The Field Guide › Paper
Kessler, Bierly and Gopalakrishnan use the sinking of the Swedish warship Vasa, which capsized and sank within minutes of leaving harbour on its maiden voyage in 1628, as a case study in how ambitious projects and new products fail. The Vasa was too tall and too heavily gunned for its beam and so unstable, a condition made worse by scope creep of an extreme kind: hearing that Denmark was building a two-gun-deck warship, the king ordered the Vasa enlarged to match, and the keel already laid in the ground was physically extended, the hull widened only in its upper sections because the keel was fixed, with no formal specifications drawn up for any of it. The lead shipwright had never built a two-decker and scaled his plans by proportion and instinct, which was not negligence but the state of the art: in 1628 there was no method for calculating a ship's centre of gravity, and you found out how a ship sailed by sailing it. From this the authors generalise a set of recurring organisational pathologies they call the Vasa syndrome: lack of external learning capability, goal confusion, an obsession with speed, feedback system failure, communication barriers, poor organisational memory, and top-management meddling. What makes the case genuinely instructive for a corpus about psychological safety is a detail easily lost in the telling. This is not a story in which nobody spoke. The boatswain Matsson raised concerns about the ballast and was brushed aside by Admiral Fleming with the assurance that the shipbuilder had built ships before and he should not worry; Matsson's recorded reply was that God grant the ship would stand upright on her keel. The shipwright had long suspected she was too narrow. The sailors who ran the lurch test, in which men ran side to side across the deck, stopped it early because the ship was already rolling alarmingly, and she sailed anyway. The knowledge existed and was even voiced. What it lacked was a path upward: at every layer of the hierarchy there was more reason to absorb a concern than to carry it to the next person, and so it never reached anyone with both the power and the will to act. The inquiry that followed found no one to blame, and could not honestly have done otherwise, since the king had approved the plans and armament, the shipwright was dead, and the admiral had run his test and sailed regardless; responsibility was so thoroughly distributed that no single decision looked, in isolation, like the fatal one. That is a strikingly modern conclusion to reach in 1628, and it makes the Vasa a fitting prologue to the systems-thinking tradition that would take another three centuries to arrive. Its limits are those of a practitioner-facing case essay built around a single vivid story: the syndrome is a compelling pattern rather than a tested theory, and the seventeenth-century setting does the persuasive work that data would in an empirical paper. (Text drawn from the 2001 Academy of Management Executive paper, 15(3), pp. 80-91.)