Never underestimate the kind of things that a bad culture
You may think there is a limit to bad culture - a point at
which when the potential effects could be so catastrophic that people would
pull back, but the space shuttle Challenger disaster of January 28, 1986 proves
to us that the lives of seven people were naught compared with the power of
The disaster resulted in a 32-month suspension in the shuttle
program and the formation of the Rogers Commission, a special commission
appointed by Ronald Reagan to investigate the accident. The Rogers Commission
found NASA's organizational culture and decision-making processes had been key
contributing factors to the accident. NASA managers had known contractor Morton
Thiokol's design of the SRBs (Solid Rocket Boosters) contained a potentially
catastrophic flaw in the O-rings (gas tight rubber seals between the sections
of the SRBs) since 1977, but failed to address it properly. They also
disregarded warnings from engineers about the dangers of launching posed by the
low temperatures of that morning and had failed in adequately reporting these
technical concerns to their superiors.
It is also pertinent and ironic to mention that cultural
problems also surrounded the Rogers Commission itself, particularly the role of
theoretical physicist Richard Feynman. His direct and apolitical style of
investigating rather than following the commission schedule put him at odds with
Rogers, who once commented, "Feynman is becoming a real pain".
But, even though there was an appalling disaster caused by
problems deeply rooted in culture, at least the Rogers Commission and their
report and recommendations would correct these failings and at last the power
of culture to do massive harm would be curtailed…
Well, the power of culture is so powerful that even that was
not the limit…
After another Space Shuttle disaster (Columbia in 2003),
attention once again focused on the attitude of NASA management towards safety
issues. The Columbia Accident Investigation Board (CAIB) concluded that NASA
had failed to learn many of the lessons of Challenger. In particular, the
agency had not set up a truly independent office for safety oversight; the CAIB
felt that in this area, "NASA's response to the Rogers Commission did not
meet the Commission's intent". The CAIB believed that "the causes of
the institutional failure responsible for Challenger have not been fixed,"
saying that the same "flawed decision making process" that had
resulted in the Challenger accident was responsible for Columbia's destruction
seventeen years later.
It is pertinent to consider how ignorance is interpreted
differently in the law and in business.
In the law - “Ignorance is no defence” but in business
Ignorance is the “perfect defence”. You can see it used on a daily basis
especially for those senior people whose job it is to be accountable, claiming
ignorance of knowing the bad things “workers” had been doing and promising that
they will be punished. But these are not bad people.
There are no bad people, only bad
Culture is the most important environment of them all and it
is Management that is responsible for setting it. Good or Bad.
What are the biggest “disasters”
your Enterprise has faced?
Did Culture play a part, and
if so, what part?
Were lessons learned or not?
What are the top five Cultural
problems facing your Enterprise?
What would your Enterprise
look and feel like if those problems were solved?
What will you do to solve or
How seriously does your
Enterprise take Culture?
What does your Enterprise do
to improve Culture?
Are they succeeding?
Are they doing enough?
What problems have been
encountered within your Enterprise whose root cause can be traced back to
Cultural problems (in whole or in part)?