Organizations exist because they allow us to do things together we could never do on our own. Relationships determine how well they function. When organizations are unhealthy, this is embedded in everything they do. It’s the ghost in the machine.
Korean Air Cargo Flight 8509
The instruments failed on Korean Air Cargo Flight 8509 when it took off from London on December 22, 1999. As the Captain banked the plane to turn left, his instruments showed it was not responding. The Flight Engineer shouted warnings, to no effect. The Captain banked further and further left. The First Officer stayed silent, even though his instruments, functioning properly, showed their imminent peril. An alarm sounded urgently, signaling that the Captain and First Officer’s instruments displayed different readings. Still the Captain took no corrective action. The plane crashed nearby 55 seconds after take-off, exploding instantly. All four crew members were killed.
Investigators concluded the main reason for the accident was the autocratic culture in the cockpit, where the pilot’s authority could not be challenged. Challenging the Captain was an act of dishonor that could bring a quick end to a career. The First Officer’s reluctance to challenge the Captain was heightened by the Korean national culture of autocratic leadership.
Korean Air had 16 aircraft incidents and accidents between 1970 and 1999, with almost 700 casualties, but this pattern ended when the airline changed its crew training program and company culture to promote greater equality in the cockpit.
Space Shuttle Challenger
Space Shuttle Challenger had already made nine journeys into space before it blasted off the launch pad on its tenth mission on January 28, 1986. It broke apart 73 seconds after launch, at an altitude of 48,000 feet. An O-ring seal in its right solid rocket booster failed at liftoff, triggering a series of structural failures that led to the breakup of the spacecraft. All seven crew members were killed when the free-falling crew compartment crashed into the ocean.
The Rogers Commission appointed to investigate the accident concluded NASA’s organizational culture and decision making processes contributed to the accident. The agency had violated its own safety rules. Six delays in the launch schedule due to weather and equipment problems in the previous week increased the sense of urgency. NASA managers ignored warnings from engineers about the dangers posed by low temperatures on launch day, and did not relay these concerns to their superiors.
The Commission Report concluded communication failures and “incomplete and sometimes misleading information, a conflict between engineering data and management judgments, and a NASA management structure that permitted internal flight safety problems to bypass key Shuttle managers” led to the fateful decision to proceed with the Shuttle launch.
Engineering a New Car
In Presence: Human Purpose and the Field of the Future, MIT lecturer Peter Senge and his coauthors tell the story of an engineering program mandated to develop a new car. The five-year project employed the equivalent of a thousand full-time engineers, and was budgeted at $1 billion. A dozen special teams focused on different aspects of the product.
When the engineering teams encountered a design problem they had two choices. They could collaborate to find solutions or apply quick fixes on their own. More often than not, they chose to make quick fixes. This produced problems for other teams, who made their own design adjustments. Time pressures created a sense of urgency, but delays caused by continuous rework increased these pressures, creating a reinforcing loop.
This all became clear, the authors say, when one of the teams created a system diagram that showed what was going on.
“All the details were very familiar to them – the problems, the reactions, and the strained relationships that characterized their work environment. Now they were actually seeing the systemic pattern that caused this, and they could see that no one individual was to blame. They had created this pattern together. Each team did what made sense to it, but no one saw the larger system their individual reactions created – a system that consistently produced poor technical solutions, stress, and late cars.”
With new insight the engineers began working more collaboratively. The car was completed almost a full year ahead of schedule.
The Bottom Line
We are often blind to the true costs of organizational breakdown. Poor relationships make organizational life stressful and uncomfortable – a phenomenon that is more common than not. They also limit an organization’s ability to carry out its mission. Organizations that foster open, respectful, and healthy dynamics among people produce better results. There’s a lot at stake.
This article is an excerpt from a book in progress on collaboration and transformative change. It was first posted on September 12, 2017, on LinkedIn.