Implementation – The Overlooked Root Cause

A recent group discussion entitled “Should Failure be Rewarded” inspired me to ponder botched implementation as a persistant yet overlooked root cause of failure in most organizations. Here’s my response, elaborated on for this blog:

Insist on a thoughtful analysis of “failures.” Reward people for learning and applying lessons from failure. Companies fail to implement social and technical solutions on a regular basis, yet rarely learn from their mistakes. Instead they blame the solutions and move on to the “next best thing.” In those cases, how they implement is the root cause, but rarely considered in a serious way. As George Santayana said, “Those who cannot learn from the past are doomed to repeat it.”

By reward I simply mean reinforce learning and applying lessons learned. Challenge the behavior of moving on without objective analysis. It’s tempting to move on without thoughtful analysis because “failure” is embarressing and disapointing to whomever was involved. But the lessons learned can potentially far surpase the value of whatever “failed.”

For more food for thought, here’s a piece I wrote a few years back:

Anatomy of a Failed Implementation – A Cautionary tale

In a culture that prides itself on rational decision-making, irrationality temporarily took charge, and nobody noticed.

Wow, thought the CEO, performance is much better at plant Alpha. What happened? When he found out (“we implemented XYZ”), he said something like,
“everyone should do this!” And hence, another corporate initiative was launched.

The First Nail in the Coffin, or Lessons Learned  #1: Be Wary of Mandating Change. As outlined in Human Factors 1.2 (available for free download at our website at, mandated change generates extraordinary resistance. Use it sparingly, be prepared to lead it with a very hands-on style, and allow people as much influence as possible within the overall goals of the mandate.

The GM of Alpha plant, who was genuinely pleased with XYZ and the people who delivered it, conveyed the good news to the vendor. “You’re going to be busy. The CEO wants this fleet-wide!” The vendor was thrilled. Yet vaguely troubled. He was advised he would be working through the site GMs, instead of the CEO who had initiated the change. Confident after a long string of successes, he ignored the warning bells in his head. “After all,” he reasoned , “the GMs are no slouches. If they want it at their plants, they can make it happen.” Of course, the converse is also true. He who can makeit happen can make it die, intentionally or unintentionally, by simply focusing their energy elsewhere.

Coffin Nail #2: Don’t bobble your hand-offs. Sponsorship hand-offs should not be taken lightly. If there must be a hand off, carefully manage the transition, or consider canceling. The odds that the next person will have the same passion that you do about the thing that you started are low, no matter how fabulous the initiative may be.

Meanwhile, far off the radar of the vendor, the ship of fleet standardization had set sail. The CEO and other company leaders had been tackling a tough problem. Success had led to the acquisition of many plants, with a resulting mish-mash of processes, systems, equipment, procedures, and cultures. No one wanted to change, so HQ began pushing for the sites to agree on or develop best practices. Progress was made, but at a price. The sites bickered, delayed, and postured, while at the same time bonding in their resentment of standardization. Project XYZ, before it was even launched, was quickly lumped in by many as one more element of the corporate initiative.

Coffin Nail #3: Learn from your other implementations, and consider their impact on new initiatives. If people are miserable about what’s already happening, they’re going to be miserable about whatever is next.

Despite feeling overwhelmed with multiple initiatives and the demands of daily operations, the sites bucked up and began complying with the directive to implement XYZ. The Bravo GM filled in her Assistant. “Find out about this XYZ. The CEO says we have to do it. Let’s make sure we get scheduled before these guys get tied up with the other plants.”

The Assistant was anxious to book the resource and meet his GM’s expectations. Without a clear understanding of what XYZ is, the Assistant contacted the vendor and assured them that Bravo was “fully committed.” They were, after all, a strong performing plant, and the Assistant reflected that confidence. “The GM wants this done, and we’re going to do it.”

Coffin Nail #4: Overconfidence. Success breeds it.

Three other plants jumped on board, a detailed schedule was set, and the on-site planning began. Unfortunately the Bravo GM was called away to the corporate HQ, and missed the planning process. “Don’t worry,” the Assistant assured the vendor, “we have the Plant Manager. He can make this thing happen.” The Plant Manager assured the vendor that XYZ fit well with their current strategy, and that Bravo was ready to go.

Coffin Nail #5: Two many priorities. Every corporation seems prone to this malady. It’s better to implement a few things well, than to implement a plethora poorly.

At Charlie plant, the GM leveled with the vendor that he was concerned because he had no idea what XYZ was, and was only proceeding “because we have to…”

Coffin Nail #6: Compliance versus Ownership. If the change agent is doing all the communicating, sponsorship has failed.

During the planning session the Charlie GM began to see how XYZ could fit their site strategy. His interest grew, and he confirmed the decision to proceed. The next meetings went even better. The Delta GM had used XYZ in the past with strong results, and the Echo GM had been looking for a solution like XYZ. He was eager to lead the charge. At each site the GMs (and the Bravo Plant Manager) agreed to inform their sites about XYZ. Local sponsorship seemed to be in place.

Soon after, as the sun was rising on a beautiful Monday morning at Bravo, an Engineering Manager named Flo arrived at her desk to begin another harried week at work. As she began to dig through her to do list, her manager called. “We need you right away in room B. We’re implementing something called XYZ and I need people to participate.” “You’re kidding,” said Flo, reacting to the late notice. “I have a huge pile of work to do. What is this thing?” “I don’t really know,” admitted her boss. “I think it’s part of fleet standardization. They did it at Alpha. I know it’s ridiculous, but we’ve got to do it. Go check it out and tell me what you think.” “Great,” thought Flo, as she hurried to the meeting. “What will these idiots think of next.”

Flo wasn’t alone. Many of the personnel present hadn’t received word of the meeting until the Friday before. One had even interrupted his vacation. Worse yet, the GM still wasn’t present, and the Plant Manager greeted the vendor moments before the opening session, asking, “do you want me to say something before this begins?”

Coffin Nail #7: Communication Breakdown, ain’t it a Drag. Poor communication compounds resistance. See coffin nail #5 for a likely root cause.

Aghast, the vendor responded. “Yes! You were going to explain how XYZ fits into your overall plant strategy. Remember?” The Plant Manager, however, had been pre-occupied since the planning session covering the GM’s absence as well as their own duties, and had put minimal effort into preparing the site for XYZ. He winged a quick introduction. The personnel gathered for the kickoff were in no mood to listen, and the Plant Manager’s speech did little to bring them on board. He handed the ball back to the vendor and took a seat.

Coffin Nail #8: Kickoffs do matter. If you can’t explain clearly why you’re doing something, why do it?

As word spread that XYZ had been implemented at Alpha, things only got worse. “Those guys at Alpha need all the help they can get.” “If Alpha did it, we sure don’t want it here!”

Coffin Nail #10: Site complacency. Sites that have been performing well tend to dismiss outside resources and feedback, especially from sites that have struggled.

Sensing that their leaders had doubts, the focus shifted subtly from implementing to critiquing. The leaders present were poorly positioned to dissuade this behavior, uncertain themselves about the value of XYZ. Midway through the first session they informed the vendor they had to leave “in order to deal with issues at the plant.” Although many of those present warmed up to the vendor and the product, the were not nearly as vocal as the dissenters.

Coffin Nail #11: Systems cater to the unhappy minority. Just because they are loud, doesn’tmake them more valid. Wise leaders listen to the quiet as well. Hard work, and even harder if the loud are telling you what you want to hear.

Feedback from the vocal few was sent to the GM, questioning implementation and suggesting radical changes in XYZ. Bravo’s leadership began to wonder if XYZ “was a good fit for their site.” Word spread quickly to the other GMs. XYZ, after one botched kickoff, was essentially doomed.

Coffin Nail #12: Critique was focused on the product and the personnel delivering the product, not on the corporation’s approach to implementation. Tempting targets, because they are “them” (and the corporation is “us”), but probably not the root cause. The root cause almost certainly lies in flawed implementation. That is a cause worth understanding, because it is within your control, and will impact future implementation performance.

The vendor and their staff left the site scratching their heads. They wracked their brains thinking about what they could do better to make the next kickoff go smoother. They incorporated some of Bravo’s written feedback, but rejected ideas that they believed would impair the effectiveness of the product. Because of this, they began to be perceived as “defensive and unresponsive.”

Coffin Nail #13: Labeling people adds insult to injury. If you have concerns, be direct. Talk to people, not about them to others. Scapegoating diverts from root cause (see Human Factors 3.3 and 7.1 for more detail, available for free download at

The following week began smoother. The Bravo GM was there, and after meeting the vendor, realized he had seen good results from a product similar to XYZ. He kicked off the session with a clear message about what could be gained. The work went closer to the norm, and the feedback, while still mixed, no longer contained the more radical suggestions. The vendor had reason to believe XYZ had turned the corner. Little did they know…they were a wildebeest in a system that feeds on wildebeests. As the mid-managers at Bravo put it, “We call it the wounded wildebeest syndrome. No one wants to be the wildebeest. When a member of the lead team starts challenging one of us public, the others join in, like a pack of lions. It.s like they smell blood. The other wildebeests watch in stunned silence. The lead team calls it coaching. If the wildebeest fights back, they call them defensive. The best thing is to keep your mouth shut and not make waves.” The vendor wanted to talk to the GM, but was advised not to. Even though the second session had gone better, the smell of blood was in the air.

Coffin Nail #14: Culture matters. If the culture is to pile on, only the brave and/or the foolish will challenge the pack.

Echo plant.s kickoff was next. By now the project was snake bit. Echo’s GM, who had intended to lead XYZ in a hands on manner, accepted a lateral transfer and departed just days before the kickoff. The new GM arrived the same week as the project. Key leaders were pulled away midstream to meet with her, and for a site visit from the CEO. Despite these distractions, Echo’s implementation had the smoothest start to date, and positive feedback from site personnel. The vendor was hopeful.

Coffin Nail #15: Good news travels slow. Bad news travels fast. Bad news can kill a project before good news has a chance to catch up.

The end, however, was already near. Charlie plant was next, and the GM had been pulled offsite since the planning session. A bewildered department head introduced himself to the vendor moments before the session. “I just learned that I’m supposed to kick this off,” he said, sheepishly. “I haven’t been told a word about what it is.” It was another rough start, but the vendor could see a positive trend. After all, there was finally GM involvement at Bravo, Echo and Charlie were underway, and Delta was next, where the GM was knowledgeable and enthusiastic about XYZ.

Again, as she is wont to do, fate intervened. Delta plant took an unplanned and costly outage. XYZ would have to be delayed. Soon after, the Delta GM left the company. The lead team at Delta dropped XYZ. Like a row of dominoes, it was cancelled throughout the fleet. Time, money, and the potential gains of XYZ had all been lost. The coffin was nailed shut.

Moral of the Story:  Good programs and products are often botched by bad implementation (see Human Factors 1.3, 2.2, and 7.2 for sound advice on managing change, available for free download at Learning from mistakes is difficult, because mistakes are embarrassing. Failure to learn from mistakes (such as botched implementations) means you’re doomed to repeat them.

About crosbyod

Crosby & Associates OD is a catalyst for high performance & morale. Our methods are a unique blend grounded in research and decades of experience. In the spirit of Kurt Lewin, the founder of OD, as we partner with you in the present we transfer our methods to you so you are independent in the future. Learn more at
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4 Responses to Implementation – The Overlooked Root Cause

  1. Julian Goh says:

    This sounds interesting to me, and here my question to you, ‘aging management crisis’ is going to be considered as a MDF – mass disruptive factor which i may consider it be part of my research areas, see I have included the first one raised my Al Mac. There were some private exchanged people sent to me concerning SKYPE, and social media are very disruptive to them.

    • gilcrosby says:

      Hi Julian, I may write about “aging management crisis” next, as it is shared by both Malaysia and one of my main customers, the US nuclear industry.
      Meanwhile, I would add smartphones to your “mass disruptive factors,” as many people focus more on their phones at home and at work than they do on the people they are with and the activities (including driving!) that they are engaged in.

  2. Julian Goh says:


    i think both of us can co-authored this topic. I am interested to participate and send to Performance Measurement Association Newsletter. I have a column to contribute every quarterly. The deadline of submission would be the end of this month.

    I will pen the overall context to address the needs to take serious steps.

    The word length is 500-1000.

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