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When It All Goes Wrong!
As organizations become ever more complex, there is that much more chance that sooner or later they will break down, and the very people they seek to serve will suffer as a consequence.
It is the human condition that often underlies this potential breakdown. We humans seem to be neurologically predisposed to a number of characteristics that make us, lemming-like, accept, adapt, and carry on regardless, even when a situation rationally dictates otherwise. As Richard Feynman points out in his addition to the report of the Challenger accident, people get used to living and dealing with situations that are known will lead to disaster.
As if to underscore this, as I write these words, my TV flashes the first news reports of the Columbia shuttle breaking apart on re-entry. A multitude of opinions as to what happened and why, as well as where to aportion blame, are begining to materialize. But the fact is - as IO psychologists know from work on neurologically based predispositions and from cognitive science - many disasters are avoidable, if only we are sufficiently aware of the totality of the organizational system's constraints beforehand and do not become complacent as the years go by.
Time will tell, however, exactly what the cause of this terrible tragedy was.
But, when the organizational system breaks down completely, with the behavior of professionals who have responsibility for others being affected, the worst kinds of people are left free to behave as they will, as the Victoria Climbie case so sadly shows. The safeguards were off, with horrific consequences. We can only hope that lessons are learnt.
All the diverse reports and case studies below have in common that the human element within the system failed in some way, with the result that, for example, the organizational system wasn't sufficiently cohesive, managers wouldn't listen, technology wouldn't work apprpriately, bad practices predominated, or, quite simply, people just gave up and didn't care enough anymore...
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Most of the documents are pdf, and a viewer, downloadable from Adobe, is required. |
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To download a document below, right click your mouse over the title link then choose 'save target as...' from the presented menu. |
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Report of the Inquiry into the London Ambulance Service
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| An analysis of the reasons why the UK's LAS computer system, that controlled ambulance dispatch, failed. This report is notable for its assessment of managerial failures.
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| The Victoria Climbie Inquiry (summary report) |
| The damning report of the UK's social services that allowed a little girl, Victoria Climbie, to fall through the net. Besides social services, her situation was known to the police, hospitals, and a variety of 'care' agencies that should have been responsible for her welfare. Yet, she was tortured and killed by her aunt and her aunt's boyfriend.
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The 9/11 Joint Inquiry Staff Report |
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Findings
Recommendations
Additional Views:
1,
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| The initial government report, recently published, examining the failure of the security services to warn of the terrorist attack on the twin towers. While many observers were expecting a document that sought to more stongly address the issues and concerns that allowed this atrocity to happen, this report does, however, highlight many of the organizational failures present that need attention if the USA is going to have a well-run, integrated homeland security .
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Report Extracts of the Presidential Commission on the Space Shuttle Challenger
Accident
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| This report, also known as the Rogers report, highlights the problems believed to be the cause of the Challenger accident. Nobel Laureate Richard Feynman's additional report in Appendix F provides illuminating insights into the predominating culture at NASA at the time, and is seen as a contributing factor to the accident. In light of the recent Columbia disaster this document is worth more than a casual glance in order to consider whether needed organizational change really did occur.
(Download individual chapters from the contents page). |
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