Obstacles to Finding the Reasons Why
by Rick Brenner
When we investigate what went wrong, we sometimes encounter obstacles. Interviewing witnesses and participants doesn't always uncover the reasons why. What are these obstacles?
Cunard's R.M.S. Lusitania coming into port, possibly in New York. The passenger liner was sunk by a German U-Boat early in World War I, on May 7, 1915. At the time, she was carrying 1,959 passengers and crew, 1,198 of whom were killed. She sank within 18 minutes of being struck. Her sinking was viewed by many as what we now call a war crime, and it led to the entry of the United States into the war.
During the investigation that followed, investigators encountered many of the obstacles to truth-finding that are listed here. The question of the number of torpedoes provides an example of fabrication. One torpedo was deployed, but since two torpedoes would deflect responsibility for loss of life away from Cunard and the ship designers, witnesses were pressured to report two torpedoes. An example of concealment was the withholding of information about the ammunition cargo that the ship carried. Explosive cargo might have been identified as a reason for the rapid sinking. Photo from the George Grantham Bain Collection (U.S. Library of Congress).
Following unwanted outcomes, we often commission "lessons learned" exercises to investigate the conditions that brought about the unwanted outcomes. We want to learn how to prevent recurrences of those outcomes or any other unwanted outcomes that might flow from similar conditions. In too many organizations, these exercises yield useless or misleading results.
What we seek is Truth: the reasons why the unwanted outcome occurred. But these investigations rely on reports from people who participated in or witnessed events leading to the outcome. To find the truth we must interpret the reports we receive, and those reports can contain a variety of misleading elements. Here's a short catalog of those elements.
- Confusions and mistakes
- Relying on memory and impressions, witnesses and participants sometimes get it wrong. They get confused about the order of events, or who did what. They confuse what they actually witnessed with what they heard about second-hand.
- An excuse is a fact, condition, or situation that provides protection for someone from blame for the unwanted outcome. Excuses are those offerings that, if true, most people would accept as relieving someone of being regarded as having caused or contributed to causing the unwanted outcome.
- An allegation is the opposite of an excuse — it's a fact, condition, or situation that, if true, affixes to someone blame for the unwanted outcome. While excuses tend to be offered by the person excused, allegations tend to be offered by someone other than the one blamed.
- Reports that omit relevant information can also mislead investigators. Omissions can be intentional, but they need not be. They can result from numerous factors including faulty memory, emotional trauma, and poor technique by the investigator.
- Concealment To find the truth we must
interpret reports that can
contain a variety of
misleading elementstranscends intentional omission. It includes deliberate actions to deflect the investigator from the information concealed, such as destruction or obfuscation of information, or propagating false accounts of events. It can also include actions that make the information difficult to retrieve. For example, important witnesses might be relocated, terminated, or transferred.
- Fabrications are fictions intended to mislead the investigator. When well crafted and when delivered by someone who is unaware that they are fabrications, they are difficult to detect, because the deliverer isn't actually lying. Detecting them often requires tracing them to their source.
In determining who acted (or did not act) so as to contribute to the genesis of the unwanted outcome, there's a high risk that some witnesses and participants might experience the investigation as a search for someone to blame. The investigators themselves might adopt this belief.
In organizational cultures that tend to affix blame, investigations are unlikely to uncover much Truth, because people fear blame. Over time, people who don't master these tools for misleading investigations tend to be discredited, ejected from the organization, or allocated to less central roles. Organizations that want to improve outcomes would do well to eliminate blame from their cultures. Top Next Issue
For indicators that an organizational culture is a blaming culture, see "Top Ten Signs of a Blaming Culture," Point Lookout for February 16, 2005. The words blame and accountability are often used interchangeably, but they have very different meanings. See "Is It Blame or Is It Accountability?," Point Lookout for December 21, 2005, for a discussion of blame and accountability. For more on blaming and blaming organizations, see "Organizational Coping Patterns" and "Plenty of Blame to Go Around," Point Lookout for August 27, 2003.
Are you fed up with tense, explosive meetings? Are you or a colleague the target of a bully? Destructive conflict can ruin organizations. But if we believe that all conflict is destructive, and that we can somehow eliminate conflict, or that conflict is an enemy of productivity, then we're in conflict with Conflict itself. Read 101 Tips for Managing Conflict to learn how to make peace with conflict and make it an organizational asset. Order Now!
Your comments are welcome
Would you like to see your comments posted here? Send me your comments by email
, or by Web form
About Point Lookout
Thank you for reading this article. I hope you enjoyed it and found it useful,
and that you'll consider recommending it to a friend
Point Lookout is a free weekly email newsletter. Browse the archive
of past issues. Subscribe for free.
Support Point Lookout by joining the Friends of Point Lookout,
as an individual or as an organization.
Do you face a complex interpersonal situation? Send it in,
anonymously if you like, and I'll give you my two cents.
More articles on Organizational Change
- Conventional Foolishness
- Every specialization has a set of beliefs, often called "conventional wisdom." When these beliefs are so obvious that they're unquestioned and even unnoticed, there's an opportunity to leap ahead of the pack — by questioning the conventional wisdom.
- Outsourcing Each Other's Kids
- Outsourcing is now so widespread that it has achieved status as a full-fledged management fad. But many outsourcing decisions lack the justification that a full financial model provides. Here are some of the factors that such a model should include.
- When Fear Takes Hold
- Leading an organization through a rough patch, we sometimes devise solutions that are elegant, but counterintuitive or difficult to explain. Even when they would almost certainly work, a simpler fix might be more effective.
- Letting Go of the Status Quo: the Debate
- Before we can change, we must want to change, or at least accept that we must change. And somewhere in there, we must let go of some part of what is now in place — the status quo. In organizations, the decision to let go involves debate.
- Good Change, Bad Change: Part I
- Change is all around. Some changes are welcome and some not, but when we distinguish good change from bad, we often get it wrong. Why?
See also Organizational Change and Workplace Politics for more related articles.
I offer email and telephone coaching at both corporate and individual rates.
Contact me for details at rbrenner@ChacoCanyon.com
or (617) 491-6289, or toll-free in the continental US at (866) 378-5470.
Get the ebook!
Past issues of Point Lookout
are available in six ebooks:
Reprinting this article
Are you a writer, editor or publisher on deadline?
Are you looking for an article that will get people talking and get compliments flying your way? You can have 500 words in your inbox in one hour. License any article from this Web site. More info
- The Race to the South Pole: Ten Lessons for Project Managers
- On 14 December 1911, four men led by Roald Amundsen reached the South Pole. Thirty-five days later, Robert F. Scott and four others followed. Amundsen had won the race to the pole. Amundsen's party returned to base on 26 January 1912. Scott's party perished. As historical drama, why this happened is interesting enough, but to project managers, the story is fascinating. Lessons abound. Read more about this program. Here's an upcoming date for this program:
- The Race to the South Pole: The Power of Agile Development
- On 14 December 1911, four men led by Roald Amundsen reached the South Pole. Thirty-five days later, Robert F. Scott and four others followed. Amundsen had won the race to the pole. Amundsen's party returned to base on 26 January 1912. Scott's party perished. As historical drama, why this happened is interesting enough. Lessons abound. Among the more important lessons are those that demonstrate the power of the agile approach to project management and product development. Read more about this program. Here's an upcoming date for this program: