
Roger Boisjoly, the Morton Thiokol engineer who, in 1985, one year before the catastrophic failure of the Space Shuttle Challenger, wrote a memorandum outlining the safety risks of cold-weather launches. He successfully raised the issue then, and many times subsequently, including the evening prior to the launch. In 1988, he was awarded the Prize for Scientific Freedom and Responsibility by the American Association for the Advancement of Science. The report of the Rogers Commission investigation of the Challenger failure is an example of what accountability-oriented cultures can achieve. Although the commission found defects in hardware, they also found defects in decision processes going back to 1977. In their words, they found the disaster to be "an accident rooted in history."
Photo courtesy the Online Ethics Center at the National Academy of Engineering.
We can classify organizational cultures by examining how they deal with failure. One class of organizations seeks people accountable for a failure; a second seeks people to blame for the failure. (For a brief summary of the differences between blame and accountability, see "Is It Blame or Is It Accountability?," Point Lookout for December 21, 2005) In an accountability-oriented culture, when we look for factors that led to failures, we seek out people who have relevant knowledge. They know that we're trying to change things to avoid repeating past errors. They're willing to offer what they know about what happened, because they feel safe doing so. With the information they provide we devise changes in processes that reduce the probability of repeating mistakes. Complete repair might be a bigger job than we can take on right now, but we make what changes we can. We take steps in the right direction and monitor our progress.
In a blame-oriented culture, when we look for the sources of failures, we try to isolate a few people, and hang the whole thing on them. Even better: isolate a single individual. There's no point in hurting more people than necessary. The whole exercise is a fiction anyway, because we know that the true causes are complicated. Many, many people contributed in one way or another. To truly fix things to avoid a repetition would be a daunting task that we have neither the time nor the resources to address. So we designate the scapegoats and move on.
Comparing the two cultures
The differences In a blame-oriented culture, when we look for
the sources of failures, we try to isolate a
few people, and hang the whole thing on thembetween these two cultures — Accountability-Oriented Cultures (AOC) and Blame-Oriented Cultures (BOC) — have material consequences for their respective abilities to succeed. AOCs tend to facilitate learning and steady improvement. BOCs tend to suppress learning and stall improvement. Here are three phenomena that account for some of this difference.
- People harbor differing views as to where safety lies
- When failure occurs, people naturally seek safety. In AOCs, people feel safer when they're confident that something is being done to reduce the probability of failure in the future. They voluntarily contribute whatever they can to advance those efforts. These measures increase the probability that the investigation might produce information that could enhance organizational learning.
- In BOCs, people feel safer when they find a place as far as possible from the investigation into the conditions that contributed to the failure. They do what they can to deflect the investigation from themselves or their own activities. They don't volunteer what they know. Indeed, they might withhold information or even misrepresent what they do know. These measures reduce the probability that the investigation might produce information that could enhance organizational learning.
- People learn how to deal with investigations of failures
- Over time, people learn how to succeed in the organizations in which they work. In AOCs, success depends on keeping up with ever-improving processes. People advance when they demonstrate capability and make positive contributions to organizational efforts. One category of efforts worthy of positive contributions includes the investigations of failures. That's why these investigations produce valuable results.
- In BOCs, success depends on avoiding entanglement with any effort that has produced disappointing results. Even among those who left the effort prior to the failure's becoming visible, there is recognition of the wisdom of keeping out of sight once the investigations begin. This pattern limits the value of the results these investigations produce.
- Organizations use critical thinking skills differently
- To understand the factors that contributed to failure, investigators must analyze the available data using critical thinking skills. That entails applying careful reasoning to the available evidence to reach objective conclusions. AOCs tend to let evidence and reason lead them to conclusions.
- BOCs do use critical thinking skills, but they use them to find ways to connect evidence to the conclusions they prefer. In BOCs, conclusions are more likely to be preconceived, even before evidence is available. Indeed, in what might be termed organizational confirmation bias, preferred conclusions often guide the evidence collection activity. BOCs are therefore more likely to permit preferred outcomes to bias the conclusions of failure investigations.
Last words
The findings of failure investigations distinguish Accountability-Oriented Cultures from Blame-Oriented Cultures. BOCs are more likely to attribute failures to a single decision or a few individuals. AOCs are more likely to find complex webs of contributing factors, with many individuals playing roles that contributed to the failure. The appeal of the BOC approach is its simplicity. Regrettably, it rarely has a strong connection to reality. Top
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