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
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.