The Crash Everyone Saw Coming

One of the things that has always fascinated me about large organisations is that they often contain far more information than they appear to use.

When a major project fails, the post-mortem frequently uncovers facts that seem obvious in hindsight. Risks had already been identified. Warning signs had been discussed. In some cases, the problem had even been documented months earlier. Yet somehow the organisation continued moving in the same direction until the issue became impossible to ignore.

I've witnessed variations of this pattern more than once throughout my career and, for a long time, I accepted the explanation that is usually offered in these situations: culture.

The organisation had a poor escalation culture. People were reluctant to speak up. Managers avoided difficult conversations. Bad news travelled slowly.

There is certainly some truth in that explanation. But over time I began to wonder whether culture was the cause or merely the visible symptom of something deeper.

After all, the people involved were rarely incompetent. In most cases they were experienced professionals who had successfully managed other projects before and would continue to do so afterwards. In fact, some of the best decision-makers I have worked with possess an almost instinctive ability to recognise situations that are likely to require escalation long before escalation becomes necessary. They identify weak signals, challenge assumptions and act pre-emptively to prevent small problems from becoming large ones.

The mystery was not why people failed to recognise the problem. The mystery was why they behaved as if recognising it was not enough.

That distinction matters because it changes the question entirely.

Instead of asking why people did not escalate, we can ask why escalation was apparently not the most attractive option available to them.

Most organisations genuinely want people to escalate risks. In fact, if asked directly, few executives would argue otherwise. Early visibility creates options. Late visibility removes them. The logic is straightforward.

Yet organisations rarely operate according to a single objective.

The same manager who is expected to raise concerns early may also be expected to maintain client confidence, protect team morale, deliver on schedule, remain within budget and demonstrate control of the situation. Most of the time these objectives coexist peacefully. Occasionally they collide.

When that happens, escalation ceases to be a purely operational decision. It becomes a trade-off.

A risk raised too early may be perceived as alarmist. A risk raised too late may be perceived as negligent. Between those two extremes lies a large grey area where judgement, experience and self-preservation all play a role.

In my experience, the most effective leaders rarely respond to these situations by simply hoping for the best. When they are forced to follow a path they do not fully believe in, they tend to do one of two things. They either create the conditions to mitigate the risk while ensuring accountability is shared appropriately across stakeholders, or they refuse to continue down a path they genuinely believe is unlikely to succeed. What they rarely do is continue quietly while hoping reality will eventually cooperate.

Viewed from that perspective, many post-mortems begin to look slightly different.

The interesting question is no longer why individuals failed to act. The more interesting question is whether the organisation had created an environment in which acting differently was genuinely attractive.

After all, incentives are rarely as explicit as management literature suggests. Very few organisations reward people for concealing problems. Equally few openly penalise people for speaking up. The signals are usually more subtle than that.

They reside in who gets promoted, who gets trusted, who receives additional responsibility and how difficult conversations are handled when they arise.

Few people need to be told explicitly how an organisation works. Most figure it out by observing what happens to those who bring good news, bad news and inconvenient news.

This is also why I have become somewhat cynical about culture as an explanation. Culture only matters if it survives contact with incentives. Most organisations are perfectly capable of describing the behaviours they want. The real test is whether those behaviours remain attractive when projects become difficult, commercial pressure increases or uncomfortable trade-offs emerge.

"Walk the talk" is one of the most overused expressions in business, but it captures something important: people pay far more attention to what organisations reward than to what organisations declare.

I was once part of an organisation whose motto was "We Always Deliver." It was intended to communicate commitment, accountability and customer focus. In many respects it did. Clients appreciated it. Employees took pride in it.

Yet I often wondered about its unintended consequences.

Every slogan creates incentives, whether intentionally or not. The difficulty with "We Always Deliver" is that it subtly shifts the discussion from whether a commitment should be made to how it will be honoured. In most situations that distinction is irrelevant. In difficult situations it becomes critical.

An organisation that defines success exclusively through delivery may inadvertently discourage the conversations that prevent failure in the first place. Escalating a concern, challenging an assumption or recommending that a project be paused can begin to feel inconsistent with the identity the organisation has created for itself.

The slogan remains the same. The incentives change.

This is one of the reasons I have become increasingly sceptical of explanations that place the entire burden on individuals. In many organisations, behaviour that appears irrational from the outside is often a perfectly rational response to the environment people find themselves operating in. If the signals, rewards and expectations point in one direction while the official values point in another, it should not surprise us when people follow the former.

That does not mean culture is irrelevant. Far from it. But it does suggest that culture may sometimes be the consequence rather than the cause.

When a particular behaviour appears repeatedly across projects, teams or business units, it is worth asking whether the organisation is observing a people problem or a system problem.

The answer is not always obvious. Some people escalate issues despite personal cost. Others avoid difficult conversations even in environments that encourage them. Yet, at scale, patterns usually tell us something important. If intelligent and well-intentioned people consistently behave in similar ways, the explanation is unlikely to be found solely in their personalities.

Looking back, the project itself is no longer particularly memorable. What stayed with me was a different realisation. The organisation already possessed most of the information it needed to avoid the outcome that eventually occurred. Many of the warning signs that seemed obvious in hindsight had, in fact, been visible long before hindsight became available.

That observation changed the way I think about organisational failures. The challenge is often not discovering problems but creating an environment in which recognising a problem is enough to trigger action. In many cases the information already exists; what is missing is the ability, willingness or confidence to act upon it.

Which, perhaps, brings us back to the original question. If the first person to recognise a serious issue would hesitate before raising it, the explanation is unlikely to be found solely in the individual. More often than not, it tells us something about the system in which that individual is operating.

The answer would probably reveal more about the organisation than any culture survey, because culture is ultimately observed in behaviour, not declared in values.