The opening sentence of the 325-page internal investigation report on a death-dealing scandal at General Motors paradoxically runs too long yet gets right to the point:
"In the fall of 2002, General Motors personnel made a decision that would lead to catastrophic results - a GM engineer chose to use an ignition switch in certain cars that was so far below GM's own specifications that it failed to keep the car powered on in circumstances that drivers could encounter, resulting in moving stalls on the highway as well as loss of power on rough terrain a driver might confront moments before a crash."
Aha, we first thought, the culprit - unmasked!
But the deeper we read into the report lead-authored by Chicago attorney and former federal prosecutor Anton Valukas, the less we cared about an engineer in 2002, and the more we learned about the dereliction of so many employees who should have known better. So many employees who have so much in common with ... those of us who work in other complex organizations.
There's a lesson in this debacle that we ignore at grave peril - to ourselves, to our employers, and most of all to customers who trust us.
And, echoing in our memory bank, there's an intervention step that the chief executive of Chicago's then-Sears, Roebuck took during his company's scandal that every one of us can and should take today. (No need to first wait for a scandal to surface.)
First, though, parse the GM investigation and:
• You find "an astonishing number of committees" at GM that devoted attention to the ignition switch problem. But all those meetings of all those committees merely enabled a pass-it-on culture in which "No single person owned any decision."