Organizational Distortions and Failures: A Method to Expose Them

摘要

As engineers, we pride ourselves on being problem solvers. The paper, however, defines a class of problems that are serious, pervasive, and largely ignored. These are complex human problems that include widespread distortion of information. A methodology is presented to expose such problems. It draws upon two abilities long practiced by engineers: We learn from experience and draw sketches. Through this methodology, the paper describes how information can be distorted with catastrophic consequences even though the individuals involved are normal and well adjusted people who see their own behaviors as proper and reasonable. Blaming individuals often misperceives such problems. The paper provides an alternative to blame. The methodology has potentially widespread application for the study of accidents, failures, and environmental degradation.