Moving Name Tags Around Vs. True Change

25 August 2003

New ways of thinking interest me. Organizations quick to say, ”we’ve already done that or that won’t work,” are particularly interesting. Gut-feel, intuition and instincts are great for some types of work. Other types of work in the same organization require a fresh approach.

Fact-based management is rare. Experience breeds managers who can shoot from the hip with apparent impunity. Yet, when you dig into a business problem with these kinds of managers, you quickly discover just how many flaws reside inside their intuitions.

Tomorrow, NASA will release the report about the Columbia accident. Yesterday’s New York Times ran a good article by John Schwartz about the guy who has led the investigation.

Here’s an eye-catching quote:

As the board members studied the shuttle disaster, he said, they realized that they needed to look beyond failing hardware and simple human error into NASA’s culture, to see if there were elements that all but compelled bad decisions.

There is likely to be a methodology for future accident investigations that can grow from this report. One tell-tale sign is this:

Diane Vaughan, a sociologist at Boston College whose study of the Challenger accident in 1986 helped inspire Admiral Gehman to broaden the board’s approach, said the outcome could be a model for others to follow. ”This report is truly an intellectual breakthrough in terms of accident investigations,” she said.

Dr. Vaughan described a system in which internal pressures and external factors like politics and even budgets came together to produce a misguided decision to launch that shuttle.

As we investigate more and more disasters, from the bombing of the USS Cole to the bombing of the UN Headquarters in Baghdad to the recent power outage, this retired admiral may provide the way:

He got a call last week from the commission investigating the power blackout.

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