Is it the system or is it the people? When we experience a problem, the traditional mindset of management tends to blame the individual rather than identifying a system of elements as the real root cause, says Bill Bellows, Associate Fellow at Aerojet Rocketdyne in California.

The prevailing style of management must undergo transformation. A system cannot understand itself. The transformation requires a view from outside. The aim of this chapter is to provide an outside view – a lens – that I call a system of profound knowledge. The system of profound knowledge provides a lens. It provides a map of theory by which to understand the organizations that we work in.  

 W. Edwards Deming, The New Economics, page 92

Beginning in the late 1980s, Dr W. Edwards Deming used the term “the prevailing style of management” to describe the administration style of organisations that are characterised by directives that foster, if not promote, sub-optimisation, wherein what’s good for the organisation is subverted by what’s good for the elements of the system.

One persistent symptom of this management style is “reductionism”, as practiced by reducing cycle time, waste, non-value added efforts, variation, part counts, and costs, all with the assumption of savings for each “separate” action and the ability to tally these savings using addition. Missing is the realisation that savings only add when the accumulated efforts are independent of each other. Sub-optimisation results when the local savings trigger unintended consequences, including losses that surpass the anticipated savings.

Additional symptoms of these organisations are the apparent existence of a “most important part” (as opposed to a strong sense of the purpose and relatedness of all parts), and a prevalence of blame placed on individuals (rather than the greater system in which they operate). The management actions (and thinking) that unknowingly sustain such non-systemic behaviors are driven by an unrecognised and, therefore, un-stated, set of beliefs and assumptions that are the focus of this article. Another tell-tale sign of these beliefs are management practices that focus on parts and ignore, if not underestimate, relationships and interdependencies. A favorite mental picture of the prevailing style of management is a view of the completed individual elements, seemingly independent and floating in close formation, never connected to each other.

Instead of a focus on the relationships between the elements of the many sub-systems within an organisation, the prevailing style of management divides wholes into manageable parts and tasks and then assigns measureable completion requirements to these elements. The essential feedback mechanisms within this task-focused environment are measures of percent completion for all requirements, including being on time, on budget, and, ideally, defect-free, always and everywhere.

Within moments and, well before the ink dries, silos are created as task owner’s focus with a palpable sense of accountability on their own responsibilities. “One for all” and “all for one” interdependencies are overlooked as the essential systems conversations, including “How well do the elements integrate?” or “How well did my element perform?” are replaced by a laser-focused accounting on the “goodness” of each element. Team work equates to “my task was completed,” “my team is me,” and the remarkable discovery of the letter “i” in team.

Dr Deming emerged as a high profile management consultant in the summer of 1980, after his television appearance in the NBC “White Paper”, If Japan Can, Why Can’t We?   While the US economy struggled with double-digit interest rates, the Japanese economy was thriving, with significant credit given to Dr Deming in this documentary, for contributions that began with his visit in 1950, or, perhaps earlier, with his visit in 1946.

While acknowledging a contribution to Japan’s economic progress since the end of World War Two, Dr Deming explained to Priscilla Petty, a business journalist, in her 1990 video, The Deming of America, that he “felt unworthy… it was merely a matter of luck.”

In doing so, Dr Deming also acknowledged he was part of a system of causes of Japan’s success, consistent with the viewpoint that “it takes a village to raise a child.” Much the same as many straws are needed to break a camel’s back. Then again, in the prevailing style of management, we are most likely to see the last straw as the root cause of failure.

And, so it goes, when we relentlessly focus our attention on one of many causes as the singular cause and miss the system. This is an easy recipe for blaming an individual within a system (be it the pilot after an airplane crash, the conductor after a train crash, or the captain after a ship sinks) rather than a greater open system of causes. Dr Deming proposed an appreciation of his System of Profound KnowledgeTM as a means to shift our narrow viewpoints from the last straw to boundary-less systems of contributions.

While the Arabic proverb speaks of the straw that broke the camel’s back, Wikipedia reports variations on this causality chain theme, including the straw that broke the donkey’s back, the melon that broke the monkey’s back, and the feather that broke the camel’s back. Such “if not for this… one element” views of blame extend to nursery rhymes that remind us that “for the want of a nail…the kingdom was lost.” In doing so, one may be led to believe that the last straw not only acted alone, but plotted alone, planned alone, trained alone, and succeeded alone, without accomplices. Surely, hero status in the making, ready to be honored by a Frank Sinatra recording for doing it “my way.”

In an education system where grades are earned by students, who speak of “my GPA” (grade point average), might they leave school ready to think and act alone, into organisations where they may well encounter pursuits of a root cause, unaware it may get personal one day if they are perceived as the last straw.

When once asked to describe the prevailing style of management to a new acquaintance, I replied with the question, “What would it be like to work in an organisation where everyone firmly believed that the last straw broke the camel’s back?” After a few moments of thought came his reply, “I wouldn’t want to work there.”    When asked why, he replied, “If something happened and I was viewed as the last straw, they would all blame me.” As to “What else?,” he replied, “the other straws would watch, thinking they had nothing to do with the incident.” On a repeated series of “What else’s?,” came the following replies;

  • “There would be a culture of blame.”
  • “Because of the blame, there would be separation.”
  • “Because of the separation, there wouldn’t be sharing of resources.”
  • “Because of the lack of sharing, there would be duplication of efforts.”
  • “Because of the blame, there would be attempts to hide failures.”
  • “Because of the hiding of failures, lessons wouldn’t be learned elsewhere.”
  • “Because of the lack of lessons learned, there would be duplications of failures.”

After three-four minutes of “What else?” inquiries, he replied, “That’s my company!” to which I explained it as the unfortunate series of symptoms of the belief in “the last straw.” I’ve also explained it as “The Lament of the Last Straw.”

What allows us to focus on the last straw and miss the others? If we grew wise to the damaging consequences of this mistaken belief of separation of the straws, coupled with our inability to perceive the gradual weakening of the camel by each added straw, each a cause, would the ensuing activities of blame, duplication of efforts, and lessons unlearned, all disappear? Perhaps, but far easier said than done when we are surrounded by failures on a worldwide basis that routinely include a failure investigation, often leading to a root cause. But, there are glimmers of hope.

On October 12, 1999, a terrorist attack on the USS Cole in Yemen, later credited to Osama bin Laden, resulted in the death of 17 sailors. After a lengthy Pentagon investigation to determine causality, documented in a 1,600-page final report, the USS Cole’s captain, Kirk Lippold, was found to be amongst the causes of the bombing, along with the suicide bombers, and, according to a New York Times’ article, “many shortcomings in training, intelligence, equipment and security support” in the Yemeni port of Aden.

In referencing the report during a press conference, Secretary of Defense William Cohen acknowledged the role of “collective blame.” In the spirit of seeing a system of causes, he added, ”I think that we have pointed out that we didn’t do all that needed to be done.” His “we” included “the chain of command, all the way from the central commander, right up through to the secretary of the Navy, the chairman of the Joint Chiefs and myself.”

Within hours after this press conference, several members of the US Senate, who remained unconvinced of the systemic nature of many causes of this incident, spoke of the need (in the spirit of the “prevailing style of management”) to seek the root cause of the bombing and the subsequent damage to the USS Cole. Without surprise, they were determined to isolate the ship’s captain, Lippold, as the solo cause of the ship’s damage. The tale of retired Captain Lippold does not end here, as the world remains divided on his primary or contributing, systemic, role in the protection of the USS Cole.

Ten years ago, on August 14th, 2003, moments before 4:10pm eastern time in the US, 10 million people in Ontario, Canada and 45 million people across eight US states suffered from the power outage known as the “Northeast blackout of 2003.” In the days that followed, President Bush stated that the investigation would be exhaustive and that “names will be named.” Consider the potential size of this list. In addition to the

obvious names of the power companies in New York, Ohio, and Canada, as well as the owners of the electric grid, will the list expand to include the elected officials who passed the legislation that governs the operation of these companies, or to the voters who elected these officials? What about those who enjoy the pleasure of air conditioning on hot and humid days? Did they contribute? Did weather contribute?

For anyone who has visited a doctor’s office, the use of a sphygmomanometer to measure blood pressure is routine. As routine as a nurse’s effort to measure heart rate by timing the pulse rate in your wrist. In both cases, data is being collected in your arm. But, is the data a measure of the performance of your arm, or a measure of a larger system that includes your arm?

Treating the pulse data as a measure of your wrist would be as anti-systemic as concluding that “the last straw broke the camel’s back.” As much as we might like to think we are smarter than such narrow interpretations of data, consider how often our explanations are limited to thinking about “the last straw.” In doing so, we ignore the other straws that were applied, only earlier or elsewhere. A similar interpretation would be to conclude that last night’s basketball game was won in the closing seconds, as the result of the last shot taken – all other shots ignored as readily as all other straws are ignored on the camel’s back.

Likewise, in a classroom setting, a teacher might easily conclude that a student’s grade on an exam is a reflection of the student alone, as opposed to being a reflection of the student’s education system, which includes the teacher and parents, as well as the school board and a host of other influences. On a national level, such thinking would lead the President’s or Prime Minister’s press secretary to give full credit to his or her boss for recent news on the state of the economy. Assuming, of course, it was good news, in which case being the last straw is sometimes an advantage.

Returning to blame, bad news might be explained as the result of the ill-conceived policies of the previous administration, or other actions outside of the control of the current administration. Reflecting on these examples, someone trained to see open systems would appreciate that all of the straws act to break the camel’s back and that pulse is a measure of the performance of the system, in this case – your body, connected, of course, to the air we breathe and our ancestry. In a world of endless relationships, summed up nicely by expressions as “the circle of life” and “what goes around, comes around”, one would interpret the remarks of the press secretary as either selective associations or selective disassociations, where positive associations lead to awards and honors for the root cause of success.

In appreciation of Dr Deming’s efforts to point out the weaknesses of the prevailing style of management and to “provide a view from outside” with his System of Profound Knowledge, one can welcome the systemic prose of the 18th century poet William Blake, who asked us “to see the world in a grain of sand and a heaven in a wild flower.”   In doing so, we would possess the ability to see systems of causes, experience the power of team work, and not be distracted by the relentless pursuit of the last straw.

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