Here's a riddle. What is the only business book ever to spend more
than 19 weeks on the New York Times best-seller list, sell more than
a million copies, and be nominated for the prestigious National Book
Award?
Give up? It's The 9/11 Commission Report , which is
shaping up to become the surprise hit of the last year. It's a
trick question, granted: The 9/11 study isn't a traditional business
book; at least, it's not the overhyped, how-to, warmed-over fluff
that all too often dominates the genre. But the commission's report
is a careful analysis of flawed organizations, and of the devastating
effects of siloed cultures and ineffective management.
We live and work in a world where organizational failure is endemic
-- but where frank, comprehensive dissections of those failures
are still woefully infrequent; where success is too easily celebrated
and failures are too quickly forgotten; where short-term earnings
and publicity concerns block us from confronting -- much less,
learning from -- our stumbles and our blunders.
Now we have an opportunity to buck the tide -- in the form of
three brutally honest anatomies of catastrophe, none of them directly
from the business world, published in the last year and a half.
The 9/11 Commission's gripping book, the Columbia Accident Investigation
Board's thorough report of the space-shuttle tragedy, and the
New York Times ' reflective account of the scandal involving the
fabrications by reporter Jayson Blair are windows on our own organizations'
vulnerabilities. With the glaring clarity of hindsight, all of
these tragedies are striking reminders that while individuals
can be quite adept at picking up on hints of failure in the making,
organizations typically fail to process and act on their warnings.
Reacting to those weak signals -- to the information trapped
within the system -- may or may not have prevented these catastrophes.
Indeed, we cannot begin to sift through every cause that led to
what are unthinkable disasters. But each report stresses one of
three factors -- imagination, culture, or communication --
as the greatest culprit in ignoring, trapping, or suppressing
crucial warning signs. These were the factors that made the blinking
red signals so hard to see.
Culture -- Disturbing the Perfect Place
The National Aeronautics and Space Administration (NASA) spent
the 1960s, quite literally, shooting for the moon. The seemingly
impossible successes it achieved during the Apollo era made
it a symbol of human accomplishment, establishing a remarkable "can
do" culture. But even as the mission
of NASA changed, and
its goals shifted from man-on-the-moon triumphs to routine shuttle
operations, the early glories held fast. NASA had become a "perfect
place," wrote Yale professor Garry Brewer back in 1989. In
such cultures, he wrote, the ability to listen to dissent requires "the
shock of heavy cannon."
Somehow, even the Challenger disaster of 1986 was not
heavy enough.
Then, early on the morning of February 1, 2003, the Columbia
shuttle exploded over the piney woods of East Texas. The physical
cause for the accident may have been a piece of foam debris
that struck the shuttle's left wing just seconds after launch,
but that wasn't the only problem. "In our view," writes
the Columbia Accident Investigation Board (CAIB) in its report, "the
NASA organizational culture had as much to do with this accident
as the foam".
NASA, in a nutshell, remained conditioned by its past success.
Even after Challenger , the CAIB authors write, NASA suffered
from the symptoms of the perfect place. Its decision making
was still marked by unwarranted optimism and overconfidence. NASA
was still a place where lessons-learned programs were voluntary,
where frontline engineers feared ridicule for expressing their
concerns, where, writes the CAIB, "the intellectual curiosity
and skepticism that a solid safety culture requires was almost
entirely absent."
How do we eliminate perfect-place arrogance in our own organizations?
First, don't be straitjacketed by traditional perspectives.
After the foam strike was discovered, engineers called it almost
an "in
family" event. This meant it was treated in the same way
as well-known, traditionally "accepted" risks and therefore
was wrongly written off as posing no harm. Although top shuttle
management quickly dismissed the threat, lower-level engineers
were concerned and asked for better photos in order to more
accurately assess the damage. Though they tried three different
bureaucratic channels, all of their requests were denied.
"Take your labels lightly, don't hold them dogmatically," says
Karl Weick, who has studied high-risk organizations extensively.
In addition to the in-family label, Weick notes, NASA had long
thought of the shuttle as being "operational" when it
had really never left the experimental phase. "Once you attach
that kind of label to it, you seal yourself
off from any likelihood
that you're going to learn anything."
NASA's perfect-place culture also led to a warped outlook on
safety. After the engineers' requests for photos were denied
because there was no "requirement" for them, they found themselves "in
the unusual position of having to prove that the situation was
unsafe," write the CAIB authors, "a reversal of the
usual requirement that a situation is safe." This may sound
like mere semantics, but it meant NASA
exhibited an overconfident, prove-it-wrong attitude rather than one that demanded engineers
prove it right.
To help break down such attitudes, Weick suggests a similar semantic
reversal. By restating a close call as a near hit, you turn
the event on its head. You almost failed, rather than barely succeeded.
It's simple, but it can be a great reminder that the system
is all too capable of big mistakes. "In general, it just breeds
a kind of wariness, a kind of attentiveness," says Weick. "Complacence
is what you're worried about."
So does all this mean we don't shoot for the moon? That we dwell
on our failures rather than taking pride in our triumphs? Not
at all. But there's a fine line to walk between a proud culture
and a prideful one, between celebrating a healthy history of
success and resting on your laurels.