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Never underestimate the kind of things that a bad culture can create.

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 culture.

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 environments.

Culture is the most important environment of them all and it is Management that is responsible for setting it. Good or Bad.


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Questions to ponder...

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 does your Enterprise do to improve Culture?

Are they succeeding? Are they doing enough?

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