Don't Tell the Boss!: How Poor Communication on Risks within Organizations Causes Major Catastrophes

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Contents
About the Authors
1 Introduction
1.1 Personal Observation of Failures in Intra-Organizational Risk Communication in Critical Infrastructure Companies
1.2 Previous Research on the Causes of Poor Internal and External Risk Communication
1.3 Study of the Causes of Poor Internal Risk Communication
Part I The Problem
2 Examples of Failures in Intra-Organizational Risk Transmission in Past Disasters
2.1 Unreadiness of the Soviet Red Army for the Nazi Invasion (USSR, 1941)
2.1.1 Confrontation Between Soviet Politicians and Red Army Executives
2.1.2 Distorted Red Army Casualties in the Finnish Campaign
2.1.3 Stalin’s Self-Deception
2.1.4 Subordinates Provide Calming Reports to Stalin
2.1.5 Concentration of Political and Military Power in Stalin’s Hands for Effective Decision-Making
2.2 The Great Chinese Famine (China, 1958–1962)
2.2.1 The Experience of Socialist Construction in the USSR and the Famine of 1930–1932
2.2.2 The Communist Party of China and the People’s Republic of China Were Established with the Direct Political, Economic and Military Support of Soviet Russia and the USSR
2.2.3 Mao’s Competition with the USSR and Western Countries
2.2.4 Absence of Frank Feedback on Mao’s Initiatives from His Subordinates
2.2.5 Total Collectivization During the Great Leap Forward
2.2.6 Proper Planning Depends on Background Information
2.2.7 Suppression of Bad News About the Famine and Shifting the Blame
2.2.8 Quarrel with the USSR
2.2.9 Meeting with Reality
2.2.10 The Cultural Revolution
2.3 Collapse of the Banqiao and Shimantan Reservoir Dams (China, 1975) and the Machhu Dam-Ii (India, 1979)
2.3.1 Collapse of the Banqiao and Shimantan Reservoir Dams (China, 1975)
2.3.2 Collapse of the Machhu Dam-II (India, 1979)
2.4 Problems With the Rear Cargo Door of Mcdonnell Douglas DC-10 (USA, 1970s)
2.5 Challenger Space Shuttle Accident (USA, 1986)
2.5.1 Outdoor Temperature, O-ring Problems and Decision-Making Before the Launch
2.5.2 History of the O-ring Problem
2.5.3 Constant Struggle Within the US Space Shuttle Program to Increase Launch Frequency, Avoid Delays and Face US Government Financing Shortages
2.5.4 Reports to Management of Delays or Other Problems Were not Welcome
2.5.5 Acceptable Risk
2.5.6 Disclosure of Additional Factors Influencing Decision-Making Before the Launch
2.6 Chernobyl Nuclear Disaster (USSR, 1986)
2.6.1 Geopolitical Context and the Civil Nuclear Program Race
2.6.2 Strengths and Challenges During the Development of RBMK Reactor
2.6.3 RBMK Reactor Design and the SCRAM Effect
2.6.4 Economic and Political Pressure to Push Ahead with the RBMK Reactor Program in Order to Meet Increasing Demand for Electricity
2.6.5 A Fatal Regulation Mistake
2.6.6 Tragic Lack of Communication Between the Main Responsible Agencies
2.6.7 Meetings of Politburo in July 1986: “RBMK Reactors Are Potentially Dangerous”
2.6.8 Internal Transmission of False Information Immediately After the Disaster
2.6.9 Mismanagement of Communication to Soviet Citizens and the International Community
2.7 Barings Bank Collapse (Singapore-UK, 1995)
2.8 Staphylococcus Related Food Poisoning in Snow Brand Dairy Products (Japan, 2000)
2.9 SARS Outbreak (China, 2002–2003)
2.9.1 Concealment of First Cases of the Disease and Inaction of Different Levels of Chinese State Hierarchy
2.9.2 The Warning of the WHO
2.9.3 WHO Leadership During the Crisis
2.9.4 Concealment of Disease Transmission in Beijing Before the National People’s Congress
2.9.5 Belated Reaction of the Central Government
2.9.6 Lessons from the Outbreak
2.9.7 Revision of the International Health Regulations
2.10 Amagasaki Train Derailment (Japan, 2005)
2.11 Sayano-Shushenskaya Hydropower Station Disaster (Russia, 2009)
2.11.1 The Problems Arise from the Common Soviet Practice of Aiming at the Simultaneous Design and Construction of Highly Sophisticated Energy Infrastructure (as We Have also Seen in Previous Cases)
2.11.2 Lack of Communication About Minor Incidents in the Soviet Electro-Energetics Industry in the 1980s as a Key Cause of the Accident at SSHPS in 2009
2.11.3 Soviet Electro-Energetics in the Post-Soviet Russian Market-Oriented Economy
2.11.4 Tragic Consequences of the Ultra-Liberal Reforms of RAO UES on the Safe Operation of SSHPS
2.11.5 The Problems of Assessing the Real Characteristics of the Vibrations in Turbine 2
2.11.6 The Investigation
2.11.7 Comprehensive Internal Risk Monitoring System of RusHydro
2.12 Upper Big Branch Coalmine Blowout (USA, 2010)
2.12.1 Publicly, Safety Was First, While in Reality Safety Was Overshadowed by Production
2.12.2 The “Members’ Club” Culture Discouraging External Risk Disclosure
2.12.3 Role of the Massey CEO
2.12.4 Continuous Conflict of the Mine Operator with the MSHA
2.12.5 Lobbyism
2.12.6 Conclusion
2.13 Deepwater Horizon Oil Spill (USA, 2010)
2.13.1 Geological and Regulatory Contexts
2.13.2 BP’s Long-Term Business Philosophy of Cost Reduction
2.13.3 Business Pressure and Miscommunication Between BP, Halliburton and Transocean
2.13.4 Lack of Learning from Earlier Disasters
2.13.5 Conclusion
2.14 Raspadskaya Coalmine Blowouts (Russia, 2010)
2.14.1 Short-Term Strategy of Private Mine Owners
2.14.2 Ineffective Regulation of Coalfield Exploitation with High Concentrations of Methane
2.14.3 Raspadskaya Mine Had the Reputation of Being the Safest in Russia
2.14.4 Volatility of Prices on the Commodity Market After the 2008 World Economic Crisis
2.14.5 The Disaster Revealed the True Situation with Safety in the Mine
2.14.6 The Remuneration System for Coalminers Encouraged the Withholding and Distortion of Information About Methane Levels in the Mine
2.14.7 A False Economy
2.15 Great Wildfires in the European Part of Russia (Russia, 2010)
2.15.1 Deregulation of State Forest Management
2.15.2 Sending Reassuring Reports to Moscow Even During the Disaster
2.15.3 Delayed Federal Response
2.16 Fukushima-Daiichi Nuclear Disaster (Japan, 2011)
2.16.1 Summary of the Disaster
2.16.2 Environmental and Economic Consequences of the Disaster
2.16.3 Common Interests of the Japanese Government and Private Corporations Towards the Development of the Civil Nuclear Industry in Japan
2.16.4 Unlearned Lessons from Three Mile Island and Chernobyl Accidents
2.16.5 Concealment of Minor Incidents Was a Decade-Long Practice Within the Nuclear Industry
2.16.6 Tragic Underestimation of the Threat of High-Amplitude Tsunamis to TEPCO’s Nuclear Power Plants
2.16.7 Internal Risk Communication Failure
2.16.8 External Risk Communication Failure
2.16.9 Repetition of the Mistakes Done During Chernobyl Accident in the Japanese Crisis Response Actions to the Nuclear Disaster
2.16.10 Absence of Decisiveness in Taking Urgent and Costly Solutions
2.16.11 Struggle Between Political Camps as a Major Obstacle to the Adequate Risk Information Transmission in Crisis Situation
2.16.12 Distortion of Information About the Condition of the Plant Led to Inadequate Governmental Crisis Response Measures
2.17 The Volkswagen Diesel Engine Emissions Scandal (Germany-USA, 2000−2010s)
2.17.1 Summary of the VW Case
2.17.2 Tighter Emission Regulations Were a Challenge for All Carmakers
2.17.3 Penetration of the American Small Passenger Car Market by the New VW Diesel Engine
2.17.4 VW’s Corporate Culture of “Success at Any Price” and “No Bad News”
2.17.5 Untightening of the Plot
2.18 Collapse of the Fundão Tailing Dam at Samarco Iron Ore Mining Site (Brazil, 2015)
2.19 Severnaya Coal Mine Blowouts (Russia, 2016)
2.20 African Swine Fever Epidemic in China (China, Since 2018)
2.20.1 Summary
2.20.2 Historical Context for the Spread of ASF in the USSR and Russia
2.20.3 ASF Epidemic in China
2.20.4 Concealment of the Epidemic at Local and Provincial Levels
2.20.5 Assessment of the Damage from the Epidemic
2.20.6 Questionable Praise of Chinese Anti-Epidemiological Efforts by the World Organisation for Animal Health
Part II Why the Problem Exists
3 Causes of Failures in Intra-Organizational Risk Transmission
3.1 Top 10 Factors Which Discourage Subordinates or Contractors from Reporting Risk-Related Information Internally, or Encourage Managers to Ignore Early Warnings When They are Reported (Based on Analysis of 20 Disasters Explored in This Book)
3.1.1 Priority of Short-Term Socio-Economic, Financial and Operational Goals Over the Long-term Safety and Well-being of Citizens, Customers and Employees
3.1.2 Ambitious Organizational Goals
3.1.3 Fear Among Subordinates and Contractors that They Will Be Blamed and Punished for Reporting a Problem
3.1.4 Ineffective Government Regulation; Cozy Relationships Between the Industry and Government Representatives (In Some Studied Cases)
3.1.5 Fear Among Subordinates and Contractors of Being Seen as Incompetent
3.1.6 Permanent “Rush Work” Culture
3.1.7 “Success at Any Price” and “No Bad News” Culture
3.1.8 Ignorance About Risks and Wishful Thinking/Overconfidence/Self-Suggestion/Self-Deception
3.1.9 Weak Internal Control Within an Organization
3.1.10 Competition Pressure
3.2 Results of Other Researches on the Challenges of Voice and Silence in an Organization
3.2.1 MUM Effect
3.2.2 Deaf Effect
3.3 Survey on the Reasons Why Information is Concealed or Distorted by Employees in Government Administrative Services
3.4 The Practitioners’ Viewpoint: Causes for Poor Upward Feedback in Organizations Running Critical Infrastructure
3.4.1 Who Creates an Internal Climate Where It is not Acceptable to Talk About Problems in an Organization?
3.4.2 Top 10 Reasons Why Leaders Don’t Want to Hear About the Problems in Their Companies
3.4.3 Top 10 Reasons Why Employees Are Reluctant to Disclose Risks in Dealing with Managers
4 Conclusion
Discussion. Concealment of SARS-CoV-2 Outbreak in Wuhan (China, 2019–2020)
Introduction
I International Legal Framework Concerning Warnings About SARS-Suspicious Events
II Dating of First Suspected Cases of COVID-19
III Rising Evidence of Obfuscation of Information in the Search of the Biological Origin of SARS-CoV-2
IV Examples of the Concealment of the Outbreak in Wuhan at the Municipal and Provincial Levels
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IV.1 Delay with Publication of Genome Sequencing of the New Virus
IV.2 Punishment of Doctors Who Tried to Warn Their Colleagues About the New Virus
IV.3 Failure to Report Patients with SARS-Related Symptoms to the National Infectious Disease Information System
IV.4 China Did not Proactively Inform the WHO About the Disease in Wuhan
IV.5 Inappropriate Handling of the Evidence of Human-Human Transmission
IV.6 Use of Over-Stringent Criteria for Confirming Cases
IV.7 Political Congresses Were not Canceled During the Outbreak
IV.8 Allowing 5 Million Migrants to Leave Hubei During the Epidemic
IV.9 Allowing a Huge Public Gathering to Take Place
IV.10 Information Distortion in Reports to the Representatives of the Central Government
IV.11 Questions Concerning the Declared Numbers of Cases and Deaths in Wunan and Hubei
V Requirements of the IHR Concerning National Response Measures to an Unknown Outbreak
VI Why the Central Government Hesitated to Take Decisive and Rapid Response Measures as Soon as They Heard About a New SARS-Related Virus Remains a Point of Debate
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VI.1 Sociopolitical Stability of the Whole Country and the Coming Celebration of the Chinese New Year
VI.2 The National Leadership Did not Understand the Severity of the Situation on the Ground in Wuhan and Hubei Because the Reports Reaching Them Through the Chinese State Hierarchy Were Distorted
VI.3 There Was a Lack of Personal Leadership from Top Chinese Officials to Respond to the Crisis Comprehensively and Quickly Until the Third Decade of January 2020
VI.4 Neither the Population nor the Health System Were Prepared for Urgent and Very Strict Non-pharmaceutical Control Measures
VII The WHO Was Misled About the True Scale of the Outbreak in China
VIII Might the Global Disaster Have Been Avoided if Risk Information Had Been Transmitted Properly and Epidemiological Response Measures Had Been Implemented Swiftly?
Conclusion
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