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Organisations regularly experience crises, or incidents or "never events". For example, signals passed at danger (SPAD) regularly occur on the railways and swap errors, where the wrong aircraft is repaired by maintenance staff, commonly occur. Although these incidents may provoke an investigation, either internally or by an external agency, that results in a set of recommendations, it is common for the event, or something very similar, to re-occur sometime later.
Why? Is there an explanation for why organisations should apparently fail so regularly to learn from the outcomes of incident investigations?
Our research, based on a series of 10 in-depth case studies in both public and private sector organisations and published by Routledge in Managing Change in Extreme Contexts, provides six possible explanations for this observation.
Blame or "scape-goating" are typical responses to a crisis rather than organisational change. This is encouraged by root cause analysis techniques that tend to focus on the immediate and well-understood causes rather than the wider systemic, contextual and temporal factors.
Investigators who lack credibility or investigations that have disputed outcomes produce this type of negative reaction. This makes necessary change unlikely and increases the probability of re-occurrence.
Implementing a set of recommendations arising from a report is unexciting. Moreover, those individuals tasked with delivery often have their own already established priorities. So those belonging to someone else are unlikely to be accorded top priority. Consequently, the change agenda implicit in the set of recommendations is not a high priority for anyone and successful implementation is not assured.
Those who feel they were not involved in the crisis or made no contribution to the occurrence of the incident do not "own" the crisis. Any changes imposed on them as a result of the recommendations following the investigation may engender resentment, and encourage defensive behaviours.
If recommendations suggest changes that fail to align with personal or professional values, or simply interfere with existing ways of working, then resistance is likely. This may result in the development of a parallel set of practices, so that neither new nor old are implemented effectively. This is especially likely in crises involving several organisations, which each have their own distinct organisational cultures or logics.
Finally, energy and enthusiasm for change can be successfully dissipated by those that suggest that the recommendations are tackling the "wrong" problem and attention is consequently diverted to solving a different issue. This is particularly prevalent where some groups or organisations are implicated and others are not. Reframing helps to divert attention away from the implicated parties and minimise blame.
If you have experience of organisational responses that are different from these suggestions, then please do get in touch. I would love to hear from you.