Is the Post Office Horizon scandal a ‘Man Made Disaster’?

It is almost 30 years since the untimely death of Professor Barry Turner, a pioneer of organizational theory and at the time the emerging discipline of risk management, in which he published the seminal book (now sadly out of print) ‘Man Made Disasters’ [1, 2].

Through detailed analyses of official reports, such as that of the inquiry into the Aberfan mining disaster, where a generation of schoolchildren in the small Welsh village of Aberfan were wiped out when their classrooms were engulfed by a deadly slide of mining slurry, Turner showed that such ‘organizational disasters’ were not unfortunate accidents but, in fact, result from years of organizational neglect.

In one of his great insights, Turner wrote that “disasters, other than those arising from natural forces, are not created overnight.  It is rare that an individual, by virtue of a single error, can create a disastrous outcome in an area believed to be relatively secure.  To achieve such a transformation, he or she needs the unwitting assistance offered by access to the resources....  of large organisations, and time”.  In other words, such disasters are systemic not idiosyncratic events!

If Turner were alive today, he would certainly be asked to run his perceptive eyes over the Post Office Horizon fiasco [3], a prime example of what he characterised as an ‘organizational disaster’. Turner argued that an organizational disaster or “cultural collapse” takes place because of “some inaccuracy or inadequacy in the accepted norms and beliefs” of a firm. This means organisational disasters build up gradually over time and the signs SHOULD be apparent to management, but instead, the warning signs go unnoticed or ignored because of “cultural rigidity”, which manifests itself in erroneous assumptions and reluctance to face unpalatable outcomes.

The Post Office certainly suffered for decades from ‘cultural rigidity’ refusing to countenance that collectively they were wrong, and their “accepted norms and beliefs” were inaccurate and inadequate. This phenomenon is sometimes called ‘wilful blindness’ but on an organizational, rather than an individual, scale.

Today, we are in the all-to-familiar ‘cherchez the scapegoat” phase of this disaster, and with the Post Office there are very many candidates.  However, finding a scapegoat does not provide any deep insights into what caused the disaster, merely a feeling of ‘there but for the grace of God go I’.  Finding an obnoxious scapegoat does not solve any problem, since if you don’t know what you are fixing, you cannot fix it!

[Note, all scapegoats become by definition 'obnoxious', since if there were not at the beginning they become so after their heretofore perfect reputation is trashed!]

But why should operational risk and operational resilience managers care about Turner’s work or even the Post Office fiasco?

For operational risk managers, the Post Office case has all the components of operational risk: (1) people - making unconscionable but self-justifying decisions; (2) processes - clearly inadequate legal and operational processes; (3) systems – manifest failures of the Horizon system and outsourcing and system renewal; and external – government interference, or, as Turner identified, the ‘involvement of strangers’ (muddying the waters).

For operational resilience managers, the Post Office case shows that when an accident occurs, it is already too late to do anything meaningful but tidy up and that potentially disastrous incidents must be identified and corrected WELL BEFORE they manifest themselves. Turner’s work shows where to start looking.

Operational risk and operational resilience are two faces of a multi-faceted problem – how to avoid disasters that could potentially cripple a firm.  But both tend to be focused on the outcome and proximate causes when they should ALSO be focused on understanding the deep underlying causes and the weaknesses in the organizational foundations.

Understanding that  organizational disasters don’t just happen but materialise over time should help prevent at least the worse excesses of such failures. And Turner’s valuable insights provide a roadmap for doing so.

[1] Turner’s book ‘Man Made Disasters’ is out of print, but the following article (unfortunately behind a paywall) summarises Turner’s arguments.

Turner, Barry A. 1976. “The Organizational and Interorganizational Development of Disasters.” Administrative Science Quarterly 21(3):378–97. doi: 10.2307/2391850.

[2] For an appreciation of Professor Turner’s work, see

Bills, Kym, Leesa Costello, and Marcus Cattani. 2023. “Barry Turner: The Under-Acknowledged Safety Pioneer.” Safety 9(4):68. doi: 10.3390/safety9040068.

And

Jeffcutt, Paul. 2007. “Obituary: Professor Barry Turner (1937–1995): Studies in Cultures, Organizations and Societies: Vol 1, No 1.” Retrieved June 18, 2024 (https://www.tandfonline.com/doi/abs/10.1080/10245289508523441).

[3] Wallis, Nick. 2022. The Great Post Office Scandal. Bath Publishing.