{"id":94009,"date":"2020-03-16T13:22:22","date_gmt":"2020-03-16T20:22:22","guid":{"rendered":"https:\/\/www.questionpro.com\/blog\/?p=94009"},"modified":"2023-08-11T11:22:08","modified_gmt":"2023-08-11T11:22:08","slug":"the-root-cause-is-at-the-top","status":"publish","type":"post","link":"https:\/\/www.questionpro.com\/blog\/the-root-cause-is-at-the-top\/","title":{"rendered":"The root cause is at the top"},"content":{"rendered":"

On April 20, 2010, the Deepwater Horizon, an oil rig leased to BP Exploration & Production, suffered a series of explosions caused by the uncontrolled flow and ignition of oil from the well onto the rig platform. This happened 50 miles off the coast of Louisiana. With 5 million barrels of oil that spread into the fragile ecosystem of the Gulf of Mexico over 36 hours and the death of 11 workers, Deepwater Horizon became the largest marine oil spill in the history of the petroleum industry. An unprecedented environmental disaster.<\/span><\/p>\n

During the exploratory drilling, workers pumped cement down the well to create a casing that would prevent the pressure from the well from forcing the oil back up the drill and onto the platform. The workers thought they were preventing a problem.<\/span><\/p>\n

This is what stood out for me from the executive report:<\/span><\/p>\n

\u201cThe team did not identify any single action or inaction that caused this accident. Rather, a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation, and team interfaces came together to allow the initiation and escalation of the accident. \u201d<\/span><\/p>\n

A common theme<\/b><\/p>\n

As you see here, this is not a one person or one team problem. BP had a series of problems that spanned across teams and across processes. A lot of postmortem interviews were done after the incident. Fundamentally, the teams did not talk to each other.\u00a0 “I did my job” was the common theme that was extracted from the interviews after the incident.<\/span><\/p>\n

The engineering teams did not know what the operational teams were going through on a daily basis. The mechanical failures were fixed as patches and when the head of the operational team was questioned about the issues, he said that with a tight timeline it was hard to talk to other teams.<\/span><\/p>\n

“Hard to talk to other teams”\u00a0 – BP Operational Lead<\/span><\/p>\n

A team of interviewers found that the BP Operational Lead and the BP Engineering Lead only talked when there were active issues that were then shared across teams. According to their colleagues, they were also not working well together and ignored each other often. They were not talking unless they needed to!<\/span><\/p>\n

Why don’t leaders talk<\/b><\/p>\n

When you look at your organization, you will see pockets of this happening.\u00a0 If your leaders impacting the most critical delivery of services or products only talk when there is an issue, you have a leadership problem.\u00a0\u00a0<\/span><\/p>\n

There are two strong reasons why a lack of communication at the top happens :<\/span><\/p>\n