Human Error

The sound was deafening and the confusion was debilitating. Blake was struggling to pick himself up off the floor and wondering what had just happened. The only light streamed in through a small window near the ceiling as the sun crawled over the horizon.

As Blake strained to scan the room, he could see others getting up. They were all covered in dust and debris. His ears were still ringing from the explosion.

Just a moment before, he was beginning his first meeting with his leadership team as the new CEO and then, this. . . .

“Is everyone okay?” Blake yelled.

“I’m okay,” came a voice though the shadows.

“Me, too,” said another.

A third voice asked, “What happened?”

“I don’t know,” Blake said, as smoke began to fill the room. “We need to leave the building—now! Where’s David . . . and Sally?”

Becky shouted, “They’re over here!”

Blake jumped across the table to find both of them on the floor. He leaned over and from what he could see, it didn’t look good. They were both unconscious.

“Are they okay?” Amanda screamed.

“I don’t know, but we’ve got to get them out of here,” Blake said. “Tim, you and Bill take Sally, and I’ll get David.”

Luckily, the group had only one flight of stairs to navigate to reach the street level. When they emerged, they found many of their fellow employees had already found their way out of the building. Thankfully, the sound of sirens could be heard getting closer.

Blake and his team laid Sally and David on the grass. David began to cough and sat up; Sally didn’t—she wasn’t breathing. Blake started administering CPR—no response. Blake continued until the paramedics arrived and took over. They were able to restart Sally’s heart and whisk her away to the local hospital.

The employees on the street watched as their building was engulfed in flames. The bright orange flames battled with the rising sun as smoke billowed hundreds of feet into the air. The heat pushed everyone back as several fire engines appeared on site.

Blake approached a man he thought was the plant foreman and said, “Did everyone make it out?”

Regrettably, he said, “I don’t think so.”

“Who’s missing?” Blake demanded.

“We have six team members unaccounted for, sir.”

Two weeks had gone by since Blake’s fateful first morning on the job. The explosion had marked him and the entire organization forever. They had, indeed, lost six lives that morning. The cause was reported to be “human error.”

This tragedy compounded the challenge Blake faced. He had been brought in to turn around a struggling company. Now he had to manage the grieving process, rebuild trust, physically rebuild the building, and along the way, change a culture of hideously low engagement and diminishing performance.

As he drove toward the temporary office they had constructed on site, he reflected on the last decade of his life—an emotional, challenging, and fulfilling journey.

After learning to lead during his tenure at Dyna- star, the last few years as CEO of a small business had helped him understand what leading an organization demanded. His initiative to teach his entire staff to play chess, not checkers had revolutionized their business. The success they earned had catapulted their performance and market share, and the sustained superior performance brought Blake his share of recognition.

The attention, fueled by a couple of magazine articles, landed Blake on the radar of several executive search firms. In the beginning, he didn’t take their calls, but one day he decided to return a call. After hearing an offer that seemed too good to be true, he and his wife Megan decided the upside of this new opportunity was worth the hassle of a move.

Blake’s new company was a mid-sized firm in a slow-growth industry. However, his organization was not enjoying any growth; sales were actually declining, and profits were not far behind. Also, he had learned the last engagement survey reflected declining morale as well. He knew these indicators were the result of deeper root causes. He just needed to figure out what they were—and quickly.

Today’s meeting would be a challenge. There was a lot to do before the accident; the list of pressing issues was now staggeringly long. The attendees would be the same as two weeks earlier with one exception:

Becky Gonzales, Sales & Marketing

Tim Godfrey, Manufacturing

David Baldwin, Operations

Bill Alexander, Chief Legal Counsel

Amanda Chesterfield, Chief Financial Officer

The notable absentee was Sally Danbury, the former head of Human Resources. After what happened, she decided to take an early retirement and spend more time with her grandchildren. After thirty years in the workforce, she felt like she’d earned a break.

“Good morning,” Blake said in a tone more subdued than usual.

The team acknowledged his greeting but said nothing.

“How are you?” Blake said addressing the entire group.

A few people expressed their still-raw emotions regarding the accident. David Baldwin, head of Operations, gave a report on the cause of the explosion and presented some process changes being implemented to improve safety in the future.

“That’s fine,” Blake added, “but I think the solution may be much more difficult than what you just presented.”

“What do you mean?” David asked.

“We certainly need the highest safety standards. We must rebuild the trust of our people, and these process changes will help, but as I understand it, the safety measures we had in place before the accident would have worked—if they had been followed. Is that correct?”

“Yes sir, that is correct,” David admitted.

“Ladies and gentlemen, this incident is a graphic and tragic indicator of our problem. To call what happened ‘human error’ is a disgrace to those who died; the root cause would be more accurately labeled ‘leadership error.’ Leadership failed and people died.

“Based on the last engagement survey data, the vast majority of our people are sleepwalking through their days! This is not an HR problem; it is not the front-line supervisors’ fault, and it’s certainly not the employees who created this toxic work environment. This is a leadership issue—it is our responsibility.

Leaders are responsible for the culture in an organization. We will raise the bar.

Leaders are responsible for
the culture in an organization.

“A decade from now, we will look back on what happened here as both a tragedy and a turning point. We’ll create a better organization as a result. I wish we could have changed before it came to this point, but we are where we are.

“For today’s meeting, let’s hear a quick report on how the plant situation is going to affect the business over the next 90 days and look at the impact on our annual projections,” Blake said.

After the final report, Blake said, “I have one more item on our agenda for today. We need to talk about who will take Sally’s place as head of HR. Any thoughts?”

Nothing from the group—not a word. Impatiently, Blake asked, “You guys have been talking about succession planning, haven’t you?”

Becky spoke for the group, “Well, I’m sorry to say, no; no, we haven’t.”

“OK,” Blake said in disbelief. “I’ll do some homework and we’ll address the Human Resources issue during our next meeting.”

“Anything else?” Bill asked.

“Yes, one more thing,” Blake said. “At our next meeting, come prepared to talk about your leadership bench. I know now may not feel like the best time to tackle this topic, but if we’re not careful, the present will always press out the future. As senior leaders, we must work on both today and tomorrow.”

As if choreographed, the group all began to fidget. Blake picked up on it right away. “What did I say?”

“First, can you tell us what you mean by a leadership bench?” Amanda requested.

“Sure, I apologize—that may be new language for you guys. A leadership bench is a term to talk about current and emerging leaders. It is often represented in a plan that outlines your best thinking regarding succession—everyone’s ‘next man/woman up’ strategy and the replacement’s replacement as well. Ultimately, I want us to be three deep in every key leadership position.”

“I hate to tell you, Blake, but we have nothing like that.” Becky seemed to have revealed herself as the spokesperson for the group or at least its most outspoken member.

“Okay, that will be one of the topics on the next agenda. We may need to extend the meeting. We have a lot to talk about. Please bring what you have regarding your current and emerging leaders.”

Immediately after the meeting, Blake decided he had enough information to contact his mentor, Jack Deluca. Jack had been a wildly successful CEO, and Blake thought a conversation would be helpful.