Is "culture" a real root cause?

Harry Stonecipher,
Boeing 1997-2001, 2003-2005.

Boeing and Toyota have both been in the news recently, and it's not the kind of publicity anyone wants. For Boeing, the news has been about Quality problems in their aircraft—most dramatically, in the 737 MAX-9 flying as Alaska Airlines flight 1282, which blew out a door plug six minutes after takeoff, at a height of nearly 16,000 feet. (Fortunately, no one was seriously injured. I wrote about this accident here and here.) For Toyota, the news has been about faking test data on multiple models over many years. (I wrote about that revelation here.)

How can these things happen? I trust (or hope!) both companies are conducting detailed investigations, to find the causes and ensure they never happen again. But we in the public are unlikely ever to see the results of those investigations. At the same time, there has been extensive discussion and speculation in the press. And for both scandals, one of the likely suspect causes has been "company culture."* In other words, the suggestion is that Boeing and Toyota, respectively, are just the kinds of places that do these kinds of things.

Phrased so vaguely, the accusation looks like an excuse: "Gosh, I dunno. These things just happen." We can be excused for not taking it seriously. And yet, ... and yet, .... We all know there is such a thing as company culture. You can detect it in little things: Do you address your boss by first name, or by last-name-plus-title? How do you dress for the job? How punctually do you arrive in the morning? And so on. These subtleties affect how you act on the job, and what decisions you make. Is it really just an excuse to think they might have an impact on the actions and decisions that lead to an accident, or to fraud? Why can't we consider culture a root cause (possibly among others)?

What is a root cause?

As you recall from our earlier discussions of problem-solving (especially here and here), a root cause has several distinctive features:

• A root cause really is a cause. That is, there is an objective, logical chain of causation which leads from the root cause to the effect.
• A root cause is deep enough to solve the problem permanently. If you correct it, you prevent any further instance of the problem.
• A root cause does not assign personal blame. The point is to improve the system, not to single out one person. If he could do it wrong, maybe the next guy will too.
• A root cause is actionable. It's a waste of time to name a "cause" that you can't do anything about.

How far does culture meet these criteria?

I think the hard ones are the first and the last. With respect to the second criterion, culture is as deep as you are ever likely to get. If anything, it may be too deep. But if you can find a causal chain that implicates it (the first criterion) then I don't think you need to look any farther. As for the third criterion, culture is surely a system-level phenomenon. Individuals might strive to shift a company's culture in one direction or another—Harry Stonecipher famously (and avowedly**) strove to shift the culture of Boeing from one centered on engineering to one centered on profitability—but everyone participates in a culture. The culture influences decisions that its instigator (if there is one) doesn't know anything about. So it is not a matter for personal blame.

This week, let me unpack the first criterion. Is culture really a cause? Then next week I'll discuss what we can do about it.

Is culture really a cause?

Koichi Ito, President Toyota Industries Corp.

We look for causes by using some method like a 5-Why analysis. And an important way to double-check that your 5-Why analysis has not gone off the rails is to read it backwards from the last cause to the first. Can you say, "E, which caused D, which caused C, which caused B, which caused A" and have it make sense? So to ask whether culture is discoverable as a cause is equivalent to asking, Could we ever find ourselves saying, "Our company culture is like so, and therefore the engineer didn't tell his manager that the design was unsafe"?***

Well, maybe. It's important to remember that 5-Whys uncover more than just direct or proximate causes. (These are sometimes called technical root causes.) In addition, it is always fair to ask, What is it about the way our system is set up that allowed this situation to arise in the first place? This is the managerial root cause, and it can be summarized by the whimsical remark that "Everything that goes wrong is the fault of senior management." (See also the extended treatment of this topic in this post here.) 

For example, "The part is crooked, because the machine slid out of alignment, because management didn't implement a preventive maintenance program." 

Or, "The circuit failed, because the engineer designed in the wrong component, because he copied the design from another product without realizing there is a different use case, and no one caught it because the development process doesn't require a Design Review." 

A full causal analysis (sometimes called a 2x2x5-Why) should include such elements, so it is not crazy to think that a reference to the company's culture might turn up.

Even so, notice that the managerial root causes identified in the examples talk about specific programs (preventive maintenance, design review) that should have been implemented but weren't. The presence or absence of such programs contributes to a company's culture, but the actual causation is tied to the concrete program, and not to the culture as a whole.

What about the fictitious*** example that I invented*** a few paragraphs ago: "Our company culture is like so, and therefore the engineer didn't tell his manager that the design was unsafe"? How would that show up in a 5-Why analysis? I imagine the chain of reasoning might look something like this:

Why did the part break?

It was subjected during normal use to strains that it could not withstand.

Why was it built so that it could not withstand the strains of normal use?

It was built to the design.

Why was it designed so that it could not withstand the strains of normal use?

No objections were raised during the Design Review.

Why were no objections raised during the Design Review?

The engineer feared repercussions for causing a schedule slip.

Why did the engineer fear repercussions?

Our company culture ... blah, blah, blah ....

So yes, in a case like that the culture does finally show up in the line of inquiry. But it's not really a single event or action. It comes in as a general explanation for some other concrete action, namely, an engineer not speaking up about a design flaw for fear of repercussions. And if you wanted to prevent recurrence of the problem, you would start with the concrete instances that showed up in your analysis.

I think this means that culture is less a root cause in its own right than it is a summary of multiple other root causes, including some possible causes that might never actually come to light. And that means that corrective action has to be focused more narrowly than just "change the culture." I'll talk about this more next week.     

__________

* See, for example, this article about Boeing or this article about Toyota.

** "'When people say I changed the culture of Boeing, that was the intent, so that it's run like a business rather than a great engineering firm,' Stonecipher once said." From "Boeing's quality-control process and company culture are being heavily scrutinized after the 737 Max Flight 1282 blowout," Business Insider, Jan 13, 2024. https://www.businessinsider.com/boeing-737-max-quality-control-company-culture-merger-finances-2024-1. 

*** To be very clear, I invented this sentence as a fictitious example. I am making no allegations of any kind against any person or persons, company, or other organization.