Ingeniously Simple
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Ingeniously Simple

The Importance of Culture

Why Culture Matters.

This is Air Florida, Flight 90, sat on the runway in Washington DC.

The crew of this plane were based in Florida and one thing you’ll know about Florida is you don’t often get weather like this.

Air Florida Flight 90

As they sat on the runway, the Captain and co-pilot began to work through through the checklist as they’d done many times before. As they do they are on (if you’ll excuse the terrible mixed-metaphors) auto-pilot. The exact dialog has lots of technical terms, so I’ll simplify greatly.

Does the plan have two wings?

Is the Engine Anti-Ice On?

Put simply, they’d just gone through the checklist without considering the changes in the outside world.

Why’s this a problem? Well, the engine anti-ice is a tool that ensures you can have accurate readings of the thrust the engine is generating. If the engine anti-ice isn’t on, then in cold conditions you get a misleading reading of how much thrust is being generated.

This sets up a situation where what’s happening in the outside world, and what’s happening according to the instrument panel are no longer aligned. This dissonance creates confusion and is one of the most dangerous situations for both the pilots and the plane.

As they start the take-off procedure, here’s the exact dialog (as captured from the Black Box Recorder).

Captain: It’s spooled. Real cold, real cold.

Co-pilot: God, look at that thing. That don’t seem right, does it? Uh, that’s not right.

Captain: Yes it is, there’s eighty.

Co-pilot: Naw, I don’t think that’s right. Ah, maybe it is.

Captain: Hundred and twenty.

Co-pilot: I don’t know

Captain: Vee-one. Easy, vee-two.

Pay particular attention to the language of the co-pilot. He’s noticed that somethings wrong and he tries to bring attention to the Captain, but he does so obliquely and passively (“that doesn’t seem right, does it?”). The assured responses of the captain show he’s paying no attention. As the Captain announces V1 speed has been reached, the fate of the plane is sealed.

As they reach take-off, both captain and co-pilot notice something is wrong.

Captain: Forward, forward, easy. We only want five hundred.

Captain: Come on forward….forward, just barely climb.

Captain: Stalling, we’re falling!

Co-pilot: Larry, we’re going down, Larry….

Captain: I know it.


The plane has failed to create enough thrust to generate lift. The plane stalled and crashed into the River Potomoc with the loss of all on board.

Extract from the FAA investigation into the crash

There were many reasons behind Flight 90’s crash, but the one I’m going to focus on is Culture.

If the culture onboard that flight had been an open, transparent culture of equality then this crash simply wouldn’t have happened. The co-pilot would have shared his concerns directly, the captain would have listened and ultimately lives would have been saved.

This crash (and many others like it) caused the airline industry (and other safety critical industries) to change its practices to allow for critical conversations to happen in difficult circumstances.

What can we (the Software Industry) learn from this and apply to our work to create the cultures?

But before that, we should find out what culture really is.

What is culture?

If you ask someone what is culture, they might tell you that culture looks like this:

Clearly a winning culture!

It’s a bunch of people with big smiles who are clearly winning! Unfortunately, you can’t define culture by stock images.

You might also see some companies who confuse perks with culture. Just because you do yoga with goats twice a week doesn’t make your culture great.

Your value statements, mission statements and company values don’t define your culture.

  • Volkswagen groups values in 2013 said “the group’s goal is to offerr attractive, safe and environmentally sound vehicles”. That didn’t work.
  • Enron said the “are satisfied with nothing less than the very best in everything we do”. That didn’t work either.

Put another way, you aren’t going to create the culture you need to succeed by holding a focus group asking what your values should be.

So what IS culture? Well, it’s simple. It’s the way you do things. It’s the way it feels when you open your office door on a Monday morning. It’s the way “stuff” happens in your organization, the way work gets done. It is the essence of your organization.

Yeah. But does it REALLY matter?

If you’re an employee it’s easy to see culture matters. If you’ve worked somewhere with a poor culture, you’ll know it sucks.

If you’re in a leadership role though, you’ve got a different set of constraints. You need to show that culture matters; you need to demonstrate there’s a graph that goes up and to the right associated with culture.

Thankfully, you don’t need to try too hard to do this. The Accelerate book (you’ve read that, right?) shows that having the right type of culture is positively correlated with job satisfaction, software delivery performance and ultimately increased organizational performance.

You’ll have already read Google’s work on Project Aristotle and you’ve understood that the most important thing that makes teams succeed is “psychological safety”. That term seems to be widely misunderstood though. Psychological safety is defined as:

being able to show and employ one’s self without fear of negative consequences of self-image, status or career

For some, this seems to have been interpreted as “don’t say boo to a goose” (don’t talk about anything that might cause offense!). In fact the exact opposite is true — if you’ve created a psychological safe environment you MUST talk about the issues directly without fear of offense.

Anyway, I digress. The case for culture and organizational performance has been made. You can (and should!) invest in improving it.

Where am I and where do I need to get to?

The Westrum model

A chap called Ron Westrum came up with a model to describe organizations. His work was based on the medical profession (a safety critical industry if ever there was one). He used the spectrum above to classify organizations based on the way information flowed around that organization. He identified three broad categories.

In pathological organizations (think Chernobyl), messages are suppressed. Anomalies or warning signs don’t come out until too late.

In bureaucratic organizations, the emphasis is on reporting incidents in the best possible light rather than finding the root cause. As an example, consider a Dev team celebrating success because they hit a deadline, and the QA team celebrating as they’ve found all the problems. Imagine telling the customer that all departments are reporting success whilst they still haven’t got any working software.

Finally, he introduces the generative organization. In these kinds of organization, any failure prompts inquiry and a root level understanding of what caused the problems. This style of organization reflects, learns and continuously adapts processes so that problems don’t happen.

A generative organization is typified by:

  • Alignment
  • Sense of ownership
  • Proactive flow of information
  • Psychological Safety
  • Organizational Learning

It’s this type of organization we (as software engineering leaders) should be trying to cultivate in our organization.



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