Prevent Disaster by Righting Cultural Dysfunction on Your Team

The space shuttles Challenger and Columbia were two of NASA's biggest disasters. Investigations into these accidents discovered the engineering issues responsible, but management practices and cultural barriers also were found to be contributing factors. Does your organization have a healthy culture that lets you safely voice concerns? It could help you prevent tragedy.

An anthropologist friend described culture as the unspoken and unwritten rules of how a group of people behave and interact. She observed that culture could be helpful, harmful, or benign.

This is just as true for societies around the world as it is for people put together on an agile team. Understanding the team’s culture and its norms is important for anyone on that team, as well as for anyone who interacts with that team. Some behaviors can have both positive and negative influence in the same organization, depending on context.

Dedication to the mission, for example, can be a positive thing when a team must go the extra mile to accomplish a near-term goal. That same dedication can have negative consequences if it encourages unethical actions or leads to the staff being crushed from trying to achieve impossible goals.

And in extreme cases, unquestionably adhering to cultural patterns can end in tragedy. I’m going to oversimplify and summarize the analyses of the space shuttles Challenger and Columbia—two NASA shuttles that broke apart in flight, both of which resulted in crew deaths—to make some points about organizational culture. 

These shuttle systems were dangerous, experimental, and extremely complicated—after all, it was rocket science. In the case of both accidents, the components responsible had been identified as serious problems before they failed.

So, what happened? What role did culture play in these disasters?

The Challenger and Columbia Disasters

First of all, no disrespect is intended to my heroes at NASA. I encourage you to check out the original, fascinating source material for the Space Shuttle Challenger and Space Shuttle Columbia accident investigations to get the more in-depth stories.

The Challenger report noted communication failures that didn’t provide decision-makers with information necessary to scrub the launch, even though the shuttle was launched in weather thirty degrees colder than any prior launch, and engineers had raised serious concerns that the cold might (and ultimately did) result in catastrophic failure. Furthermore, it found that managers for various elements of the program were more concerned with performance of their element than the overall program, leading to decisions responsive to pressures other than overall flight safety and mission success.

Communication failures, uninformed decisions, managers concerned with the performance of their department more than the overall mission … does this sound familiar? Have you worked on a project like that? The teams were smart and dedicated—no one was evil or foolish—but the consequence of that culture was tragedy. 

In the case of the Space Shuttle Columbia, NASA’s budget was constrained, and pressure to maintain its launch schedules was increasing. Because the shuttle was (incorrectly) determined to be a “mature and reliable system,” headcount for ongoing maintenance, as well as engineering checks and balances, were reduced. Meanwhile, the shuttle infrastructure was aging.

The Columbia Accident Investigation Board (CAIB) report states:

The White House and Congress had put the International Space Station Program, the Space Shuttle Program, and indeed NASA on probation. NASA had to prove it could meet schedules within cost, or risk halting Space Station construction ... The new NASA management viewed the achievement of an on-schedule Node 2 launch as an endorsement of its successful approach to Shuttle and Station Programs. Any suggestions that it would be difficult to meet that launch date were brushed aside. [Emphasis added]

Insulating foam striking and damaging the shuttle had been observed on every space shuttle flight—a clear violation of specifications that was initially treated as a severe problem. Once identified, numerous remedies were tried on successive flights, without solving the problem. Under the pressures of schedule and resources, it is understandable how management might come to interpret engineers’ concerns as overly conservative. 

From the CAIB report:

With each successful landing, it appears that NASA engineers and managers increasingly regarded the foam-shedding as inevitable, and as either unlikely to jeopardize safety or simply an acceptable risk.

Can you identify the cultural barriers to good decision-making? In the context of constrained resources and inflexible schedules, toxic tacit agreements can emerge, and you often hear these phrases:

  • “We need to take more risks.”
  • “We can fix that later.”
  • “Yes, the schedule is impossible, but management doesn’t want to hear it.”
  • “Well, that’s not going to work, but it’s on them, not us.”
  • “I just work here.”

When these cultural patterns become routine, the result can be dangerous—even tragic. Risk-taking isn’t inherently bad, but accepting risks should be a conscious and informed choice made by the appropriate level of management. Deferring functionality might be prudent but may not be considered if managers aren’t taking issues seriously, or if staff members are fed up with their suggestions being brushed aside and have stopped effectively communicating their concerns.

Recognizing Cultural Dysfunction on Your Team

I’ve always been a NASA fanboy, and I’m not dissing an organization that has accomplished amazing things and earned a great deal of respect. Subjected to the same pressures, I’ve made similar mistakes.

Cultural dysfunction can be a natural response to an untenable situation, but it doesn’t have to be an inevitable or irrevocable response. With insight and effort, you can make more constructive choices, but first you must be aware of your organization’s culture and norms. Culture is all around us. The challenge is learning to see it.

What cultural rules are at play in your organization or on your agile team?

  • Is discussion of risks welcome, or is the subject taboo? When risks are identified, are they captured, managed, and shared with executives?
  • What are the expectations for staff? Are they expected to do whatever it takes to hit schedule or scope targets? The occasional need for and willingness to go the extra mile for a project is generally a positive attribute, but if it becomes a routine expectation that team members work overtime in order to compensate for efforts that are not appropriately funded or staffed, the organization is likely avoiding a hard conversation about the project parameters of schedule, scope, and resources.
  • Do all the entities participating on a project share the same priority for it? If not, the management communication problems this suggests will be realized in schedule slippage and conflict.
  • What contributions does your organization reward—thoughtful anticipation of problems, or heroics to address problems once they materialize? If people are rewarded for extinguishing fires rather than preventing them, you are likely to experience an increase in preventable fires.
  • Is collaboration safe and encouraged in your organization? When something goes wrong, is the first problem-solving step about gathering information to address the problem and prevent a recurrence, or is the priority figuring out who is responsible and who is to blame? Are team members encouraged to help one another, or are they evaluated on their individual productivity without credit for time spent mentoring and problem solving with their peers?
  • Is clear and forthright communication valued, or are people punished for delivering bad news and having a “negative attitude”?

It’s important to regularly take stock of your culture, as it’s not uncommon for the norms to gradually change. Organizations with healthy cultures (NASA usually being a good example) may find that their culture has become negatively influenced by contextual factors. When you notice cultural shifts, it’s useful to ask, “Why does this appear to be changing?” and “Is this change a conscious choice?”

What contextual forces might be influencing your organization? What cultural responses do you see? Are the responses serving the organization? What different choices or behaviors might be more effective? How might you elevate those behaviors to conscious decisions and socialize them to change the culture?

An organization’s culture is complicated and ever present, but it’s not always obvious. There are no easy answers. Managing and nurturing an effective culture can be as daunting as any engineering or management challenge—and as important to success.

The first necessary step is learning to be aware of your organization’s culture. Transparency, visibility, and communication are integral to collaboration on an agile team, and promoting these priorities can help build a culture that makes it safe for people to ask questions, take appropriate risks, and voice concerns.

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