Let's continue this seemingly never-ending series by examining culture change in two domains near to my heart:
Space Shuttle Challenger (1986)
As soon as the button was pressed to mute NASA from our meeting,
the managers said "we have to make a management decision", said Boisjoly.
The general manager of Thiokol turned to his three senior managers and asked what they wanted to do.
Two agreed to go to a launch decision, one refused.
So he (the general manager) turns to him and said "take off your engineering hat and put on your management hat" --
and thatís exactly what happened, said Boisjoly.
He changed his hat and changed his vote, just thirty minutes after he was the one to give the recommendation not to launch.
I didnít agree with one single statement made on the recommendations given by the managers.
The teleconference resumed and NASA heard that Thiokol had changed their mind and gave a recommendation to launch.
NASA did not ask why.
I went home, opened the door and didnít say a word to my wife, added Boisjoly.
She asked me what was wrong and I told her
"oh nothing hunny, it was a great day, we just had a meeting to go launch tomorrow
and kill the astronauts, but outside of that it was a great day".
-- from Remembering the mistakes of Challenger
For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.
-- Richard Feynman (in Rogers Commission Report on the Challenger disaster)
Space Shuttle Columbia (2003)
Although changes were made by NASA after the Challenger accident, many commentators have argued that the changes in its management structure
and organizational culture were neither deep nor long-lasting.
After the Space Shuttle Columbia disaster 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 decided 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.
-- from Space Shuttle Challenger disaster (wikipedia)
Incredibly, NASA, with so many talented people,
had somehow (twice!) failed to remedy a glaring Conflict of interest
organizational structure/culture problem.
It seems they failed to find a way to ensure that the technical team making launch safety decisions were
allowed to do so without pressure or coercion from outside interests.
(Which BTW reminds me of the poor old Release Manager in commercial software companies
being relentlessly pressured by senior management to ship the next release ... less common perhaps in the open source world,
though release management remains stressful).
Perhaps the root cause of NASA's Space Shuttle woes was an unhealthy mix of commercial/financial and engineering/scientific culture.
Certainly, NASA have achieved many breathtakingly brilliant successes in the purely engineering/scientific domain,
such as the venerable Hubble Space Telescope
and the recent stunning New Horizons mission
to Pluto and beyond.
It will be interesting to see in the coming decade if
or Jeff Bezos
or Sir Richard Branson
can create a more effective culture for commercial space flight.
Social psychologist and former IBM researcher Geert Hofstede identified
five dimensions of culture in his studies of national work related values:
- Power Distance. How accepting are people of unequal power distribution?
- Individualism. Is individual achievement or collective achievement emphasized?
- Masculinity. How much does the culture accept gender roles?
- Uncertainty Avoidance. How anxious are folks about uncertainty and risk?
- Long-term Orientation. Do people take a long-term view of their work?
Hofstede found that these five dimensions varied considerably
between countries. The United States, for example, rated highest on Individualism,
while Russia and India rated highest on Power Distance.
Japan scored the highest on the Masculinity index.
Russia and Japan have high Uncertainty Avoidance, while Denmark has a low score.
Japan, South Korea and India have a much stronger Long-term Orientation
than Canada, the UK and the USA.
How this affects software teams was discussed previously at Nobody Expects the Agile Imposition (Part IV): Teamwork.
The captain made the decision to land despite the junior officer's disagreements, eventually bringing the plane down short of the runway,
highlighting how a pilot can contribute to a disaster.
In high power distance cultures, it is uncommon for subordinates to question their superiors.
High power distance can be seen as the willingness to be in an unequal position,
making it a challenge for an officer lower in the hierarchy to question the decisions of the one in power.
-- Impact of culture on aviation safety (wikipedia)
Korean Air had many fatal accidents between 1970 and 1999, during which time it wrote off 16 aircraft in serious incidents and accidents
with the loss of 700 lives. The last fatal accident, Korean Air Cargo Flight 8509 in December 1999 led to a review of how Korean cultural
attitudes had contributed to its poor crash history. Since then safety has improved.
-- Korean Air incidents and accidents (wikipedia)
In the cases of Korean Air flight 801 and Air Florida flight 90 one clear statement could have saved more than 300 lives.
In each case, a series of leadership errors led to the deaths of hundreds of passengers.
Cultural and contextual factors contributed to the leaders unknowingly creating unsafe conditions.
A lack of cultural awareness and understanding of the environment was a culprit in both case studies, along with dozens of other airplane crashes.
These two case studies serve as warnings for all leaders on the importance of including cultural dimensions in their leader(ship)
development programs as well as adapting programs to the specific environmental factors.
By taking a lesson from the aviation industry, other organizations can prevent similar mistakes,
create better leaders and leader(ship) development programs, and possibly save lives.
As a result of this and other accidents, Korean Airís new CEO set about an ambitious organizational change.
He made English the official language of the airline, redefined roles in the cockpit, and provided extensive communications training,
among other initiatives to change the culture (Wee, 2013).
Other airlines also made changes in response to the reoccurring communication challenges.
One notable change made by many airlines was to adopt a program known as cockpit resource management (CRM).
CRM requires the entire crew to work together and communicate (DíAmato, 2013).
Training programs provide specific skills and procedures to maximize communication and effectiveness.
CRM has proven to be very effective in reducing airplane crashes due to communication, regardless of cultural backgrounds.
-- Copilot leadership (medium.com)
It is gratifying (at long last!) to find a convincing example of where changing Organizational Culture actually worked!
Other Articles in This Series