What I have unfortunately noticed in my own longish experience is that the events in troubled organizations tend to go the same way as this scene in Willy Wonka and the Chocolate Factory:
1) Person is brought in.
2) Person is advised of what is correct behavior.
3) Person develops a mind set that an alternate behavior would bring dividends.
4) Person is warned in a futile sounding "Stop, stop"
5) Person performsa the alternate behavior anyway.
6) Undesirable outcome is manifested.
7) Person is removed, or not, perhaps is changed by the experience but perhaps not.
8) The rest of the group proceeds until the next time.
My personal experience includes a matter of material identification. I worked in a company that did not mark or label its material. When enormous and expensive forged copper billets were eventually joined by identical-looking cast copper billets (which received a different machining pattern) and my repeated suggestion to the President that "We really should mark our material so we know what it is" was met with "I don't want to bureaucratize the company," you can guess what eventually happened. The wrong billet was put in the machine, the button pushed, and about $8K of material instantly became scrap.
From that moment those copper billets were labeled as to their material, but nothing else received the benefit of this learning until the company eventually went on to certify ISO.
I learned to make small improvements without consulting my boss, the President. When items were going into the crate for shipment, some of them looked the same. They all had their invoices wedged in between them, presumably identifying the pieces. But sometimes they worked loose during trucking and the customer couldn't figure out which was what. Sometimes we would have to make a quick replacement part. Costs of poor quality went ker-ching! when this happened. So one day I just marked the invoice numbers right on the parts with paint pen. Never again did our clerk receive those maddening calls claiming "You sent the wrong part" and we never had to replace the mystery parts because they were no longer a mystery. One day the President stood over the process of packing that crate, watched me marking those pieces and made a comment. "Yes," I said, "Since I started marking these, which only takes a minute, never again has Sally gotten the call that we sent the wrong piece and need to send them another one." He nodded, slowly and silently, but did not change his behavior and I was still not let into the circle of influence, where my ideas could save the company money with their bureaucracy.
Every horse can make a choice to die of thirst.
There is plenty of evidence we can indeed help provide the company with appreciable and robust returns. For a decade, the National Institute of Standards and Technology did an annual informal study
comparing the market performance of Baldrige Award winning companies against Standard & Poor index. Until recent years, the Baldrige companies were shown to outperform S&P. Now that the real estate bubble has burst and after the dust from these takeovers and bailouts has settled, I will be interested to see if the study is repeated and what the numbers show.
Moral of the story? We can indeed learn from the mistakes, and we have freely shared amongst ourselves (I said that nicely didn't I?) our learnings and observations of these icky events. But our influence extends precisely to the line where our insights/warnings/learnings/advice are invited into the decision making process, or behavior modification if any, that brings the outcomes we see.