Joe Paterno, Penn State and the sexual abuse scandal

 The news from Pennsylvania State University (Penn State) has been riveting. For those who have not been following this story closely, a onetime football coach, Jerry Sandusky, has been convicted of molesting young boys in the showers and locker rooms of the university’s gymnasium facilities. One glaring and controversial issue is why university officials, including the famed head-football coach Joe Paterno, now deceased, as well as the President of the University, Graham Spanier, withheld the information they had about Sandusky’s crimes from as early as 1998, thus exposing more boys to potential harm.

The NCAA, the association that oversees collegiate sports, imposed extraordinarily heavy penalties on the university for this lapse. They fined Penn State $60 million, instituted a four-year ban on bowl game appearances, took away scholarships, and forced the university to forfeit victories going back to 1998. Many observers regarded the penalty, particularly its last part, as too severe. Why deprive all past football players of the record of their wins because a single coach had molested children. Moreover, as one newspaper editorial suggested, the courts had only charged two of the actors, a coach, Tim Curley and an assistant vice president, Gary Schultz, with endangering a child by failing to report. They had not yet convicted them. Could the NCAA act as the judge and the executioner before the courts established guilt or innocence? 

There were other anomalies. As one reporter noted, “Many officials in law enforcement and child-welfare organizations can’t name instances of charges being brought against individuals who failed to report a crime relating to child abuse.” Why were Curley’s and Schultz’s failures treated with such unusual severity? Finally, Paterno was a university hero. He had built the football team into a national powerhouse, had catapulted the university into the ranks of great institutions, and had helped raise millions of dollars for its academic programs.  In 2001 the university had in fact erected a statue of him in his honor, cast in bronze. But after Sandusky's crimes were revealed, the university pulled down the statute, in a gesture that was one step away from burning him in effigy. The king was dead and it seemed, deservedly so.  Paterno in fact had actually died some six months before.

In addition, some observers were puzzled by what they interpreted to be the NCAA’s “holier than thou” stance. The NCAA imposed its penalty in the context of a particular narrative. As the narrative goes, the reason that top Penn State officials had taken no action, was that they were protecting the football program from embarrassment, and perhaps disgrace. This showed, the NCAA suggested, that the football program was too revered, that people acted as if football were more important than such values as integrity and decency, values core to university life. Yet, as many observers also noted, the NCAA as a vehicle of the universities themselves, had done more than any other body to elevate the role of college sports as universities’ moneymaker.

The proximate stimulant for the NCAA's decision was the Freeh report, a report commissioned by the University’s board of trustees and written by Louis Freeh, an ex-FBI director. Yet a careful reading of the report reveals considerable ambiguities. The report highlights two incidents, the first in 1998 and the second in 2002. In the first incident, a boy’s mother told university officials, as well as the local police, that Sandusky had showered with her son in a university locker room. The police referred the case to the Department of Public Welfare (DPW) whose expert, John Seasock, found that Sandusky was not in fact a pedophile. In addition, the district attorney decided that there was insufficient evidence to charge Sandusky with a crime.  Moreover, there is a very little evidence in the Freeh report about Paterno's involvement in the events surrounding this first incident. There are simply two emails in which others reference the “coach.” Paterno’s family insists that he had no knowledge of the first event. The Freeh report provides very limited and only indirect evidence that he did.  Indeed, it notes that, “After Curley's initial updates to Paterno,” [inferred from emails written by Curley to Schultz- LH], “the available record is not clear as to how the conclusion of the Sandusky investigation was conveyed to Paterno.”

The second incident in 2002 was more complicated. It is important to note that it took place when Sandusky was no longer a university employee, but did have access to the sports facilities. A graduate student, Michael McQueary, saw Sandusky and a boy, through their reflections in a mirror, in a shower room. They were engaged in what appeared to be sexual activity. Sandusky had his arms around the boy’s waist and the boy, with his back to Sandusky, had his hands pressed against the wall. McQueary did not see "insertion" nor did he observe any signs or sounds suggesting coercion. When McQueary slammed a locker door to make noise, Sandusky and the boy separated and looked directly at McQueary, who then left the locker room.  

McQueary, on the advice of his father reported the incident to Paterno, but as one reporter notes, “out of respect for Paterno, he did not reveal the details of what he saw.” He did not use the terms “sodomy” or “anal intercourse,” even though he believed intercourse had occurred. Paterno told him, “You’ve done the right thing. I know it is probably tough for you to come here and tell me this, but you've done the absolutely right thing.” When McQueary later described what he saw to Curley and Schultz, “He again refrained from describing all of the lurid details.”

As the reference to McQueary’s less than full description suggests, what happened next, is that the story of what he saw, was transformed from one about intercourse to one about wrestling, horseplay and fondling. The most important question is whether or not this transformation was motivated, to cover up what happened, or was the result of the discomfort, or more strongly the disgust people felt in considering the scene McQueary described. Clearly, McQueary felt the details were as he notes “lurid,” and that he omitted them to protect his listeners. When Schultz testified to the grand jury he remembered McQueary describing, “some kind of wrestling around and maybe Jerry might have grabbed the boy’s genitals.” Paterno remembered McQueary as describing that Sandusky, “Had fondled the boy.” 

One possible source of discomfort, and what may have made the scene lurid to McQueary, was that that he was observing a homosexual act. Sociologists refer to the culture of male sports as “homosocial.” This means that athletes touch each other a lot to express both affection and aggression, but that at the same time this touching, wrestling and embracing must reinforce a strong taboo against expressing sexual desire, even if desire is stimulated. The touching signifies, that in this case, touching does not signify, desire.  This is a tricky boundary and it is no accident that a predator such as Sandusky would use a sports setting to satisfy his sexual compulsions. Indeed, Schultz described Sandusky as a physical person. “He always touched folks, young and old during conversations. He frequently put friends in headlocks, slapped them on the back, grabbed arms and other body parts, in physical displays of affection.”

Social taboos operate by promoting disgust, for example, a religious Jew or Muslim finds pork disgusting, and it is likely that McQueary’s story stimulated a similar disgust.  One hypothesis is that the disgust, and the anxiety this feeling created, helped transform the story from one of sexual penetration into one of wrestling, horseplay and at the most, some fondling.

As the Freeh report suggests, Paterno’s involvement in this second incident was limited, after he told Curley and Schultz what McQuery had reported. The latter two met twice with Sandusky who denied he was engaged in sexual activity. Influenced partly by the 1998 expert’s report, Sandusky’s denials, their view of the event as closer to horseplay than to intercourse, and perhaps by the fact that Sandusky was no longer an employee, they did not report this event to the police. Instead, they forbad Sandusky from bringing boys into the Sports facilities in the future. They also reported McQueary’s story to the board chair of Second Mile, an organization Sandusky helped found, which gave opportunities to disadvantaged and at risk children. He had remained active in Second Mile after his retirement from Penn State.  

The Freeh report castigates Penn state officials for not recognizing, that by failing to report a predator to the police, they were putting boys in danger. But many adults do not really understand the possible psychological impacts of sexual relationships between adults and children. Long ago the famous psychoanalyst Sandor Ferenczi described sexual relationships between adults and children as shaped by the “confusion of tongues.” In this confusion,  adults assume that a child’s ignorance protects him from experiencing sexual gestures as in fact sexual. This same confusion leads the adult to confuse the child’s submissiveness as a token of the child’s love. Moreover, the famous “Rind report,” (http://www.mhamic.org/rind/), a controversial “meta-analysis” of 59 studies of the impact of sexual abuse on children, which passed the test of peer review, noted that the impact of sexual abuse on children is in fact variable.  Girls suffer more than boys, some children find the experience positive, and the degree of coercion matters. The authors of the study concluded that the legal term, “child sexual abuse” was far too imprecise. Moreover, Pennsylvania state law mandates that certain professionals, such as teachers, physicians, social workers, child-care workers and camp counselors, are required to report an incident of child abuse. College level coaches are not explicitly mentioned in the law, and it is highly unlikely that Penn State officials ever considered themselves to be “mandatory reporters.”  By the same token, it is highly unlikely that they had any formal training on what to observe and how to report. Indeed, these last two facts may very well lead to Schultz’s and Curley’s acquittal on this charge.

There is the old saying, “There but for the grace of God go I.” It represents folklore’s counsel that we need to mitigate our tendencies to judge the wrongdoing of others by acknowledging our own potential for wrongdoing. This counsel also suggests that we judge each other too harshly when we fail to acknowledge the likelihood that we too could have made the wrong decision. Many people responded with disgust to the story of Penn State’s failures to stop Sandusky, but this disgust may protect them from acknowledging their own potential vulnerability, their own penchant for not reporting and sending a colleague to jail based on ambiguous evidence. 

Thinking organizationally, it is proper to hold leaders accountable for violations of the law, or failures of judgment. But to prevent future failures we should also understand the failure as the result of a human process, in which culture and group dynamics, also play a role. This is now the common wisdom for understanding why industrial accidents happen, or why patients are harmed in hospitals. Decisions makers are accountable, but they make decisions in a context they don't control. 

The Freeh report recommended that Penn State implement improvements to prevent future child abuse, such as appointing an ethics officer, improving background checks of prospective hires, and appointing a chief compliance officer. The problem with these suggestions, however commonsensical they may be, is that they paint the picture of organizations as machines without regard to the human processes of judgment, feelings and social ties that undergird them. The latter are the true engines of success as well as failure. One hypothesis is that even if  the Freeh report’s recommendations had been implemented prior to Sandusky’s crimes, the psychological and cultural issues that shaped peoples’ responses, would have remained the same.

We face one last question. In light of these ambiguities and complexities, what explains the rage against Paterno, as if he rather than Sandusky were the sexual abuser, so much so that we had to topple his statue? What gave the NCAA license to judge the culture of athletics at Penn State as lacking, when it was itself partly responsible for “big time football’s” corruption of academia? One is tempted to conclude, following the work of my colleague Howard Schwartz, that we take pleasure in what psychoanalysts call the symbolic, “killing of the father.” (see, Society against itself: Political Correctness and Organizational Destruction, http://www.karnacbooks.com/Product.asp?PID=28569). Perhaps, Paterno, even though his guilt was partial, had become the symbol of the corrupt father whose claim on resources and our attention results entirely from his abusiveness, rather from his achievements. 

There is in the air, a picture of society built on this kind of corruption. This picture may help us explain to ourselves why our own accomplishments may be limited, while others’ appear extraordinary.  The latter’s claims, from this point of view, are illegitimate, because they have stolen our resources and our talents.  In that sense, killing the father expresses and relieves us of our envy. There is of course corruption in society, and as the history of the recent financial crisis suggests, we have decision makers and business leaders who are undoubtedly guilty of malfeasance. But we are at risk of undermining our society’s accomplishments, of being self-destructive, if that is all we see.

Barclays Bank, Robert Diamond and the LIBOR scandal

The recent revelations that Barclays bank lied about the rate at which it could borrow money from other banks, “the LIBOR scandal,” raises interesting questions about executive decision making and the political imagination. The Bank of England (BOE) asked Barclays’ CEO, Robert Diamond to resign, several days after Great Britain’s Financial Services Authority (FSA) had agreed to settle the charges against the Bank. While the FSA had fined Barclays some $450 million dollars, it had expressed support for Diamond to remain in his role. 

The Wall Street Journal describes the details of Diamond’s firing. On July 2, the Bank of England's governor, Sir Mervyn King, “summoned Mr. Agius, [Barclay’s board chair] and Mr. Rake, [a board member], to a meeting that evening. The two directors didn't know why. At 6 p.m., Messrs. Agius and Rake sat down with Mr. King in a private reception room at the central bank's headquarters. ‘Bob [Diamond] has lost the confidence of regulators,’ Mr. King told them. He said Mr. Diamond should be gone within 24 hours and told them that the U.K. Treasury chief, Mr. Osborne, also agreed, according to a person familiar with the meeting.

Messrs. Agius and Rake were taken aback by the extraordinary dictate from the central bank's governor. They protested that the FSA hadn't objected to Mr. Diamond keeping his job and that his removal would be destabilizing to the bank, given Mr. Agius's [prior] decision to step down [as chair]. Mr. King said the matter wasn't up for discussion. The meeting was over in less than 30 minutes, the person familiar with the meeting said.

Outside the Bank of England building, Mr. Agius's Mercedes was waiting. He and Mr. Rake drove to a Barclays' office in London's Mayfair district and convened a conference call of the bank's non-executive directors. The board decided to ask for Mr. Diamond's resignation.

Then Messrs. Agius and Rake drove the few miles to Mr. Diamond's rented town house in the posh Chelsea neighborhood. They arrived after 10 p.m. Mr. Diamond was alone; his wife and children were in the U.S. for the Fourth of July holiday. Mr. Agius told Mr. Diamond about Mr. King's demand and the board's decision. Mr. Diamond responded with "stunned silence," according to a person familiar with the meeting. He told the two directors that he needed time to think and talk with his wife. He promised to call them later that night.

The directors left after about 15 minutes. Within hours, Mr. Diamond's lawyers had negotiated the terms of his exit, which included deferred bonuses that could be worth more than $30 million. Days later, he relinquished the payout amid a continued public uproar that shows no signs of abating.”

Three questions are; why was Agius taken aback; why was Diamond stunned; and why did the Bank of England (BOE) make such an extraordinary request?  The reporter’s text gives one obvious answer to the first two questions. Both the chair and the CEO believed that the bank and its CEO had the full support of the FSA. What upended that understanding, and might the answer to this question help explain the BOE’s extraordinary request? 

I want to suggest that Diamond and Agius were stunned because they lacked what we can call a “political imagination.” They believed quite reasonably that their explanation of the Bank’s malfeasance was entirely sensible and put to rest charges that the bank’s senior management had been reckless, unethical or self-serving. And from a logical point of view they are entirely right. 

In a report the Bank published the day before Diamond was scheduled to testify before a parliamentary committee, but one day after his surprised firing, Barclays highlights the following.  

There were two separate incidents of LIBOR manipulation, one in 2005 and one in 2008, during the financial crisis. In the first, lower level traders asked their peers, who submitted the bank’s rate to the LIBOR committee, to increase or decrease their submission a bit, so that particular traders’ financial positions would be enhanced. For example, if the bank paid a counterparty LIBOR plus 2%, a lower LIBOR could reduce the trader’s obligations. It should be noted however, that no bank can significantly distort the final reported LIBOR rate, since the latter is calculated as a “trimmed average” of the rates submitted by 16 banks. Banks, whose submitted rates fall within either the top or bottom quartiles, are simply excluded from the calculation. The traders and submitters at Barclays thus had limited influence on the outcome. 

In October of 2008 during the financial crisis, the situation was entirely different. Bank runs threatened many banks, and a bank’s reported LIBOR became a measure of its solvency. If other banks would lend money to a particular bank at only high rates, then how sound could the bank itself be? Indeed, while Barclays reported higher LIBOR rates than most of its peers, its senior executives believed that other banks were under-reporting their rates to look good. Since Barclays never needed a bailout, this interpretation seems reasonable. 

Indeed, in that same month, in 2008, the Wall Street Journal estimated that of the 16 banks in the LIBOR panel, Citigroup, Germany's WestLB, the United Kingdom's HBOS, J.P. Morgan Chase & Co. and Switzerland's UBS, were most likely to be under-reporting. Moreover, Barclay’s concern, that its reported rates could lead to unwarranted concerns about its solvency, was sound. For example, Bloomberg published an article entitled “Barclays takes a money market beating” on September 3, 2007. It noted that Barclays’ LIBOR submissions in three-month sterling, euro and US dollars were the highest of all banks contributing LIBOR submissions. The article posed the question, “What the hell is happening at Barclays and its Barclays Capital securities unit that is prompting its peers to charge it premium interest rates in the money market?”

Finally, Barclays raised the issue of under-reporting to the FSA, the Bank of England and the Federal Reserve Bank. Indeed, as the New York Times reports, in 2008 Barclays informed the New York Fed that it was submitting artificially low rates! “The concerns were passed on to Timothy F. Geithner, then the chief executive of the regulatory body. But the New York Fed did not tell other authorities in the United States or Europe about the specific problems at Barclays. Instead, it proposed changes to the rate-setting process.”

So what forced Diamond’s firing? 

Barclays report reproduces a note Diamond wrote after a call he had with Paul Tucker, the Bank of England’s executive director for markets. The call was on October 29^th 2008.  “By Diamond's account, Mr. Tucker told him that he had "received calls from a number of senior figures within Whitehall to question why Barclays was always toward the top end of the LIBOR pricing." 

After Mr. Diamond explained the bank's pricing, he says, Mr. Tucker reiterated that the calls he was receiving from the government were ‘senior’ and added that ‘while [Mr. Tucker] was certain that we did not need advice, that it did not always need to be the case that we appeared as high as we have recently.’”

When Diamond reported this call to his subordinate, Mr. Jerry del Missier, the latter interpreted the call as an instruction from the bank of England to lower its LIBOR submissions. And he complied. Diamond later denied that this was the note’s meaning.

Diamond’s transmission of his note and its subsequent impact highlights a familiar process. Senior executives and government leaders in politically delicate situations often speak in coded terms. By convention, the higher ups need protection, they represent the franchise, so that it is up to those lower down to interpret the code, in ways that protect the higher ups and the organization. This also reflects a fundamental survival principle in any organizational hierarchy; “make your boss look good.” Misseir’s interpretation and subsequent action in this sense appears entirely reasonable, even if unethical. He believed he was receiving an instruction from the Bank of England. Diamond’s later denial of the note’s meaning is consistent with the idea that the purpose of coded language is in fact to facilitate deniability. 

However the note’s inclusion in Barclays report raises a more fundamental issue. If the note had no salient meaning, as Diamond later argued, why was Barclays including it in the report?  One obvious explanation is that the bank was protecting its reputation by declaring that it rigged its LIBOR submission in response to a request from the Bank of England!  While the report was published the day after Diamond’s resignation, it clearly had been in preparation for some time and in all likelihood, the BOE governor, Sir Mervyn King had advance notice of the report’s content. It seems reasonable to conclude that this is what triggered the BOE’s decision to make its extraordinary request that Diamond be fired. Indeed, a former director at the FSA, Lindsay Thomas, noted that “suggestions that the Bank of England had condoned the rate-rigging practice would have been 'a Rubicon' that would have led Sir Mervyn to demand Mr. Diamond be forced to quit. He told BBC Radio 4's World at One: 'They would have been livid. I would think that the Governor would have called up Barclays and made it plain that that's what they expected to happen.’”

One question is why Diamond and his peers had been so obtuse as to include the note in the report? Indeed, as the Wall street Journal reports, while some of Diamond’s subordinates believed the note underlined Barclays’ innocence, others worried that it would launch a war against the regulators. Moreover, in 2007, “Mr. King delivered a series of speeches attacking what he described as overpaid London bankers, an apparent reference to Mr. Diamond, who was one of London's highest paid.” The regulators had declared war 5 years ago!

One hypothesis is that Diamond’s decision to include the note in the report reflected a profound lack of political imagination. The political imagination is based on two frames of reference; understanding the role of symbols and their relationship to emotions in shaping reasoning, and understanding the “games” of self-interest in which for example, “the enemy of my enemy is my friend.”

These frames of reference make contradictions look reasonable.  For example, because Barclays cooperated extensively with the authorities in Britain and the U.S.- in the words of the Department of Justice, “the nature and value of Barclays cooperation has exceeded what other entities have provided in the course of this investigation,” --it was the first to settle and therefore the first to be exposed.  But as the first, it then became the ready symbol of the “bad bank” responsible for the financial crisis a reprise of Sir Mervyn King’s earlier attack on overpaid bankers. Similarly, Ed Milliband, the head of the Labor party called for a criminal investigation of bankers who broke the law by rigging the LIBOR rates. In effect, he was siding with the Bank of England, an institution on the other side of the class divide, because the former opposed Barclays, a symbol of the “bad bank.”

Both of these understandings point to the limits of what some call “technical rationality,” that is, the logical delineation of the relationships between means and ends based on facts and data. It is likely that Diamond, a man schooled in technical rationality by virtue of his expertise in finance, was seduced by the reasonableness of his own case. He could not see beyond the logic of cause and effect which rules out contradictions, to contradiction’s reasonableness when seen through the prism of the political imagination. In addition, a person of Diamond’s stature and standing may lose site of his political vulnerability. After all, as the story of the call from the Bank of England suggests, Diamond’s subordinates protected him. His experience of being protected may have weakened his ability to exercise his political imagination. This may ultimately be why he was stunned when asked to resign. It was simply not logical.

CNN's reporting mistake

Several days ago, the U.S. Supreme Court ruled that President Obama’s signature legislative accomplishment, the Patient Protection and Affordability Act, (Health care reform), was constitutional. But embarrassingly, within minutes of the Court’s release of its decision, Fox and CNN first reported that the act had been declared unconstitutional. In retrospect the reason for the error was readily apparent. The Court had decreed that the mandate to buy insurance was coercive and thus not constitutional, but it was constitutional as a tax. Reporters who hurriedly flipped through the text, read the mandate argument first and the tax argument only later. Fox corrected itself within two minutes, but it took CNN a full seven minutes, after its announcement had circulated on the web and through its tweets. As one report notes, this error “was particularly embarrassing for CNN, which has suffered through one of its worst ratings quarters in several years, primarily due to a paucity of big news. The network eagerly awaited the court's decision, scheduled for 10 a.m., running a "countdown clock" on its screen for hours.”

In reporting on the mistake is the press making a “mountain out of a molehill?” Maybe, but a Buzzfeed report notes that CNN employees themselves were very upset. A half-dozen top on-air reporters and producers were “furious at what they see as yet another embarrassment to a network stuck in third place in the cable news race. ‘We had a chance to cover it right. And some people in here don’t get what a big deal getting it wrong is. Morons.’ ‘Shameful,’ another long-time correspondent told BuzzFeed. ‘It's outrageous and embarrassing,’ a third CNN staffer vented. ‘Maybe this will shake the company into understanding that CNN has not been the 'most trusted name in news' for a very long time.’” In an internal memo, CNN promised an investigation into the mistake. “Today we failed to adhere to our own standard; namely it’s better to be right than to be first. We take mistakes seriously, especially mistakes on such important stories. We are looking into exactly what happened and we will learn from it.”

At one level, an investigation hardly seems necessary. It seems clear what happened. The reporter, Jeffrey Toobin, who first got hold of the Supreme Court decision while inside the court, first read that the mandate had been ruled unconstitutional, and instead of reading on, reported this fact to Kate Bolduan, CNN’s congressional reporter. Everyone was primed to believe that should the mandate be declared unconstitutional the entire act would be ruled out of order. The pressure to be first with the news was great, so Toobin instead of urging caution until he read, however hastily, through the entire text, presumed that the legislation was dead.

Perhaps we can learn more from CNN’s response to the mistake than from the mistake itself. I suggest that the mistake stirred emotions that are stimulated by what we can call “extreme environments.” An environment is extreme when participants feel that the viability of the organization to which they belong is not secure and moreover, never will be. This feeling is linked to objective conditions, most importantly, hyper-competition. Witness for example the failure of Palm, the likely failure of Research in Motion (of Blackberry fame), and Yahoo’s stagnation; all companies, which not so long ago, symbolized the internet revolution and seemed on their way to becoming institutions.  

As we noted in an earlier post, CNN has been losing market share and standing as viewers have come to prefer news tinged by political bias, with Fox attracting viewers on the right, and MSNBC, viewers on the left. CNN’s reputation can therefore only be based on accuracy and timeliness. But viewers care less about the first, and the World Wide Web provides the second. This suggests that CNN lacks what marketers call a “unique selling proposition.” Instead, CNN makes money largely because it is included in the price of cable packages. Should cable companies “unbundle” their offerings, who will buy CNN? This is why it looks fragile, however many resources its reporters have presently at their command.

It seems straightforward that facing time pressure and competition people can make serious errors. The situation can create anxiety, clouding peoples’ judgment. But if the organization is experienced as fragile, the people who sustain it feel that the organization’s setting is unforgiving. One result is that errors feel more consequential than they might seem to outsiders. This may be why CNN staffers reacted so harshly to the mistake.

Thomas Kolditz a retired brigadier general, who led the Department of Behavioral Sciences and Leadership at the U.S. Military Academy, West Point, for 12 years, has written about leadership in extreme situations. He suggests that in such situations, where for example soldiers make life and death decisions, there can be “too much motivation.” People do not need to be revved up.  Paradoxically, because the situation is so demanding in itself, additional emotional arousal can be detrimental. One is reminded here of the calm tone pilots sustain when, in facing flight emergencies, they collaborate with another and ground controllers to land a plane safely.

One question Kolditz’s work raises, is whether or not the investigation into a mistake should itself be conducted in an emotional context of low arousal that is, with dispassion. If so, what are the “design criteria” for such an investigation? For example, one criterion, might be that no single person is to blame. It is presumed that the total situation, which demanded everyone’s participation, is the source of the error. Another, might be that the most senior people take responsibility for what was the organization’s total response to the situation. It would be useful to imagine what other criteria would apply. 

But dispassion may prove difficult. Psychoanalysts speak of "persecutory anxiety" to describe a person who feels chronically under attack.  Extreme environments may induce this kind of anxiety.  One lesson we have learned from psychoanalysis is that when this anxiety predominates people may become punishing and unforgiving towards each other just at the moment when they need each other the most.