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Systems Failure & Speak Up Culture

A good reminder that I married the right person is that he agrees to go to a talk about catastrophic failure in complex systems for date night. This week, Anthony and I heard Andras Tilcsik and Chris Clearfield give an overview of their new book: ‘Meltdown: When Our Systems Fail and What We Can Do About It’.

It’s a fascinating look at how many of the systems we encounter in our day to day lives are becoming increasingly complex and tightly coupled, making them more vulnerable to surprising meltdowns.

Examples like Three Mile Island and Deep Horizon are mixed with a Starbucks social media campaign fail, and the annual family Thanksgiving dinner.

For me, there are obvious parallels to the allegations of workplace sexual harassment and organizational cover-ups in the media recently. We can see the failure of policies, processes, and people that seem to have led to pervasive abuse by Harvey Weinstein and the subsequent collapse of Miramax, for example.

Tilcsik and Clearfield’s research suggests that one solution to safeguard against failure is increasing transparency in the system, through both design and learning. Of particular interest to me was the notion that listening to “voices of concern” serves as an early warning system of sorts for organizations.

In their talk and their book, Tilcsik and Clearfield point to the airline industry as an example of institutionalizing this approach. Since a series of bad accidents in the 1970’s, the airline industry had looked inwards to examine contributing factors.

“In 1994 the NTSB published a study of accidents due to flight crew mistakes between 1978 and 1990. The study reported a staggering finding. Nearly three-quarters of major accidents occurred during the captain’s turn to fly…when the captain was the flying pilot [rather than the first officer], he was harder to challenge. His mistakes went unchecked. In fact, the report found that the most common error during major accidents was the failure of first officers to question the captain’s poor decisions.

The industry introduced Crew Resource Management: essentially a mandatory process and training program, complete with detailed step by step scripts that could be read verbatim, that sought to make speaking up an everyday practice. They taught people how to speak up, and made it part of their job, and it had a profound effect on safety outcomes.

“as the researchers put it, speaking up allows crew members to “create a kind of artifact – a statement that now hangs in the air between group members and must be acknowledged or denied, but in any case, responded to”

What would this look like when it comes to harassment and abuse in organizations?

Some organizations are already implementing bystander training, to better equip employees to challenge inappropriate actions or poorly chosen words in the moment. Practicing what to say and do can be a helpful tool for targets of harassment or observers, as research shows that a very common response to harassment is to freeze, despite our best intentions.

Copying Practices Not Enough

 But wait. It isn’t simply a matter of copying the practices of another industry or organization and calling it a day. If we look past the Crew Resource Management program, it’s clear that the airline industry has a completely different mindset towards failure than HR (and most organizations) do.

They eagerly sought information about what was going wrong in their system, before it led to more accidents. They were willing to examine how actors in their system might be, purposefully or not, contributing to the negative outcomes they wished to avoid. They weren’t satisfied to measure their effectiveness with the “lagging indicators” of accidents (as Tilcsik put it).

Is the same true for workplace sexual harassment? Clearly not.

If we measure the commitment of corporate leaders (including HR) to eradicate sexual harassment by their actions rather than their proclaimed intentions, it’s clear that the vast majority of companies are more interested in avoiding liability. Sexual harassment remains pervasive and significantly under-reported.

Those in power at organizations often claim to be surprised when a meltdown occurs (such a Susan Fowler’s blog post or the NYT story on Weinstein), but such implosions seem to have been preceded by signals of impending calamity that were ignored or actively repressed as the work of ‘trouble makers’ or people “who didn’t fit with the culture”.  This despite the maddening refrain after each new revelation: “It was an open secret”, “There were rumours”.

It’s hard to believe that this is anything other than what Margaret Heffernan calls “willful blindness“.

Speak Up Culture

To get ahead of that kind of system failure, we would need to shift our mindsets about the value of these “voices of concern”, learn to listen for them as the valuable clues about system health that they are, and reward those who speak up about minor issues.

That’s simply not where the vast majority of organizations are.

How many organizations do proactive ‘climate surveys’ where they ask employees to indicate whether they’ve observed or experienced harassment? Not many.

How many organizations are actively cultivating what calls “Speak up culture”. Too few.

And yet, a culture in which problematic comments and action are addressed as a matter of course in day-to-day work is far less likely to be a breeding ground for more serious harassment and abuse. In part because seeing small issues addressed means that employees feel assured more egregious misconduct will be taken seriously, and are therefore more likely to come forward. And because the ‘leading indicators’ of how a system is doing become more visible to leaders and to HR.


 Too often in discussions like these within the HR profession there is a suggestion, stated or implied, that false reporting is a major problem.

Of course it is a concern.  But that is not the same thing as it being a problem that actually exists with any regularity (particularly compared to the regularity with which harassment occurs). To my knowledge, there is no data that suggests that false reporting is a significant problem for organizations. The data which exists about false reporting is about sexual assault (and not limited to the workplace). It suggests that it is similar to rates of false reports for any other crimes (about 4-6%).

Again, it is rightly a concern, and one that we would expect to address in our workplaces through a robust investigation process. It is absolutely not a reason to discourage people from speaking up.

As Tilcsik and Clearfield write (emphasis mine):

“is there such a thing as too much speaking up?” A few might come from disgruntled employees inclined to complain for complaining’s sake. “When you encourage people to speak up, you can’t expect that they’ll only bring good ideas to you” says Detert. “But you need to weigh the costs of wasting time on some useless ideas against the cost of missing something very important. You need to decide what matters more.” 

For resources and more information:

EthicalSystems.orgSpeak Up Culture

BetterBrave –  Guide for Allies

I’ll be speaking about this very topic at DisruptHR Kitchener/Waterloo on Tuesday. If you’re there, please come say hi!

Read This Week:

 Why HR professionals are losing their humanity – Roger Steare, HR Magazine

Well, this is awkward…

“As this graph demonstrates, in their personal lives people in HR prefer to consider good outcomes for others (love) over compliance with rules (law) or thinking about their principles (logic). But at work they become more like compliant robots who suppress their humanity and empathy for others.”

The one crucial element of a healthy workplace that every company, in every industry, can provide – Jeffrey Pfeffer

A good follow-up to the previous article, for us complaint robots:

“Research going back decades consistently shows that job autonomy—the amount of discretion you have to determine what you do and how you do it—is one of the most important predictors of job satisfaction and work motivation, frequently ranking as more important even than pay. Job autonomy also positively affects job performance, in part by increasing mo­tivation and partly by permitting people to use all of their capacities and information to do the work in the best way possible”

A bias too far – Koen Smets

A cautionary reminder that the popular interest in behavioural economics and science has led to some problematic oversimplifications for a broader audience, and the sense among “consumers” of popular research that they are equipped to use it effectively.

“ It is true that, in order to understand a topic well, having a vocabulary that describes it is essential. Dilip Soman, a behavioural economist at Toronto University, explains how this works for categories like wine, classical music and quilting: if we have terms to describe what we see, we can make sense of a complex subject. But a list of terms is not enough. You will not become a proficient speaker of a foreign language just by memorizing the definitions of a list of words, and you will not become a behaviour expert by being able to recite a list of biases.”

Photo by Lui Peng on Unsplash

5 Comments Post a comment
  1. While I generally agree with the points in this article – it ‘feels right’ , the comment “In part because seeing small issues addressed means that employees feel assured more egregious misconduct will be taken seriously, and are therefore more likely to come forward.” is one where we need some evidence to support it. It reminds me of the idea that “broken windows policing” will reduce serious crime – a concept that is highly debatable (

    March 27, 2018

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