Gospels of Failure

NASA, in a nutshell, remained conditioned by its past success. Even after Challenger, the CAIB authors write, NASA suffered from the symptoms of the perfect place. Its decision making was still marked by unwarranted optimism and overconfidence. NASA was still a place where lessons-learned programs were voluntary, where frontline engineers feared ridicule for expressing their concerns, where, writes the CAIB, "the intellectual curiosity and skepticism that a solid safety culture requires was almost entirely absent."

How do we eliminate perfect-place arrogance in our own organizations? First, don't be straitjacketed by traditional perspectives. After the foam strike was discovered, engineers called it almost an "in family" event. This meant it was treated in the same way as well-known, traditionally "accepted" risks and therefore was wrongly written off as posing no harm. Although top shuttle management quickly dismissed the threat, lower-level engineers were concerned and asked for better photos in order to more accurately assess the damage. Though they tried three different bureaucratic channels, all of their requests were denied.

"Take your labels lightly, don't hold them dogmatically," says Karl Weick, who has studied high-risk organizations extensively. In addition to the in-family label, Weick notes, NASA had long thought of the shuttle as being "operational" when it had really never left the experimental phase. "Once you attach that kind of label to it, you seal yourself off from any likelihood that you're going to learn anything."

NASA's perfect-place culture also led to a warped outlook on safety. After the engineers' requests for photos were denied because there was no "requirement" for them, they found themselves "in the unusual position of having to prove that the situation was unsafe," write the CAIB authors, "a reversal of the usual requirement that a situation is safe." This may sound like mere semantics, but it meant NASA exhibited an overconfident, prove-it-wrong attitude rather than one that demanded engineers prove it right.

To help break down such attitudes, Weick suggests a similar semantic reversal. By restating a close call as a near hit, you turn the event on its head. You almost failed, rather than barely succeeded. It's simple, but it can be a great reminder that the system is all too capable of big mistakes. "In general, it just breeds a kind of wariness, a kind of attentiveness," says Weick. "Complacence is what you're worried about."

So does all this mean we don't shoot for the moon? That we dwell on our failures rather than taking pride in our triumphs? Not at all. But there's a fine line to walk between a proud culture and a prideful one, between celebrating a healthy history of success and resting on your laurels. "I call it delusions of a dream company," says Sydney Finkelstein, a professor of management at Dartmouth's Tuck School of Business and the author of Why Smart Executives Fail (Portfolio, 2003). "It creeps up on you. That honest pride starts going toward self-confidence, overconfidence, complacency, and arrogance. It's just a natural progression."

Communication

Dissolving Environments of Separation

At its core, the newsroom of The New York Times traffics in information. Its products are stories, its suppliers are diverse voices, and its mission is to ferret out the truth. So it's hard to miss the irony spelled out by the authors of the report investigating the Blair scandal. "A failure to communicate -- to tell other editors what some people in the newsroom knew -- emerges as the single most consistent cause, after Jayson Blair's own behavior, of this catastrophe." The newsroom of The New York Times, the report's authors write, was "an environment of separation."

Add to this environment the imperious, hard-driving leadership of executive editor Howell Raines, a self-declared "change agent" bent on outdoing other papers, and you have a recipe for communication disaster. Raines's reputation for playing favorites and pushing his ideas of what should be in the paper only worsened the situation. "There was no sense that he was on [the newsroom's] side, that he respected them, that he listened to them," says USC business school professor Warren Bennis. "There's a marvelous Middle Eastern phrase about leaders who've stopped listening. They say, 'He has tired ears.' That's arrogance."

Under Raines's leadership, communication also deteriorated in an increasingly centralized hierarchy. Department heads had traditionally been crucial communication links; they were key to information flow between frontline editors and masthead-level editors, or top management. But as much of their power shifted upward, these key links in the communication chain suffered a loss of authority. With that, surely, went a decline in communication.