GM released the Valukas report on GM’s “troubling disavowal of responsibility” for crashes and deaths caused by a faulty ignition switch yesterday. Their lawyer’s no-holds-barred description of GM’s internal management failures will have a place on my regular reference shelf along with the investigations of 9/11 and the Challenger crash as stories of how organizational culture and structure can literally kill you. GM’s new leader rightfully promises a culture shift, and we can only hope that she will succeed. In my consulting practice, I see smaller examples of what the report describes as the GM “Nod,” where everyone in the room nods, and then no one does anything when the meeting is over; or the GM “Salute,” where you cross your arms and point your finger at someone else while disclaiming responsibility. From the VA to GM to BP to tomorrow’s headline, we continue to struggle with how to implement systems, structures and measurement that help us achieve our goals without having lethal side effects. It’s humbling to realize how hard it is to detect problems (the initial cause of the failures were traced to one engineer, who repeatedly denied making the decisions that caused the product failure) and how often similar problems of accountability surface in other organizations. I’m posting the Journal’s article on my wall next to a mirror, with the hope and prayer that I and the organizations I advise will do better.