Chapter 17. When Good People Do Bad Things: The Anatomy of a Corporate Disaster

Ronald M. Green

On October 1, 1999, Medhat Labib of Indialantic, Florida, was behind the wheel of his Ford Explorer, driving home after a niece's wedding rehearsal. His wife and two sons were with him, along with three friends who had joined the festivities. Just 10 minutes from home, the rear tire on the driver's side came apart at 70 mph. The 1996 Explorer rolled over three times, coming to rest in a mass of trees off Interstate 95. Labib's wife, Margaret, 42, died instantly. Their son, Andrew, 9, was thrown from the vehicle and killed. Labib, 49, was left paralyzed from the waist down. No others in the vehicle were seriously injured.^[1]

The Labib family tragedy eventually proved to be one of hundreds that would make the 15-inch, all-terrain, Firestone tires used on Ford Explorers the object of one of the most extensive product recalls in history. By the time the recall was completed over a year later, at least 174 deaths and over 700 injuries would be attributed to Firestone tire failures on Ford Explorers, and 6.5 million tires would be recalled.^[2] In reaction to criticisms, the top leadership of both Ford and Firestone would step down. Both companies would face billions of dollars in liability suits. Another casualty would be the relationship between these two corporate giants. Begun almost a century earlier in a friendship between Harry Firestone and Henry Ford, it would end in a chorus of name-calling and mutual recriminations.

How can a corporate disaster of this magnitude be explained? Some obvious answers present themselves. On both sides corporate greed probably played a role. There is evidence that Firestone cut corners on design, manufacture, and testing in order to offer Ford a tire that would be cheaper than those offered by competitors. Ford apparently placed a higher priority on the affordability of tires than on customer safety. Both companies also displayed a stubborn inability—or unwillingness—to learn from experience. In the late 1970s, faulty design and manufacturing processes caused numerous failures in Firestone's "500" line of radial tires. During that same period, Ford came under attack for fuel-tank design problems in its Pinto automobiles. These problems caused scores of fatal accidents and earned the Pinto a reputation as a rolling incendiary bomb.

Nevertheless, this history tells us that greed and stupidity are probably too simple as explanations of the Firestone-Explorer disaster. Both companies had to be aware of the financial stakes of product liability in this sensitive area. During the 1980s, Firestone lost its corporate independence to Japan's Bridgestone Tire Company as a result of the financial difficulties caused by the earlier problems with its 500 line.

Each manufacturer had to realize that it could incur billions of dollars in costs—in class-action lawsuits alone—if it were implicated in another string of fatal accidents. This suggests to me that we should look deeper for the causes of this episode. In fact, I believe that it was the result of a systematic and, unfortunately, very typical failure by both companies. It was systematic because it involved a variety of intersecting factors in the way the companies did business together. It was typical because the problems that came to light often make their appearance in other, less tragic instances of corporate negligence and misconduct. By analyzing the causes of this disaster, we can better understand why business managers sometimes make ethically poor decisions, and we can learn how to avoid such problems in our own professional life.

The Parable of the Sadhu

The quest for an understanding of the events that led to the Labib family tragedy takes us far from Florida to an episode that occurred in the Himalayan Mountains nearly two decades before. The central character in this story is a Wall Street investment banker named Bowen ("Buzz") McCoy. In 1982, Buzz took a 6-month sabbatical from his firm, Morgan Stanley, and decided to hike in Nepal. During the trip, he had a disturbing experience, which he described in an article for the Harvard Business Review entitled "The Parable of the Sadhu."^[3] Buzz came to believe that what had happened on a mountainside in the Himalayas had relevance for the field of business ethics.

Three months into his trek, Buzz and his party were ascending to a mountain pass at 18,000 feet. Their destination was the holy city of Muklinath. The group included Buzz, his companion Stephen, an American anthropologist, and several Sherpa guides and porters. In order to get to Muklinath, they had to rise early and cross a series of snow steps that would melt later in the day as the sun rose. Buzz was already suffering from the altitude sickness that had caused him to experience pulmonary edema on a trip some years before.

As the group ascended to the summit of the pass, a New Zealander from a party ahead of theirs met them. He came toward them, carrying the body of a Sadhu, an Indian holy man, whom his group had found, barefoot and almost naked, lying unconscious in the snow. The New Zealander handed the Sadhu over to Buzz and his companions, saying, "Look, I've done what I can. You have porters and Sherpa guides. You care for him. We're going on."

In a few minutes, the Sadhu revived, but he was unable to walk or explain what he was doing at those heights without shoes and clad only in a skimpy garment. With the help of members of a Swiss group, the Sadhu was soon clad in warm clothing. Buzz and Stephen were unsure what to do. Below them, they spotted a Japanese party with a horse. Buzz told Stephen that he was concerned about the altitude and wanted to cross the pass. Without much thought, he took off after some of the porters who had gone ahead.

Several hours later, Stephen rejoined Buzz at the summit. Buzz greeted him, but Stephen was angry. He explained that the Japanese had refused to take the Sadhu. Stephen reported that he then proposed to the Sherpas that they carry the Sadhu down to safety, but their leader resisted the idea, saying that they needed all their energy to get over the pass. At Stephen's urging, the Sherpas carried the Sadhu down to a rock in the sun 500 feet below and pointed to a hut another 500 feet below. To this day, neither Stephen nor Buzz knows what happened to the Sadhu.

Buzz apparently wrote about this episode as an act of contrition. He wished to extract from this experience a moral lesson of broader import. As an active layman in the Presbyterian Church, he came to believe that he had unwittingly violated his own deepest values. He had read the parable of the Good Samaritan many times in his life, but when it came time for him to act as a Good Samaritan, he missed the opportunity. In Buzz's view, what happened to him and his companions also occurs in business organizations. Because of complex group dynamics, good men and women, "nice" people with solid values, often end up doing things they regret.

Buzz McCoy's experience on the mountain brings to light a series of key factors that contribute to poor and ethically irresponsible group decision making:

1. Stress
2. Goal obsession
3. Rationalization
4. Blaming the victim
5. Failures of leadership
6. Value conflicts
7. Buck-passing
8. Bad examples
9. Decision making by technicians
10. Alien cultural environments
11. Failures of individual moral responsibility

Stress

The first item on this list is stress. For Buzz, stress took physiological form in the hypoxia at 18,000 feet altitude and the reduced physical and mental functioning associated with it. Stress can come in other forms, however, including serious organizational conflicts or acute financial pressures. Because stress reduces the quality of decision making, those responsible for organizations must manage it. They must make it part of their responsibilities to minimize the stress imposed on personnel. Since it is difficult to avoid stress entirely, they must also plan and train for handling stressful situations before they occur. The failure of Buzz and his companions to do this was a key contributing factor to their moral failure. Unlike skilled mountaineers, they never discussed how to respond to a life-threatening event on the mountainside. When they came upon the Sadhu, they had no prior guidelines or training to help them. Apprehensive and confused, they acted by instinct and ended by violating their basic moral values.

Goal Obsession

Goal obsession is the occupational disease of hard-driving executives like Buzz McCoy. It is what makes them successful, but it can also set them up for personal and organizational disasters. A colleague of mine has coined a name for this prevalent mindset: teleopathy, literally meaning goal-sickness. It occurs when the goal owns you, not the other way around. Goal obsession has two very typical features. First, like a magnet, it gets stronger as we approach the goal, sometimes making it difficult or impossible to change direction to adapt to new circumstances. Second, it often involves a confusion of one's larger or longer term goal with some immediate objective. In Buzz's case, for example, his goal was to enjoy a sabbatical experience, to get a break from Wall Street, and in the process to learn something positive about himself. Instead, he and his companions became obsessed with the narrow objective of reaching Muklinath. Pursuing this objective, he missed his chance for the most valuable sabbatical experience of all. Imagine if Buzz had seen his goal properly. Returning to Morgan Stanley, when asked, "Did you finish your trek?" he could have replied, "No. We saved a human life instead."

Rationalization

Rationalization, the third item on this list, almost always accompanies unethical behavior. Rationalization has been described as "the compliment that vice pays to virtue." It seems that as human beings we are unable simply to do wrongful things. Instead, we try to justify them in ways that soothe our conscience. For Buzz, this took the form of various excuses and reasons why he could not stop to save the Sadhu, including risks to the group if the ice steps melted. In reality, Buzz and his colleagues weren't in any danger. All the perils would have vanished if they had chosen to turn around and bring the Sadhu to safety.

Blaming the Victim

Blaming the victim is a special form of rationalization. How easy it is, when I am about to neglect or harm another human being, to somehow justify this in terms of the victim's own fault. Are AIDS drugs priced too high for millions of people in our country or abroad? "Why did they get AIDS in the first place?" Does a poorly designed toy or piece of furniture injure a child? "Why weren't the parents more careful?" In Buzz's case, it was the Sadhu who was blamed. All those who might have saved him asked themselves why he was being so foolish as to wander, flimsily clad, high in the mountains. This led to the unfortunate conclusion that maybe he deserved to be abandoned.

Failure of Good Leadership

The next item on this list, good leadership, is an essential factor if organizations are to steer their way through new and difficult challenges. Too often, however, appointed leaders are ineffective, or when unitary direction is needed, a multiplicity of conflicting voices is raised claiming attention. Buzz's group clearly lacked a leader. Buzz and Stephen had some authority, but neither was entirely willing to defer to the other. The Sherpas acted as paid employees. In the crisis, the group fractured.

Value Conflicts

Further compounding this problem of divisiveness was the value conflict that appeared in the situation. Sometimes, groups that lack a single leader can spontaneously unite around a shared set of values or goals. We see this when a volunteer "bucket brigade" forms in response to a fire. But, even formally organized groups can fracture if key personnel insist on acting on fundamentally different values. Value conflicts of this sort should not be confused with diversity of views. Open discussion and debate can enrich an organization. However, when key and core values are concerned, there must be unity, or the group will split and be unable to meet challenges. The fundamental disagreements between Buzz and Stephen had this effect. They pulled the group's two leaders in different directions. In the end, a problem that was not life threatening became one, as Stephen feared for Buzz's safety higher up on the mountain.

Buck-Passing

Buck-passing is another fatal factor in the erosion of organizational integrity and ability to respond. Buck-passing should not be confused with a proper division of labor. No member of a group can do everything. What characterizes buck-passing, however, is that no one takes responsibility for the outcomes and instead passes this essential duty onto others, often without their assent. In the case of the Sadhu, this phenomenon made its appearance when the New Zealanders peremptorily handed the Sadhu off to Buzz's group. From this point onward, it became a matter of "passing the Sadhu" to whomever was available. In the end, the Sadhu paid the price for everyone's failure to ensure that he was safe.

Bad Example

The New Zealanders' conduct points up the next item on this list: bad examples. Much more than we realize, human beings are social animals. We are powerfully influenced by what others do. Good examples raise the standard of conduct of a group; bad examples have the opposite effect. In a matter of moments on the mountainside, the New Zealanders communicated the idea that all one had to do was pass the Sadhu along to others. Without thinking, Buzz and his companions followed that bad example.

Decision Making by Technicians

The next item on the list, decision making by technicians, needs careful explanation. Technicians come in many forms. In a business organization, they include the engineering, financial, or legal experts who are needed to achieve the company's purposes. For those trekking in the Himalayas, they are the Sherpa guides and porters who know the route and conditions. In all circumstances, the advice and skills provided by technicians are essential, but they should never be confused with or be allowed to replace the higher level, value-driven direction of the group's leaders. Buzz and Stephen succumbed to this problem. Unable to see or set their own priorities, they deferred to the Sherpas. Since the Sherpas had only one objective—getting their charges to Muklinath and receiving their pay—this low-order priority became the "purpose" of the trek.

Alien Cultural Environment

Buzz and his companions were clearly operating in an alien cultural environment, a factor that entered into their poor decision making. All of the problems mentioned above are made worse when we are acting within circumstances outside the normal range of our experience. Ignorance about others' conduct or values supports our tendency to rationalize our own negligence or blame them for our difficulties. Not knowing what is expected can divide a group, puzzle its leaders, and lead everyone to defer excessively to local expert advice. In his very strangeness, the Sadhu invited all these responses. When Stephen later rejoined Buzz at the pass, he angrily accused Buzz of contributing to another person's death and asked whether Buzz would have similarly left behind a Western man or woman. Stephen's question brought home to Buzz how much the "otherness" of the Sadhu and his surroundings had distorted his judgment.

Failures of Individual Moral Responsibility

The factors itemized here help explain why people with solid values sometimes go morally awry in complex situations of group conduct. Led by bad examples, pulled by the voices of conflicting authorities, misled by inappropriate technical advice, people like Buzz and Stephen can abandon commitments that are central to their own identity. Nevertheless, while these factors can explain individual misconduct when people are part of groups, they do not excuse it. No matter how bad the group dynamics we encounter, each person is always required to act on his or her own better values. Both Buzz and Stephen know that to some extent they are responsible for the Sadhu's abandonment. By warning others of the causes of this episode, Buzz hoped to help others minimize the pressure to wrongful conduct created by group factors. However, the best group dynamics cannot replace the need for each person in a group to assume responsibility for his or her own conduct or the need to bring the group's behavior in line with one's own best values.

Firestone and Ford on the Mountainside

Accidents of the kind that devastated the Labib family resulted from the sudden failure of a Firestone all-terrain tire. A combination of heat, heavy load, and low tire-pressure caused the tread of the tire to peel off. Sudden failure of a rear tire could lead the top-heavy Explorer to roll over. Behind these immediate causes, however, were a series of decisions and actions by both Bridgestone/Firestone and Ford, stretching back over more than 10 years. Amidst these, we can see many of the factors identified by Buzz McCoy preparing the way for disaster.

Stress

For Firestone, this was a persistent factor in the sequence of events leading up to the tire recall. Crippled financially by the 1978 recall of 13 million 500 tires, the company limped through the 1980s, until in 1988 it agreed to be acquired by Japan's Bridgestone. According to executives with Firestone and other tire companies, instead of bringing relief, the acquisition increased pressure on the company, because the new owners quickly made it clear that they wanted increased volume from their American unit.^[4] The best way to do this was to expand business with the auto companies. As a result, Firestone competed aggressively to win the Explorer tire contract. It may have done so, in part, by hurrying into production a tire design and manufacturing process that skimped on materials, quality assurance, and testing.

Although Firestone won a large share of Ford's business, the demanding price and production terms that the company had to meet only increased the pressure. During this period, parent Bridgestone was also unwilling to invest heavily to upgrade its aging Decatur, Illinois, plant, where many of the defective tires would eventually be produced. As a result, during the early 1990s workers and plant managers experienced increasing production demands that led, in turn, to reduced quality controls. In the words of one line employee, "If you didn't make the numbers, you were in trouble." From 1994 to 1996, these problems were accentuated by a prolonged and bitter strike that forced the company to resort to poorly trained replacement workers. It was during these 2 years that most of the defective tires were manufactured.

Goal Obsession

We can see the presence of this factor in the pressure-inducing business decisions just mentioned. An irony of goal obsession is that it can lead people to pursue some objective that is instrumental to achieving a larger goal, but in the process causes them to lose that goal. This is exactly what happened to Bridgestone/Firestone. Obsessed with winning the Explorer contract, the newly merged company imperiled some of the key sources of Firestone's long-term worth: its relationship with Ford and the established value of the Firestone brand name.

On its side, Ford also evidenced goal obsession. This was particularly apparent in the series of design decisions that went into the Explorer model. The Explorer was initially conceived during the 1980s to fill a growing niche that Ford had identified for a comfortable, family-style, sport utility vehicle to replace its more truck-like, stubby Bronco II model. Because of the high suspension required for off-road operation, the Bronco experienced rollover problems, and Ford engineers wanted to reduce this risk on the Explorer.

However, reports during final development weren't encouraging. During testing, the Explorer prototype demonstrated a rollover response not shown on benchmark Chevrolet Blazer models or even the older Bronco II. As a result, Ford engineers and managers scrambled for a solution. Instead of reexamining the whole idea of an off-road, truck-like vehicle that could also be widely used by families in high-speed highway driving, Ford remained stubbornly locked into the Explorer concept. Some Ford managers dismissed the problem, reasoning that the company intended to market the Explorer to buyers with "a less aggressive driver profile." Another solution involved reducing the recommended air pressure in the vehicle's tires to a low of 26 pounds (Chevrolet Blazers used similar tires, but at a recommended pressure of 35 pounds). This would not only ensure a softer more comfortable ride, one of the design objectives, but it would increase the vehicle's body roll and reduce cornering confidence, thereby discouraging aggressive driving. One commentator summed up Ford's "goal-obsessed" approach to the Explorer model when he observed, "In other words, two of Ford's responses to Explorer instability were to sell it to people who didn't drive hard and to make it scary for those who did, so they'd back off before getting into more trouble."^[5]

Rationalization and Blaming the Victim

Against this background of manufacturing and design decisions, it is not surprising that denial was one of the first responses of executives at both companies to the early reports of tire failure and rollovers. Reports of accidents coming in from overseas subsidiaries in Saudi Arabia and Latin America were dismissed as resulting from the high heat and hard driving conditions in those countries. Victims, too, were blamed. Apparently, many drivers paid less attention to tire inflation guidelines than they should have. The problem was compounded by the fact that recommended inflation levels for the tires were already close to the point where increased friction with the road would cause heat to build up and the tread to separate. This combination of factors led Bridgestone/Firestone executives to point the finger at Explorer owners, who it accused of failing to maintain proper inflation levels on their tires. "Any problems associated with this tire," one manager explained, "are not problems resulting from any deficiency in the design or manufacture of the tire itself, but rather, from the maintenance habits of a large portion of American motorists."^[6]

Ford had its version of this rationalization for its questionable design decisions. When excessive loading of the Explorer was implicated in heat buildup and tire failures, Ford issued a statement clearly blaming drivers: "With the Explorer or any other truck, it is the responsibility of owners to check weight labels posted on the inside of the doors and then limit the weight put inside, with particular attention to not putting too much weight on the back of the vehicle." However, safety experts critical of this position pointed out that few sport utility customers think of their vehicles as trucks, much less check the weight ratings on the label. Indeed, it was Ford's marketing objective to move the Explorer into a non-truck category in consumers' minds. Hence, although they tried to do so, both companies could not easily evade responsibility for poor decisions on the part of the end-users of their products. If Bridgestone/Firestone and Ford were to acquit themselves ethically, they had to anticipate how customers would be likely to use the tires and the Explorer and design products with comfortable margins of safety.

Failures of Leadership and Value Conflicts

Both of these factors played a powerful role in this episode. Even under the best of circumstances, the merger of two corporate cultures is a difficult enterprise, but it becomes even more so when companies have different national identities and value systems. That Bridgestone/Firestone did not initially achieve a unified organizational culture is shown in the parent company's arms-length relationship to its North American unit and its excessive revenue demands during a stressful period of transition. Later, as tire problems developed, it was clear that this division of corporate cultures continued. In a surprisingly candid admission, Yoichiro Kaizaki, president of the parent Bridgestone of Japan, [explained at a] Tokyo news conference... [why] Bridgestone executives ignored signs of trouble. "If there was a problem with a Bridgestone tire," he explained, "our technology staff in Tokyo would rush to the site overseas to help out. But if a problem arose with a Firestone tire, they wouldn't do anything."^[7]

Earlier, I remarked that diversity of cultures in business organizations can be a positive thing. This is particularly true if differing values enrich peoples' perspectives and educate them into alternate ways of doing things. The Japanese business presence in the United States had this effect during the 1980s and 1990s, as Japanese firms like Honda and Toyota brought a new emphasis on product quality and employee performance to the American workplace. What the Bridgestone/Firestone episode reveals, however, is just the opposite dynamic at work. Instead of coming together into a larger, more powerful whole, the undigested twin cultures led to divisiveness and neglect. Like Buzz's fractured group on the mountainside, components of the new company went separate ways, and the victim in this case was not a solitary Sadhu, but millions of people who relied on Firestone tires.

Buck-Passing

Post-event analysis of the Explorer-rollover episode shows that it resulted from the combined effect of independent decisions made by Bridgestone/Firestone and Ford executives. Few doubt that many of the all-terrain ATV and Wilderness tires manufactured by Firestone during the mid-1990s were substandard or even defective. However, it was the use of these tires on Ford Explorers that created the recipe for disaster. In almost all cases, death or injury resulted when the heavy Explorer, with its imposed requirement of low tire pressure and high center of gravity, rolled over when a rear tire suddenly failed. Firestone tires on most other vehicles would not have failed so suddenly or, if they did, would not have had such a catastrophic effect. Ford Explorers equipped with sturdier or better-inflated tires would not have succumbed to their rollover tendency.

In the frenzy of name-calling that accompanied media coverage of the recall, Ford executives pointed to this latter fact in order to shift blame onto Bridgestone/Firestone. They observed that during the mid-1990s, nearly half a million Explorers had been equipped with Goodyear tires. These vehicles had not experienced significant tire failure or rollover problems. In the eyes of Ford executives, this "proved" that the Explorer was safe. Alluding to these facts, Jacques A. Nasser, Ford's chief executive, [stated flatly,] "We know that this is a Firestone tire issue, not a vehicle issue."^[8] But, of course, this obscures the role that the Explorer design played in these events. Nasser and other Ford executives' stubborn refusal to admit their part in the tragedy, their consistent efforts to shift blame, first to customers, then to their supplier, epitomize corporate buck-passing at its worst.

Decision Making by Technicians

The experience of Buzz and his companions shows us how easy and seductive it can be for leaders to hand over decision-making responsibility to technical experts of one sort or another. In the Explorer episode, we can identify many examples of this tendency, although one in particular had tragic consequences. This involved decisions by both the tire and automaker to heed lawyers' advice to avoid exposing themselves to legal liability.

This tendency manifested itself as early as 1997, when reports of the failure of Firestone tires on Ford Explorers began to arrive from countries in the Gulf region, Venezuela, and other Latin American nations. These failures were a warning sign of what was to come, but lawyers for both firms cautioned managers not to alert U.S. government officials of the problem. As one journalist reports, "Memos showed that lawyers for the auto and tire makers worried that the U.S. government might see the action as evidence of a safety defect and insist on a U.S. recall. No law required either company to report the actions, and neither did."

With the wisdom of hindsight, we can see that an early opportunity was missed to report and identify a problem that would only grow. Focusing on their narrow duty of protecting the companies in the cases at hand, lawyers for both firms missed the larger picture. Managers who heeded them and failed to appreciate the importance of a growing problem served their companies poorly and contributed to the epidemic of U.S. accidents that would occur.

It is always difficult for a manager to override the advice of a skilled legal professional, or for that matter, any professional that the company relies on for counsel. The lesson here is not that we are to ignore our Sherpas. They are an essential resource for informed managerial decision making. It is rather that theirs cannot be the last word in a complex managerial decision with ethical significance. Their advice must be weighed against fundamental value objectives that define a company and shape its ethical responsibilities. If technical advice threatens or undermines those objectives and responsibilities, it must be reconsidered, and alternate ways of reaching appropriate organizational goals must be sought.

Alien Cultural Environments

For Buzz and his colleagues, it was Nepal that posed the challenge of an alien cultural environment. For companies, however, "strange" or "new" environments come in many forms. The "alien" can arise when a Japanese company acquires a U.S. subsidiary, or vice versa.

New business opportunities, products, or technologies can also thrust managers into unfamiliar territory. In this case, perhaps the leading "alien environment" was Ford's effort to design and manufacture a new kind of sport utility vehicle. We've seen that engineers and designers accustomed to truck manufacture strained to develop a truck-based vehicle for a wholly new market. Their tendency to bring truck-based thinking to this endeavor, as evidenced by their approach to vehicle loading and suspension issues, shows how hard a transition from one sector to the next can be.

Failures of Individual Moral Responsibility

It is clear that many organizational forces working together contributed to the events that led Bridgestone/Firestone and Ford to produce a vehicle and tires that unnecessarily killed scores of people and injured many more. Understanding those organizational dynamics does not excuse the individuals whose carelessness or indifference contributed to these outcomes. All these people bear a measure of responsibility, from the line managers at Firestone who allowed uninspected tires to leave the plant to Ford designers who rationalized the manufacture of unstable vehicle as a means of encouraging driver caution.

Does this mean that organizational factors are unimportant? No, it is just the opposite. Careful attention to organizational dynamics can help spare managers from being faced with acute or agonizing moral dilemmas. Furthermore, managers' individual moral responsibilities extend to the decisions they make, whether in the examples they set or the policies they select, that shape and mold the organization's culture. Organizational ethics and individual ethical striving are not alternatives, but mutually reinforcing aspects of business ethics.

Conclusion

Nobody will ever be able to restore wholeness to the Labib family or to the hundreds of others whose lives were marred by culpable neglect and mismanagement at Bridgestone/Firestone and Ford. This terrible episode, however, offers a cautionary lesson for all business managers and for each one of us in our personal lives as well. If we are to minimize or avoid ethical disaster, we must act differently than Buzz McCoy and his companions or the Bridgestone/Firestone and Ford managers. Specifically, we must

• Seek to reduce the stress we create within organizations and prepare and train for stressful situations. Key organizational values should be discussed and implemented before stress arises.
• Beware of goal obsession. When a single objective looms so large that we can't let go of it and we risk imperiling our most basic values in its pursuit, it is a warning sign.
• Avoid rationalization and victim blaming. When we find ourselves struggling to justify things that we sense are wrong, or when we become irked at people we are harming, this should be a sign that we may be on morally questionable ground.
• Develop good organizational leaders and make sure that in times of crisis the lines of responsibility are clear.
• Achieve organizational consensus on key values, especially those related to our ethical responsibilities. Diversity and decentralization are good, but not when they lead a company to act uncertainly or in opposing ways in the face of ethical challenges. On matters of ethical integrity, all the members of an organization, from top leaders to rank file, must speak with one voice.
• Refuse to tolerate buck-passing. Managers who accept responsibility for their decisions—and even for their mistakes—are better than those who try to offload responsibility on others.
• Reward those who furnish examples of good behavior and punish or fire those who do not. Nothing rots an organization quicker than keeping "bad apples" around.
• Avoid allowing technicians to make strategic decisions. We should always ask ourselves, who are our Sherpas and who are our leaders?
• Be careful when entering alien environments. This is not a geographical issue. Managers for a staid manufacturing company can tread on unfamiliar ground when they acquire a film production division and suddenly find themselves doing business in the fast-paced world of Hollywood. New terrain can stimulate and challenge a company, but it can also cause managers to lose their moral bearings.

Exercise moral responsibility. Groups can help us or hurt our moral performance, but in the end, we stand as individuals responsible for the organizations we shape and ourselves. Above all, we must never forget that our most important measure as human beings is whether we have lived our lives with integrity. We should try to avoid having Sadhus on our conscience, whether they are holy men left behind on a mountainside or innocent victims of our company's bad products.