originally” (Fletcher, 1990, p. 75).

A particularly important form of missing information is the absence of experi­
ence with highly unusual events. Bank examiners rarely see a bank fail, nuclear
technicians rarely see a meltdown, airline personnel rarely witness a crash (March,
Sproull, & Tamuz, 1991; Perrow, 1984). Certain organizations institutionalize
procedures that encourage individuals to pay attention to such information despite
the fact that such events are unlikely to be available in their own experience. For
example, at the Federal Reserve Bank, which certifies the security of banks, senior
bank examiners deliberately recount stories of failed banks to keep junior exam­
iners aware that they should be vigilant.5 At one bank’s commercial lending
department, senior credit office�s would hold seminars and informal brown-bag
lunches to discuss past lending mistakes, particularly in areas characterized by
unusual or rare events (e.g., “problems with highly leveraged companies, real
estate, environmental liability on contaminated property”).6 By forcing individu­
als to rehearse such information, organizations help individuals learn from vicar­
ious experiences that are rare but highly informative. Furthermore, organizations
remind individuals of potentially painful information that self-serving biases
would make them prefer to ignore.

Individuals Collect Biased Information Based on Their Preexisting Theories

Research suggests that individuals tend to think of “facts, experiences, and
arguments that support a current hypothesis more readily than those that refute it”
(Klayman, 1995; see also, Baron, 1988; Kunda, 1990; Nisbett & Ross, 1980).
Thus, when individuals collect information from memory, they may focus on
information that supports their preexisting theories. Individuals may also do this
when they collect information from the external environment. For example, when
individuals collect information from others, they often ask specific, directive
questions that are likely to elicit the answer they expect (Hodgins & Zuckerman,
1993; Zuckerman, Knee, Hodgins, & Miyake, 1995).

The Chicago Board of Trade has a staff of in-house investigators who scrutinize
trades that may violate exchange rules. In these investigations, which are obvi­
ously quite sensitive, it is very important that investigators do not collect informa­
tion that is biased by their initial theories. To repair this tendency, the investigators

Cognitive Repairs 15

are trained to avoid questions that can be answered with a yes or no response.
”This forces an investigator to ask open-ended questions and allows her to draw
out as much information about the situation as possible.” By asking open-ended
questions, investigators avoid the possibility of directing the interview in a way
that elicits only information that is consistent with their preexisting theories.7

Some organizations have developed maxims that seem designed to encourage
individuals to collect data rather than relying on their (potentially biased) theories�
At Bridgestone Tire employees use two Japanese terms: genbutsu (actual product)
and genba (actual place) (Walton, 1990, p. 194). These terms remind employees
not to rely on their own theories, but to actually go out and investigate the actual
product in the actual place where the problems arose. Another group (Forum,
1992) uses a similar cognitive repair they call the three actual rule: ( I ) Go to the
actual place; (2) See the actual problem; (3) Talk to the actual people involved.

Individuals Consider Only Part of the Relevant Information

Finally, individual learners may collect biased samples because they tend to col­
lect information from only one small comer of the universe of information. This
arises from basic cognitive processes. Memory is associative-when individuals
retrieve one piece of information, they tend to think of other information that is
linked to it by strong associations, common features, or similar meaning. Even

.when individuals collect information from the external environment, they are
iikely to collect information based on the same kind of associative process.
Research in cognitive psychology has shown that individuals attend to and process
information more comprehensively when they have a mental schema that tells
them what information is needed in a given situation and where to find it (Ander­
son, 1995).

Accordingly, organizations can repair biased information collection by provid­
ing individuals wi.th a schema that reminds them of the full range of relevant infor­
mation. Many schemas of this kind can be found in the financial services industry,
where individuals must assess a wide variety of information to determine whether
to buy, sell, or lend. At the Federal Reserve Bank of New York, the Bank Exami­
nations group protects the FDIC insurance fund by ensuring that individual banks
are in sound financial condition. When reviewing each bank, examiners use a rat­
ing system known as CAMEL: they review Capitai adequacy, Asset quality, Man­
agement, Earnings, and Liquidity.8 In another bank’s commercial loan
department, credit analysts use the “Five Cs of Credit”: Collateral, Capacity, Cap­
ital, Conditions, and Character.9

Organizational schemas like CAMEL and the Five Cs are likely to encourage
individuals to collect a broader range of information than they would normally
collect. It would be very easy for individual learners to collect information on only
on the most salient factors (such as cash flow in a loan decision). Although cash
flow is certainly important, it can also be misleading or unreliable, particularly in


an environment where conditions are changing. By emphasizing the Five Cs, a
. bank can repair the tendency of individual analysts to neglect information about

important variables that are less obvious or are harder to assess. For example, the
Five Cs reminds loan officers to consider character-What are the management
skills of the owners? Do they have good personal credit records? Although the
answers to such questions are quite important, individual analysts might forget to
ask them in a numbers-oriented environment like a bank, without a cognitive
repair like the Five Cs.

Individuals Who Collect Biased Information Fail to Correct for Bias

We have discussed a number of factors that might lead individual learners to
collect biased information. However, even if learners collect biased information,
they might still be able to draw effective conclusion as long as they recognized the
bias and corrected for it. For example, suppose an individual made the statement,
“the other line always moves faster,” but then reminded herself that such situations
might be overly available in her memory. This kind of correction improves the
conclusions drawn from even a biased sample. On the other hand, even if individ­
uals are aware that they have collected biased information, they may not know
how to correct for biases after the fact. For example, after individuals ask biased
questions and therefore receive biased answers, they do not take into account how
much the answers were biased by their initial questions (Zuckerman, Knee, Hod­
gins, & Miyake, 1 995).

Because individuals do not always correct their information for biases, some
organizations attempt to ensure that individuals collect unbiased samples from the
start: Microsoft requires its software developers to use the same pmgram.r and
machines that are used by their customers. For example, programmers who were
developing the new Windows NT operating system ran the current day’s version
of the program as they programmed the next day’s version. At Microsoft this pro­
cess is known as ”eating your own dog food.” It ensures that developers collect a
large, unbiased sample of information about the current state of the program. If
Windows NT crashed while a developer was designing a new printer driver, he
had to fix the problem with NT before he could return to his driver (Cusumano &
Selby, I 995, p. 331 ). Microsoft also requires developers to use the same machine
used by customers, a requirement that has been “controversial at times” because
developers like to have the fastest, coolest machines on their desks. However,
when developers have better technology than the average customer they collect
biased information about how well their software programs perform. One man­
ager said, “every time I’ve had a project where the developers had hardware that
was a generation beyond what customers had, the [software] always had perfor­
mance problems” (Cusumano & Selby, 1995, p. 347). By requiring developers to
use the same machines as their customers, Microsoft forces them to collect an


Cognitive Repairs 1 7

unbiased sample of information about the operating speed and memory demands
of the software they are developing.

Drawing Conclusions

After generating hypotheses and collecting information, ideal learners should
evaluate the information they have collected and draw conclusions that are appro­
priate and cautious. Researchers have.

suggested �hree mai� classes of proble.ms
that real individuals face when they mterpret ev1dence. F1rst, they often we1gh
information in a way that is not statistically appropriate-for example, they
emphasize the importance of extreme evidence but they do not emphasize the rel­
ative amount of extreme versus non-extreme evidence. A second, even more
insidious problem is that individuals use their initial theories to interpret the evi­
dence. While individuals may readily accept information that is consisten

t wi�h

their initial hypothesis, they cast a critical eye on information that contradicts 11.
Third, as a result of the two previous processes and others, individuals frequently
draw conclusions that are overconfident and overly optimistic.

Individuals Weiglt Villid and Extreme Evidence More Heavily

Once individuals have collected information, how should they combine it and
·weigh it? An ideal learner would weigh information based on the quality of the
information. However, actual learners do not always assign appropriate weights to
all aspects of the decision. For example, they tend to weigh more vivid, easily
imagined information more heavily (Keller & McGill, 1 994 ). They also focus on
the extremity or strength of the available information (e.g., the warmth of a rec­
ommendation letter) without adequately attending to the amount or weight of the
evidence (e.g., the writer’s amount of contact with the recommendee) (Griffin &
Tversky, 1992). ·

If individuals tend to overemphasize vivid or extreme information, organiza­
tions might prevent this by requiring individuals to consciously classify inform�­
tion according to its appropriate weight. Many companies have internal a�d1t
groups that examine the records of company divisions to ensure that they are usmg
proper accounting procedures and spending money on legitimate expe�ses ..

audit usually uncovers a variety of major and minor “exceptions” (i.e., s1tuat10ns
where correct procedures were not followed). One auditor says that auditors mu�t
be careful not to “place too much emphasis on memorable errors, e.g., an error m
the president’s expense report or the misuse of the company car.” One auditing
group repaired this temptation by first classifying each exception· as major or
minor then consciously ignoring the minor issues.1 0

Consistent with the tendency to overweight the extremity of information and
ignore the amount, individuals frequently place higher weight on one vivid case
than on a much larger sample of information. Joseph Stalin is report ed to have



said, “The death of a single Russian soldier is a tragedy. A million deaths is a sta­
. listie” (Ni sbett & Ross, 1 980, p. 43). In a study that supports this observation, Bor­
gida and Nisbett (1 977) showed some students a statistical summary of how
dozens of students had rated various courses in the previous term. Other students
attended a panel discussion, during which two or three upper-division students
rated each cou rse on a numerical scale and provided some generic, uninformative
comments. Despite the fact that the statistical summary provided students with a
larger amount of information, individuals who heard the small sample of vivid
information were more likely to change the courses they selected.

Microsoft also discovered that individuals discount large samples of statistical
i n formation. At one point, Microsoft started surveying users to see how many of
them found it easy to use a particular feature. Software developers often refused to
believe the statistics. ”The usability group would tell the development group ‘Six
out of ten couldn’t do this.’ And the developer’s reaction would be, ‘Where’d you
find six dumb people?'” (Cusumano & Selby, 1 995, p. 379). In order to repair this
tendency to ignore base rate information, Microsoft made the information more
vivid. It built a “usability test lab” where developers can watch real users struggle
with new prod ucts from behind a one-way mi rror. Instead of presenting develop­
ers with pallid stat istics, the test lab presents them with real people (albeit a much
smaller sample). The lab manager says that when developers see a user, “twenty
ideas just immediately come to mind. First of all, you immediately empathize with
the person. The usual nonsense answer ‘Well, they can just look in the manual if
they don’t know how to use it,’ or ‘My idea is brilliant; you just found ten stupid
people’ . . . that kind of stuff just goes out the door … ” (Cusumano & Selby, 1 995, p.
379). This cognitive repair is interesting because it uses one kind of bias (over­
weighting of extreme, or vivid information) to fight another (underweighting of
statistical i n formation).

Individuals Use T!Jeir Preexisting Theories to Interpret the Evidence

Individuals not only weigh information inappropriately, they also have diffi­
culty interpreting information independently of their preexisting theories. Instead
of using the information to test their theories, they use their theories to test their
information. This often leads them to discount information that disagrees with
their preexisting beliefs.


In a classic demonstration of such discounting, Lord, Ross, and Lepper ( 1 979)
selected, undergraduates who strongly supported or opposed capital punishment
and presented them with two purported academic studies that evaluated capital
punishment’s effectiveness using very different methods. A study using one
method found that capital punishment was effective and a study using the other
method fou nd it was ineffective (the researchers counterbalanced which method
was associated with which result). Participants applauded the positive aspects of
whichever methOd supported their own preexisting theory, and they critiqued the

Cognitive Repairs 19

“design flaws” in the other. In fact, after receiving mixed results from the two
studies, subjects became more convinced of the validity of their original position .
Seemingly, they regarded the evidence as “one good

study that supports J_DY

beliefs, and one lousy study that draws the wrong conclusions.” Individual sub­
jects thus failed to evaluate the incoming information separately from their preex­
isting theories. Unfortunately, similar results have been noted with professional
scientists (M ahoney, 1 976; Koehler, 1 993).

One bank hel ped its loan officers repair the way they interpret evidence by
encouraging them to consider a nonstandard theory of lending. In mortgage lend­
ing, loan officers often look for reasons to deny loans because loans are difficult to
make (they are subject to a mountain of regulations) and potentially q uite costly
(e.g., foreclosure on a bad loan may cost up to 20% of the property value). Thus,
the initial hypothesis in many loan decisions is that an applicant should be denied
a loan unless proven otherwise. One mortgage loan department grew at an annual
rate of 30 percent by forcing loan officers to consider an alternative to the standard
hypothesis. Instead of asking whether an applicant should be denied a mortgage
Joan , it asked whether the applicant should be approved. This reversal led the
department to develop special programs for qualified applicants who had low

h · I · I I incomes or ot er specm circumstances.
Individuals use their theories to develop expectations about what is n ormal, and

they frequently label unexpected events as “problems” or “failures.” These labels
·. may be misleading, however, particularly in research and development where
unexpected events may point the way to important breakthroughs. One research
organization has developed a repair that discourages individuals from thinking
that unexpected events are failures (Sapolsky, 1 997). Jackson Laboratories breeds
mice that exhibit physiological or behavioral traits that are of interest to medical
researchers. For example, it sells mice that lack growth hormone to researchers
who are interested in understand ing the biology of mammalian growt h. It found
that the animal technicians (e.g., the people who cleaned the cages) often noticed
unusual behavior that was scientifically important. The mice that lacked growth
hormone were discovered by a technician who noticed a particular .mouse that
didn’t grow at a normal rate. Another technician noticed a mouse that didn’ t
respond normally to the loud noises that occurred when the cages were cleaned­
its offspring were found to be susceptible to hereditary deafness. After several
experiences like this where unexpected behavior produced important discoveries,
the company started holding reguJ·ar meetings with animal technicians to inquire
whether they have spotted anything unusual. These forums for high I ighting the
importance of unexpected events are called “deviant searches.”

CRSS, an architectural firm, developed a special position to repair the problem
of theory-based interpretation of evidence. “Most designers love to draw, to make
‘thumbnail sketches’,” says one manager, but this rush to draw conclusions is
often premature. CRSS created a unique job description, the “programmer,” to
ensure that some members of its design teams were not allowing their own theo-


ries to domi nate the way they evaluated information from clients. Programmers
are not in charge of designing or problem solving, they are in charge of “problem
seeking.” They are trained to use techniques that help them to resist premature
conclusions, and thus listen more carefully to clients. ‘The experienced, creative
(programmer) withholds judgment, resists pre-conceived solutions and the pres­
sure to synthesize … he refuses to make sketches until he knows the client’s prob­
lem” (Peters, 1992, p. 402).

Often, organizations ensure that individuals weigh information effectively by
forcing them to interact with others who might weigh the information differently.
One researcher has explored whether training as a scientist cures the problems that
other individuals have in evaluating evidence-(Dunbar, 1995). The answer is no.
For example, scientists, especially young ones, often believe that a single experi­
mental result has just resolved an important problem. However, when Dunbar
studied a set of microbiology labs that had been particularly successful, he found
that they placed more emphasis on group lab meetings. At these meetings an indi­
vidual scientist presented his or her results to a variety of skeptical, uninvolved
peers. When the individual scientist presented a striking new piece of evidence
(e.g., I have detected Enzyme Z in a biological process where it has never been
observed before), the individual’s peers were typically quite willing to propose
alternate ways of interpret ing the evidence (e.g., the sample was contami nated
with residual Enzyme Z from a prior proced ure). In successful labs, even when
individual scientists failed to weigh a particular piece of evidence appropriately,
their peers did so for them. Moreover, the most successful labs were those that
included members with different training and backgrounds. Such “lab meetings”
are not limited to successful molecular biology labs; similar meetings take place at
venture capital firms where firms decide whether to allocate money to new ven­
tures (Kaplan, 1995).

Individuals Draw Conclusions tl1at are Overconfident and Overly Optimistic

Imagine that individuals have generated a set of hypotheses, collected some
new information, and interpreted the relevance of the i n formation for the initial
hypotheses. How much confidence should they place in the conclusions they have
drawn? If individual learners were adequately cautious, their conclusions would
reflect the degree of uncertainty in the data. on which they are based. Over the
years, research has documented that individuals often express more certainty in
their conclusions than is warranted by the facts available to them (or by their
actual pe’rformance). This kind of problem has been documented extensively in
laboratory studies, but also in field studies of individual judgment in a variety of
professions, like the civil engi neers in the introduction (Griffin & Tversky, 1992;
Lichtenstei n , Fischhoff, & Phillips, 1982; Russo & Schoemaker, 1992).

Individuals often exhibit a particular kind of overconfidence that we might label
a planning fallacy (Buehler, Griffin, & Ross, 1994) or an optimism bias. This opti-


Cognitive Repairs 2 1

mism bias i s pervasive i n work environments. Software developers at M icrosoft
often experience burnout because they “grossly underestimate” how long it wi�l
take them to accomplish certain tasks (Cusumano & Selby, 1995, p. 94). Orgam­
zations do not always successfully overcome this individual bias. A study of pio­
neer process plants revealed that the typical plant experienced actual construction
costs that were almost double the original projections; similarly, a study of start­
ups showed that more than 80 percent fell short of their projected market share
(Davis, 1985). These examples suggest that individuals draw conclusions that
underesti mate the amount of uncertainty and error in their predictions, but they
tend to do it asymmetrical l y-they rarely overestimate a project’s cost or time to

Of course, individuals may display an optimism bias because they confront mis­
aligned incentives. Perhaps if engineers correctly estimated the true cost of a new
energy plant, decision makers might choose not to build it. However, the real
causes of the optimism bias seem to be cognitive, since individuals are overconfi­
dent by the same magnitude even in lab experiments that reward accuracy. For
example, individuals typically assume that their predictions are more precise than
they are. When they are asked to set confidence intervals around a qu antity, so that
their confidence interval has a 98 percent chance of including the true answer, they
are typically surprised by the true answer not 2 percent of the time, but 20 to 50
percent (Lichtenstein, Fi schhoff, & Phillips, 1982: Russo & Schoemaker, 1992).

How might organizations repair individual tendencies toward optimism bias

and overconfidence? One strategy is to allow individuals to make overconfident
predictions, then adjust them overtly. This was the strategy pursued by the engi­
neering profession with its safety factors. Microsoft uses a similar strategy to cor­
rect the overly optimistic projections of individual software developers: It has
rules about the amount of buffer time that should be added to projects. For reason­
ably well-understood programming challenges, such as applications programs like
Excel and Word, Microsoft typically adds buffer time that constitutes 30 percent
of the schedule. However, for operating systems like Windows, where developers
must create a system that has to mesh effectively with numerous pieces of hard­
ware and software, Microsoft may add buffer time that reaches 50 percent
(Cusu�ano & Selby, 1 995). Similar repairs have evol ved in other industries. At
one Big Six accounting firm, where teams must prepare formal plans for a con­
sulting engagement, project leaders develop their best esti mates of time, expense,

5 1 2 Th”

and contingency costs, then increase the final number by I percent. ts repa1r
has evolved despite the fact that this environment provides some incentives to
underestimate costs-bids that are too high may not be accepted.

When Microsoft adds buffer time to a schedule, it corrects the predictions of
overconfident individuals by overriding them. However, it has also developed
procedures that help individual developers decrease their initial level of overcon­
fidence. For example, the company has improved its schedules by requiring devel­
opers to create a detailed work plan that specifies which tasks they will perform


during specific windows of time. Says one manager, “The classic example is you
. ask a developer how long it “:ill take him to do something and he’ll say a month,

because a month equals an infinite amount of time. And you say, ‘Okay, a month
has 22 working days in it. What are the 22 things you’re going to do during those
22 days?’ And the guy will say, ‘Oh, well, maybe it will take two months.’ Even
by breaking it down into 22 tasks he realizes, ‘ Oh, it’s a lot harder than ] thought'”
(Cusumano & Selby, 1995, p. 254).

Some organizations repair overconfidence by forcing individuals to interact
with others who are trained to question their conclusions. For example, the Penta­
gon for many years had what they called the “murder board,” a group of experi­
enced officers that reviewed the plans for important missions, with the goal of
killing the mission. According to Pentagon lore, the failed Iranian hostage rescue
during the Carter years was not vetted by this board because high government offi­
cials were too concerned about security leaks. 1 3

Other organizations have developed norms o f frank feedback t o ensure that
individuals question others’ conclusions honestly and openly. In its feature anima­
tion unit, Disney regularly holds “Gong Shows” where personnel (including
department secretaries) can pitch ideas to a group of senior executives. Gong
Shows may attract 40 people who present their idea to the executives and other
presenters for three to five minutes. The senior executives are careful to give
exceptionally frank feedback at the end of the session, highlighting both good and
bad aspects of the presentations. “Somebody may have a great concept, but the
story may not be very good. [We can’t say) ‘Oh, that’s fabulous. Great pitch guys ! ‘
and when they leave, mumble, ‘That was awfu i ! ‘ …. We don’t pull our punches.
[Eve�tually] people begin to understand that no matter how good, bad, or indiffer­
ent the idea, it can be expressed, accepted, and thought about” (McGowan, 1996).


In this paper we have reviewed the literature on individual learning using a simple
framework that considers three broad stages of the learning process. We argued
that ideal learners would generate a broad and deep set of hypotheses, test them
with a large, unbiased set of information, and draw conclusions in a cautious and
balanced way. The psychological literature indicates, however, that real individu­
als are not ideal learners; they think and act in ways that reduce their ability to
learn effectively.

Fortunately, individual learners do not have to go it alone. We have argued that
organizations frequently repair the shortcomings of individual learners through
the use of sayings, informal routines, and formal procedures. We believe the
examples we have offered illustrate the tremendous promise of organizational
sources of cognitive repairs.

Cognitive Repairs 23

Nevertheless, we do not think that cogniti� repairs will overcome every indi­

vidual problem. Cognitive repairs are heuristil!s-like the mental processes they

repair, they are pragmatic and often efficient, but also approximate and inexact.

For example, they may solve 75 percent of individual shortcomings while incur­

ring only one-third of the costs of optimal procedures (e.g., from economics or sta­

tistics). However, they are unlikely to be perfect.
Consider the five whys. It undoubtedly prompts individuals to think more

deeply about causes, but it is only a rough heuristic. Why five questions and not
three or seven? And which questions? “Problem: He doesn’t manage well.” ( 1 )
Why? H e doesn’t manage conflict well. (2) Why? He grew up i n a dys functional
family. (3) Why? His parents were alcoholics … ” ln this example, the answers took
an unhelpful detour away from potential solutions sometime around an swer 2.

Even when repairs are reasonably effective, they may still leave room for fur­
ther repair. Consider, for example, the military’s partial repair for the fu ndamental
attribution error: “There are no bad troops. only bad officers.” This adage may
repair tendencies to attribute blame to the people who are closest to a problem (the
troops who are on the battlefield); however, it merely focuses attention en another
group of people. Thus, it may prevent individuals from fixing systems or proce­
dures that have basic flaws (Cohen & Gooch, 1 990). A more effective repair might
say, “There are no bad people, only bad systems.”

Other repairs may be imperfect because they fix one problem well, but exacer-
. bate others. For example, the Five Cs may help individual loan officers collect
more kinds of information but they may create secondary problems. First, by
emphasizing character, the Five Cs may provoke the fu ndamental attribution error.
Second, although they expand the set of factors loan officers will consider in a
loan decision, they may also institutionalize any tendency that they may have to
ignore other potentially relevant factors. Third, they may help loan o fficers collect
information, but they do not necessarily help them interpret it. They seem to indi­
cate that each c·should be weighted equally, whereas an ideal statistical model
would weigh some Cs more heavily than others.

As these caveats illustrate, cognitive repairs are unlikely to completely repair
the shortcomings of individual learners. Thus, when we assess whether a given
cognitive repair is successful, we must consider the costs and benefits of the
repair. Below, we consider six dimensions that may affect the costs and benefits of
repairs, and therefore their success.

Tradeoffs Associated w i th Successful Repairs

In order to be successful, a cognitive repair must be effective-it must mend
some individual shortcoming and improve learning relative to the status quo. To
be truly successful, however, a cognitive repair must also be accepted in the orga­
nization and actively used. A repair that is not implemented is not a repair.


Cognitive repairs are a kind of innovation, and as such, their use will undoubt­
edly be affected by many of the characteristics that have previously been men-

. tioned in li teratures on diffusion and adoption (Rogers, 1995; Scott, 1995). We
will focus on innovation characteri stics that are particularly relevant for cognitive
repairs. Cognitive shortcomings not only create the need for a repair, they also
limit what repairs may succeed.

Below, we consider six dimensions that affect whether a repair will be success­
ful: simple versus complex, domain-specific versus domain-general, familiar ver­
sus novel, corrective versus preventative, social versus individual, and top-down
versus bottom-up. (We will typically focus on the endpoints of these dimensions,
but they should be regarded as continuous rather than dichotomous.) Most dimen­
sions involve tradeoffs. For example, qualities that make a repair more effective in
solving an individual shortcoming sometimes reduce the chances that it will be
accepted and used by individuals. In the absence of perfectly effective and accept­
able repairs, we must recognize and understand the tradeoffs that make repairs
more or less successful.

Simple versus Complex

One obvious dimension along which cognitive repairs vary is whether they are
relatively simple or complex. Mimy of the repairs we have discussed in this paper
are strikingly simple-they require an individual to remember and apply a proce­
dure that is only a few steps long (e.g., the five whys or the physicians ABCs). In
contrast, many of the procedures that are taught as formal repairs in academic
environments are quite complex, and involve many stages of sorting, arranging,
and calculating (e.g., formal financial or statistical analysis).

Simple repairs have profound advantages over complex repairs. First, they are
more likely to be used because the costs are small; individuals will find it easier to
learn and implement shorter procedures. By contrast, complex repairs typically
require extensive background knowledge and tax basic cognitive resources like
attention and memory (Bell, Raiffa, & Tversky, 1988; Nisbett & Ross, 1980).
Thus, when individuals encounter a complex repair, they are likely to perceive the
costs of learning it as large and immediate, and the benefits of using it as small,
uncertain, and delayed.

Second, simple repairs are easier to remember and reconstruct than complex
repairs, and this increases the probability that individuals will accurately apply
them aqd accurately transmit them to others. Because complex repairs require
individuals to remember a number of stages, they are more likely to be distorted
when they are transmitted from individual to individual. This problem will be par­
ticularly pronounced in situations that require learning by observation and imita­
tion (DiMaggio & Powell, 1 983). Individuals who learn a repair through
observation may find it difficult to infer the complete rules of behavior for com-

Cognitive Repairs 25

plex repairs because information about the rules is incomplete, unavailable, or dis­
tributed across time i n a way that makes learning difficult.

Although simple repairs have profound advantages over complex repairs, they
also have some disadvantages. Fundamentally, the tradeoff between simple �nd
complex repairs is a tradeoff between ease of use and accuracy. Complex proce­
dures are often compl icated because they attempt to be precise. Simple repairs
gain ease of use by sacrificing accuracy. For example, a simple aphorism such as
“don’t confuse brains and a bull market” suggests the correct direction to adjust
one’s judgment, but provides no guidance about exactly how much one should dis­
credit the success of an individual trader. To precisely estimate the amount of
credit due to brains versus the market, an individual would have to perform a more
complex procedure, such as calculating the overall market performance and mea­
suring an individual’s performance relative to the dispersion and central tendency
of the market.

Domain-Specific versus Domain-General

Cognitive repairs also vary in the range of contexts to which they can be applied
(Nisbett, 1 992), with some repairs being relatively more domain-specific and
some being more domain-general. Domain-specific repairs are tail ored narrowly
for a specific context (e.g., the Feature Prioritization Process at Motorola or the
Five Cs of Credit). Domain -general repairs are described so generally and

-abstractly that they apply across most judgment tasks (e.g., the Five Whys or most
economic or statistical principles).

Domain-specific rules have at least two advantages over domain-general rules.
First, individuals find it easier to recognize that a domain specific rule is relevant
because the situation itself reminds them to use the rule (e.g., a credit analyst who
has learned to think about the Five Cs of Credit will find it difficult to think about
lending decisions without considering all five categories of information). Second,
individuals may find it easier to apply domain-specific than domain-general rules.
Consider, for example a loan officer who is trying to apply a general rule like “cal­
culate the net present value (NPV)” of making the loan. This domain-general rule
appl ies to many more financial decisions than the Five Cs; but it contains no hints
about how it should be applied to a loan decision. In contrast, the Five Cs point out
specific aspects of the loan decision that might affect the loan’s quality. Similarly,
securities traders might find it hard to benefit from a domain-general warning
against self-serving biases (e.g., “pay attention to situational determinants of suc­
cess, and don’t over-attribute achievement to personal characteri stics”). In con­
trast, they are unlikely to miss the point of a more domain-specific warning not to
confuse brains and a bull market.

Although domain-specific rules have advantages, they also have limits. Their
specific content will make them more likely to spread within their domain, but it
may also prevent them from spreading. across domains. For example, engineers

.. _.


have safety factors and software developers have buffer time, but knowing about
safety factors does not automatically suggest the need for buffer time. And even a

· s i ngle individ ual may use a rule effectively in one domain but fail to see its impli­
cations for another. Auditors are often quite good at ignoring their preexisting the­
ories about a client’s financial health when they investigate auditing problems.
However, they are less likely to do so when they confront similar problems outside
the auditing domain, even if the problem relates to their other professional activi­
ties (Smith & Kida, 1 99 1 ).

A second limitation of domain-specific repairs is that they are tightly tailored to
fit a particular task and environment. Because of this tight fit, they may be less
successful than domai n-general repairs when the task environment is in flux. A
buffer factor designed during a specific period of time-“multiply all ti me-to­
del ivery estimates by 1 .5”-may lose its effectiveness when technological or eco­
nomic conditions change. Consider that Microsoft had to develop separate buffer
factors to repair overconfidence in applications and operating systems. In general,
domain-specific rules will be helpfut · in companies or divisions where the tasks
and environments are stable over time, while domai n-general approaches will be
helpful in situations where tasks and environments change frequently (e.g., at
higher levels in an organization where tasks and decisions are less routine).

A potential method of combining the advantages of domain-specific and
domain-general rules may be to give individuals a domain-specific repair and then
train them to generalize that repair to other domains (Fong & Nisbett, 1 990; Lar­
rick, Morgan, & Nisbett, 1 990). Individuals typically find it easier to generalize by
analogy from one specific i nstance to another than to map from general principles
down to specifics (Bassok, 1 990). For example, people who learn to ignore sunk
costs in financial investments correctly recognize that this rule applies to invest­
ments of time as well (Larrick, Morgan, & Nisbett, 1 990). Similarly, a manager in
industry may find it easier to apply the specific military adage about their being
“no such thing as bad troops” than to apply a more general lesson about the fun­
damental attribution error.

Corrective versus Preventative

Cognitive repairs also differ in whether they prevent or correct the shortcomings
of individuals. Corrective repairs intervene during or after a particular cognitive
process (e.g., the accounting team that corrects their tendency to overweight vivid
exceptions by forcing themselves to consciously classify each exception as major
or minol’). At the extreme, a corrective repair might only intervene at the very end
of a process to correct the overal l outcome (e.g., safety factors). Preventative
repairs intervene early in a cognitive process before shortcomings have had a
chance to act. Microsoft prevents developers from acquiring a biased sample
about the speed of their programs by forcing them to develop programs on the
same machines used by customers.

··�· .

Cognitive Repairs 27

Some shortcomings are easier to correct than others. For example, when a short­

coming arises because individuals have the wrong rule, they may not find it diffi­

cult to substitute a different rule (Wilson & Brekke, 1 994). Trauma physicians

may learn to check airway before breathing, and accouf!tants may learn to ignore

vivid but minor exceptions. In general, corrective repairs will be appropriate when

individuals accept the need for a repair and they understand how to execute the

However, when a shortcoming arises because of some basic cognitive process,

organizations may need to intervene more forcefully by bypassing or eliminating
the faulty process (Arkes, 1 99 1 ; Wilson & Brekke, 1 994 ). For example. individu­
als may find it difficult to generate a broad and independent set of hypotheses
because associative memory leads them to consider the same alternatives they pre­
viously considered. Theoretically, Motorola could instruct individuals who are
developing a new consumer product to “i gnore what you’ve done in the past and
approach this problem creatively.” However, individuals might find it difficult to
ignore their previous solutions. Thus, Motorola prevents the problem by prohibit­
ing them from serving on more than one product development team. Simi larly, the
Chicago Board of Trade could warn its investi gators to discount the answers they
receive when they ask leading questions. Instead it prevents individual investiga­
tors from asking yes or no questions, and thus ensures that they receive less biased
information in the first place.

Familiar versus Novel

Repairs may also vary in the extent to which they are novel rather than familiar.
Novel repairs require individuals to change their assumptions or to learn a proce­
dure from scratch. For example the “programmers” at the CRSS architectural firm
had to learn to resist their tendency to sketch solutions before evaluating all the
information from � client. On the other hand, familiar repairs build on preexisting
knowledge (e.g., the CAMEL schema for bank exami ners or the ABCs for trauma
physicians). These repairs have fam iliar content-trauma physicians know that they
should attend to breathing and circulation, and bank examiners know they should
pay attention to capital and earnings. They also have a fam iliar form-they are
organized by a simple acronym that individuals already have as a part of their
mental lexicon.

Familiar repairs may be at an advantage over novel repairs because they are less
costly to use and their benefits may be more apparent. CAMEL and the ABCs
reduce costs by using a familiar acronym to remind individuals to collect types of
information that they know they should be collecting. In contrast, the CRSS pro­
grammers had to work hard to overcome the behaviors they had learned as archi­
tects, and they may have questioned the benefits of the elaborate new procedures
they were being taught. Fami liar repairs are also less likely to provoke resistance


than novel repairs. Anything that requires individuals to throw out old practices or
adopt new beliefs may be technically and psychol ogical ly difficult.

However, familiar repairs may sometimes be too familiar for their own good.
First, they may be less likely to create enthusiasm. If individuals think that a new
repair differs only trivially from current practice, they may see no advantage to it.
Because individuals often ignore the famili ar, would-be change agents often strive
to create the perception that their programs are novel and unique (Abrahamson,
1 996). Second, familiar repairs may be subject to distortion. If a repair seems par­
tially famil iar, individuals may neglect its unfamiliar aspects or force them to
mimic the more familiar aspects (a process that psychologists call assimilation).
For example, the proper technique for brainstonning requires a specific sequence
of steps: first, a creative, idea-generation stage which does not allow criticism,
then a stage where ideas are evaluated and selected. Although organizations fre­
quently report that they use brainstonning, carefu l examination reveals that the
organizations are actually engaged in a more fami liar activity: a basic business
meeting (Zbaracki, in press). The novel aspects of the brainstonning procedure,
such as the separation of stages and the “no criticism” rule, are often lost as brain­
stonning is assimilated to the more familiar practice of the standard business
meeting. In the end, only the attractive label remains. In situations where assimi­
lation is a problem, repairs that are novel may be less likely to su ffer distortion
than repairs that are more famil iar because novel repairs do not evoke the preex­
isting knowledge that leads to assimilation.

Social versus Individual

Many of the cognitive repairs we have considered are social; they work because
individuals interact with others (e.g., single-case bore questions in the Deming
Prize organization, or the murder board at the Pentagon). Other repairs are indi­
vidual; individuals apply them to their own learning processes without the inter­
vention of others (e.g., individuals Jearn to use the Five Whys, and individual
investigators at the Board of Trade learn to avoid “yes or no” questions).

In general, we suspect that many successful repairs will be social because indi­
viduals may not recognize the need to repair themselves. The very cognitive short­
comings that organizations might hope to repair will make it difficult for
individuals to see their own flaws. As we have discussed, individuals tend to retain
current assumptions in the face of conflicting data (Klayman, 1 995). Also, they
interpre� events in ways that protect their self-image; they avoid potentially threat­
ening feedback (Frey, 1 986; Larrick, 1 993) and attribute their poor outcomes to
luck or forces outside their control. Although individuals may find it hard to rec­
ognize their own biases, they may find it easier to recognize the biases of others.
Many of the repairs we document have the feel of (friendly) social gamesmanship.
For example, learners at FP&L did not consider the hypothesis that they had been
“rucky”-their colleagues considered it for them. Similarly, during weekly micro-


Cognitive Repa irs 29

biology lab meetings, researchers did not have to suggest alternative ways of inter­

preting their evidence, their peers did so. Social competition among i ndividuals

aids the spread of repairs even when individuals are overconfident and believe

they would have done just as well without the repair.
Social repairs do have to overcome some di sadvantages. For example, individ­

uals may not appreciate others who attempt to repair their biases, and they may
dismiss the repair attempts as the product of picky or abrasive person alities. Thus,
social repairs may be more successful when an individual understands that his or
her tonnentors are playing an i mportant, fonnal role. Individuals may find it easier
to entertain an antagonist’s critiques when he or she is labeled as a “devil’s advo­
cate,” or when the individual is appearing before the “murder board.” Disney clar­
ified the role of the evaluators and the occasion by establishing its nonn of frank
feedback and by labeling its tryouts as “The Gong Show.”

Eventually, social repairs may be transfonned into individual repairs as individ­
uals learn to imitate the patterns of analysis forced on them by others . l n order for
individuals to learn, they need vivid, immediate feedback. Social encounters are
likely to provide a key source of such feedback. For example, when Deming
examiners ask single-case-bore questions, or when lab colleagues try to shoot
holes in a lab presentation, individual learners may eventually learn tQ engage in
preemptive sel f-criticism in order to look better during social encounters (Tetlock,
1 992). (Many academic papers are better because authors learn to mentally simu­
late potential rev iewer’s comments.) Such repairs invoke social forces at two dif­

‘ferent levels: individuals who anticipate social interaction may be more aware of
some of their own shortcomings, and then actual social interaction may overcome
additional shortcomings that individuals cannot repair on their own.

Top-Down versus Bottom-Up

Some cognitive repairs originate from “top-down” within an organization. Typ­
ically these repai rs are deliberately designed and im plemented by m anagers or
outside experts. Others arise from bottom-up through infonnal observation or ser­
endipitous discovery from the people who are doing the work.

The source of the repair is important because it is likely to affect its fonn . In
general, bottom up repairs, such as organizational adages, will be simpler and
more domain-specific than top-down repairs designed by tech nically sophisti­
cated engineers, statisticians, or management gurus. The local origin of bottom-up
repairs may also make them feel more familiar and acceptable than top-down
repairs. Thus, the origin of a repair will be highly correl ated with many of the
tradeoffs we have already discussed.

More importantly, the origin of the repair is also likely to affect how potential
adopters perceive it. Top-down repairs may be perceived with suspicion or hostil­
ity precisely because they originate outside the organization or are imposed from
above. Front-line workers may doubt that outsiders like consultants understand


their situation well enough to make wise recommendations. When managers sug­
gest a repair, they seem to imply that employees have been performing poorl y or
cannot be trusted to perform their job correctly. If so, then individuals may resist
adopting a repair because of the same kind of self-serving biases we di scussed ear­

Top-down repairs may also be resisted because they will be perceived as driven
by politics or fashion and not by the demands of the task. Some top-down repairs
may be resisted because they seem too political. Particularly when top-down
repairs rely on fixed procedures, they may provoke resistance because individuals
may think that they are designed to centralize control or remove individual discre­
tion. Other top-down repairs may be resisted because they seem to be driven by
fashion. Institutional theorists contend that organizations adopt new practices for
reasons other than greater efficacy. Organizational members may share simi lar,
cynical intuitions (Adams, 1 996), and will resist repairs that they see as mere win­
dow dressing or as this year’s fad. When individuals have trouble recognizing
their shortcomings, then they may be particul arly likely to attribute top-down
repairs to politics or fashion because they will not recognize the repair’s true

Bottom-up repairs will often benefit from their local, homegrown origins. Local
repairs have a meaningful history that makes them memorable and appeal ing.
Even a repair that is potentially threatening, such as “you were rucky,” may be
more acceptable if organizational members see it as their own invention. Just as
lawyers are entitled to tell lawyer jokes, organizational members are entitled to
develop self-critical repairs and to convey their insider status by using them. And
homegrown repairs evoke a stronger sense of ownership; at the same time that
they call attention to a potential shortcoming, they also give the user credit for fix­
ing it.

Conclusions: Successful Repairs

We have considered six different dimensions along which cognitive repairs can
be classified. For example, the physician’s ABCs are simple, domain-speci fic,
corrective, familiar, individual, and top-down . Although we have suggested some
advantages and di sadvantages of each endpoint of each dimension, we believe that
our discussion suggests at least some preliminary conclusions about successful
repairs. For example, because individuals have limited faculties, organizations
who �ish individuals to learn complex, domain-general repairs will find them­
selves devoting a great deal of scarce time, money, and effort to ensure that such
repairs are learned and used. Similarly, because individuals are overconfident
about their own conclusions, they may not spontaneously execute individual
repairs to correct their own biases. Based on the advantages and di sadvantages we
have considered, we suspect that the most successful repairs will be simple,
domain-specific, socially administered, and evolved from bottom-up rather than

Cognitive Repairs 31

developed from top-down. We find this conclusion intriguing because it describes
repairs that differ sharply from those that are recommended in academic litera­
tures on decision analysis, statistics, and economics.

Implications for Research

Cognitive psychologists often think of people as rugged cognitive individual­
ists, constrained by their own cognitive limitations and a poor environment in
which to learn. Cognitive researchers continue to argue over how well individuals
actually perform the cognitive tasks they encounter in their lives (see Anderson,
199 1 , and accompanying commentaries, and the debate between Gigerenzer,
1996; and Kahneman & Tversky, 1 996). However, it is important to remember
that much of what people do, including much of their cognition, takes place in the
context of organizations and other social structures.

Some recent approaches in psychology do explore cultural and social contribu­
tions to individual learning. For example, work on “transactive memory” (Weg­
ner, Erber, & Raymond, 1 99 1 ; Liang, Moreland, & Argote, 1995) shows how
individuals reduce their memory li mitations by distributing memory-heavy tasks
across multiple people. Thus, there can be collective memory that does not reside
in any individual. Our concept of organizational repairs is in the same spirit, but i t
deals with “higher order” cognition: Reasoning and decision making can also be
improved through social structure and cultural bootstrapping.

We also bel ieve that organizational psychologists could better understand orga­
nizational processes if they thought more about the cognitive processes of the indi­
viduals who make up the organization. Research tying individual psychology to
organizational behavior certainly has a long and venerable pedigree (March &
Simon, 1958), but recently, some researchers have expressed concern that that
approach is still underutilized. For example, in the context of institutional diffu­
sion processes, Zucker ( 1 99 1 ) has warned that .. without a solid cognitive, micro­
level foundation,· we risk treating institutionalization as a black box at the organi­
zational level, focusing on content at the exclusion of developing a systematic
explanatory theory of process” (p. 1 05). And Miner ( 1 994) warns, .. inost evolu­
tionary discussions of organizational change discuss routines as though they exist
independent of individual human beings” and .. evoke images of disembodied enti­
ties removed from day-to-day human interaction” (p. 87). Knowledge of individ­
ual cognition can be crucial to understanding why things happen as they do in an
organization. For example, why do engineering firms use a system by which the
best engineers make their best estimates, only to have the firm second-guess them
by adding a huge safety factor? Any explanation would be incomplete without an
understanding of individual overconfidence. Understanding the abilities and con­
straints of individuals permits a kind of- cognitive archaeology of organizational
practices that may allow organizational researchers to better understand why cer­
tain rules, norms, and procedures develop in organizations, and why others fail.


Implications for Practice

Managers who think explicitly about cognitive repairs will, we think, be in a
better position to foster improvements in their organizations. Managers already
think about factors such as incentive systems and information technology as tools
to foster learning and innovation. We believe that cognitive repairs will be a useful
addition to the toolbox. Managers who consciously consider individual cognition
may be able to recognize a larger number of repair opportunities and may target
top-down repairs more effectively. Furthermore, they may design more effective
repairs if they take a cognitive approach and consider repair dimensions like the
six we discussed earlier.

Even when repairs are developed bottom-up rather than top-down, a manager
who is informed about individual cognition might have a positive in fluence. As
has been observed by researchers who think about evolutionary approaches to
organizations, one of the critical components of organizational learning is to start
with a rich and varied pool of alternative practices (Levitt & March, 1 988; Miner,
1994). Savvy managers can enhance the pool of alternatives that are available by
teaching organization members about the concept of repairs and by encouragi ng
them to identify existing repairs and to seek new repair opportunities. Managers
can recognize and reward individuals who discover cognitive repairs, and they can
dissemi nate effective repairs via demonstration, training, communication, and
rotation of personnel.

Managers may also lind it very important to think about cognitive repairs when
they evaluate existing organizational practices. Consider, for example, a new
executive who discovers that her development group is split up into six separate
teams, each trying to solve the same problem without any communication with
each other until well into the process. This might seem like a paradigm of bureau­
cratic inefficiency. Yet, this is the kind of system that Motorola has found to be
effective in generating a broader set of options. Without understanding the poten­
tial value of this repair, the new executive might be sadly surprised by the results
of streamlining the process.

Managers might also benefit from a cognitive approach because cognitive
repairs, like other innovations, may suffer from the law of unintended conse­
quences. A repair that is intended to fix one problem can well end up creating
another. Recall, for example, Microsoft’s laudable attempt to make the customer
more salient to program developers by having them watch live customers attempt
to use their products in the usability test lab. The test lab repaired the developer’s
tendency to be unmoved by cold statistics, but it probably exacerbated their ten­
dency to bel ieve that small samples were reliably representative. In response to
seeing one customer i n the test lab, developers might waste time altering a feature
that would have been okay for most customers. Managers who .take a cognitive
approach would, we hope, be more likely to avoid unwanted side effects, or at
least be in a better position to recognize and cope with them.


Cognitive Repairs 33

Final Words

In contrast to Hamlet’s enthusiasm, we argue that there is good reason to be
aware of the limitations of individual learners. People are not “infin ite in facul­
ties” or “noble in reason.” As individuals, we make systematic mistakes that com­
promise our ability to learn from our experiences and to understand the world. On
the other hand, we mortals are not all fools. We are able to form social structures
that have the potential to magnify some of our abilities and to minimize some of

our failings. In this paper we have concentrated on demonstrating that effective
organizational repairs happen. We do not mean to imply that organizations cure
any and all individual shortcomings, nor even that organizations always make
things better rather than worse. Nevertheless, we do believe that the organizations
in which we work can provide us with norms, reminders, protocols. and proce­
dures that help us move beyond our individual shortcomings.


We thank the Graduate School of Business, University of Chicago and the Fuqua School of

Business, Duke University. for research support. For helpful comments on this project, we
thank participants at Rod Kramer’s 1996 conference on Organizational Learning; we also
thank Jim March. Cade Massey, Elizabeth McS weeny, Sim Sitkin, Dick Thaler, Elke

Weber, and John Wright.


I. We primarily want to distinguish problems of incentives from problems of mental proce ss. In
this review we will not distinguish between mental errors that arise from ‘”motivated reasoning'” and
those that arise from ‘”colder” processes.

2. Personal communication. Abhay Joshi.
3. Personal communication. Robert Alan Fisch.
4. Personal communication, Jan Elsbach.
S. Personal communication. Francisco Bayron.
6. Personal communication, Dean Siewert.
7. Personal communication. Justin Scott Bradley.
8. Personal communication. Francisco Bayron.
9. Personal communication. Dean Siewert.

10. Personal communication, Ken Myszkowski.
I I . Personal communication. Leo Tucker.
12. Personal communication, Raymond Stukel.
1 3 . Personal communication, John Payne


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Tips for mastering the write-ups:
There rarely exist right answers to these questions. That’s what makes the prompts interesting,
useful, and fun (we hope). Good write-ups will always reflect a solid understanding of the
material but more importantly you should be able to apply the concepts to the prompt. This means
that you should not provide definitions and examples from the reading, but instead figure out
what concepts are relevant and how they apply to this business situation.
The following are a few tangible, specific tips based on years of grading write-ups. I offer them to
you in roughly decreasing order of how frustrating their violations are to a grader.
1. Don’t regurgitate the reading. You never need to waste space including definitions from the
reading. Write as if your audience not only has read the assigned materials but also knows
them well. When necessary, cite a concept as briefly as possible. The fact that you’ve done
the reading should be revealed to us by your thinking, NOT by some quotation.
2. Start quickly and end abruptly. For these short write-ups, introductions, background, and
conclusions are entirely unnecessary. Even worse, they take away space that is better used in
other ways. We don’t expect these things to read like English essays. Nor are we strangers to
why you’re writing in the first place. Treat it like an email to a colleague and jump right in.
3. Choose specific over abstract. Precision is good. It’s good for communication, and it’s good
for sharpening thinking. When you feel yourself getting fuzzy, think to yourself: I need an
example. We love examples. Make it real.
4. Be realistic. There is nothing more irritating than a cute suggestion (for example, of how an
organization might mitigate a particular bias) that works theoretically but is utterly infeasible
in the real world. Perhaps the best criterion is to ask yourself if you’d be willing to sit in a
manager’s office advocating his or her use of your recommendation.
5. Less is more. Believe it or not, a common mistake is to include too many ideas — not
because too many ideas itself is bad, but because these ideas, as intriguing, tantalizing, and,
yes, right as they might be, are often too poorly developed. Don’t make this mistake! We’re
not impressed with laundry lists. It’s much better to write about a few things really well.
Oh, and have fun! This is an opportunity to be creative (the risk-reward tradeoff for creativity is
very attractive). A student who is thoughtful and having fun when writing these is generally going
to do pretty well. And get more out of it. Thanks!

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