When something goes catastrophically wrong, it can be easy to blame the people immediately involved. They get lazy, tired, bored, distracted, jealous, or into any number of other possible mental states which can cloud judgement and lead to mistakes. When inevitable disasters occur, the short-term approach is to blame human error, but in many cases the longer-term approach is to blame the system and correct it instead. That isn’t to say that humans are never at fault – they are often grossly incompetent, but sometimes they receive blame which should rightly be aimed higher, at the system they work within.
David Sanborn Scott, explained the title of his book, Smelling Land (( Smelling Land is about the topic of replacing fossil fuels with Hydrogen, a strategy I am partially gung-ho for and partially skeptical of. I have not read the book, but I have listened to interviews with the author of substantial length )) , with this classic legend of a fleet of ships in a fog:

It is told that when the fleet was still some distance off the islands, a cabin boy came to the admiralâ??s stateroom to say, â??Sir, I smell land. I think we should heave-to until the fog clears.â?? Advice from a cabin boy to an admiral of the Royal Navy was neither expected nor welcome-especially not in 1707, and especially not to Admiral Cloudesley Shovell. The boy was reprimanded and sent away. Yet he must have gone on deck for another whiff, because soon he was back at the admiralâ??s door, no doubt apprehensive, but not enough to stop him repeating his warning: â??Sir, I smell land. I think we should put about.â?? And that is why he was swinging from the yardarm when the fleet crunched ashore on the land he had been smelling.
The easy response to the story is to blame the Admiral – blame he deserves – but it is also important to call into question the overly hierarchical navy structure of the time. While the truth of the story can’t be verified, as the fleet was largely lost (and roughly 1400 men with it) the story is a good parable for many organizations. Had the culture been a little more bottom-up, rather than top-down, maybe it wouldn’t have happened.
(( Image of Chernobyl taken from Wikipedia )) James Reason, in his article for the British Medical Journal, asserts that the role of culture in an organization plays a large role in how reliable, safe, and mistake-prone they are. Open, bottom-up, and “just” organizations are more likely to be less mistake-prone. He uses the example of the Chernobyl disaster, a disaster in which bad policies, faulty design, and lack of education turned a test of operations into a literal meltdown. The lack of a reporting culture in the USSR was the underlying cause, which itself was caused by a lack of trust between the top and bottom of the hierarchy. Nobody was willing to speak up about their lack of education on what they were doing, or on the faulty design of the control mechanisms in place. They didn’t want to be the cabin boy who smelled land.
Fixing cultures and other such larger systems is much more difficult than blaming whoever was at the instrument panel when things took a turn for the worst. As James Reason puts it “Blaming individuals is emotionally more satisfying than targeting institutions.”