Nate Dimeo hosts a great storytelling podcast called The Memory Palace, where each episode is a short historical vignette. Episode 316: Ten Fingers, Ten Toes is about how people have tried to answer the question: “why are the bodies of some babies drastically different from the bodies of all others?”
The stories in this podcast usually aren’t personal, but this episode is an exception. Dimeo recounts how his great-aunt, Anna, was born without fingers on her left hand. Anna’s mother (Dimeo’s great-grandmother) blamed herself: when pregnant, she had been startled by a salesman knocking on the back door, and had bitten her knuckles. She had attributed the birth defect to her knuckle-biting.
We humans seem to be wired to attribute negative outcomes to behaving insufficiently virtuously. This is particularly apparent in the writing style of many management books. Here are some quotes from a book I’m currently reading.
For years, for example, American manufacturers thought they had to choose between low cost and high quality… They didn’t realize that they could have both goals, if they were willing to wait for one while they focused on the other.
Whenever a company fails, people always point to specific events to explain the “causes” of the failure: product problems, inept managers, loss of key people, unexpectedly aggressive competition, or business downturns. Yet, the deeper systemic causes for unsustained growth go unrecognized.
Why wasn’t that balancing process noticed? First, WonderTech’s financially oriented top management did not pay much attention to their delivery service. They mainly tracked sales, profits, return on investment, and market share. So long as these were healthy, delivery times were the least of their concerns.
Such litanies of “negative visions” are sadly commonplace, even among very successful people. They are the byproduct of a lifetime of fitting in, of coping, of problem solving. As a teenager in one of our programs once said, “We shouldn’t call them ‘grown ups’ we should call them ‘given ups.’Peter Senge, The Fifth Discipline
In this book (The Fifth Discipline), Senge associates the principles he is advocating for (e.g., systems thinking, personal mastery, shared vision) with virtue, and the absence of these principles with vice. The book is filled with morality tales of the poor fates of companies due to insufficiently virtuous executives, to the point where I feel like I’m reading Goofus and Gallant comics.
This type of moralized thinking, where poor outcomes are caused by insufficiently virtuous behavior, is a cancer on our ability to understand incidents. It’s seductive to blame an incident on someone being greedy (an executive) or sloppy (an operator) or incompetent (a software engineer). Just think back to your reactions to incidents like the Equifax Data Breach or the California wildfires.
The temptation to attribute responsibility when bad things happen is overwhelming. You can always find greed, sloppiness, and incompetence if that’s what you’re looking for. We need to fight that urge. When trying to understand how an incident happened, we need to assume that all of the people involved were acting reasonably given the information they had the time. It means the difference between explaining incidents away, and learning from them.
(Oh, and you’ll probably want to check out the Field Guide to Understanding ‘Human Error’ by Sidney Dekker).