The Lieutenant Who Saw the War Coming

On October 1, 1973, a young intelligence officer at Southern Command handed his superior a report. Lt. Binyamin Siman-Tov had been watching the Egyptian army’s exercise along the Suez Canal, and he suspected it could be camouflage for a real operation. Two days later he submitted a more detailed assessment, again warning that the exercise could be cover for an attack.

His reports did not travel far. His superior, Lt. Col. David Gedalia, accepted the assessment of Military Intelligence’s Research Department and did not circulate the lieutenant’s reports. Headquarters held to what Israelis would later call “the Conception”: Egypt would not go to war until it could challenge the Israeli Air Force, and Syria would not go to war without Egypt. On October 5, the head of Military Intelligence, Maj. Gen. Eli Zeira, described the chance of war as “lower than low.” The next day, Egypt and Syria attacked.

An office for disagreement

The Agranat Commission later concluded that rigid adherence to the Conception had led Military Intelligence to misread the warnings of an impending attack. It recommended removing Zeira and several officers, including Gedalia and the head of the Egypt desk. But the most useful thing Israel did after 1973 was not to remove people. To break the monopoly of a single assessment, Military Intelligence created a team whose job is to argue against the prevailing view. Its name, Ipcha Mistabra, is Aramaic for “the opposite is plausible.” Israel did not wait for braver lieutenants. It built a place where disagreeing is the assignment.

The price of bad news

In my book, Amplianism: The Economics of Error, I argue that every organization sets a price for bad news, whether it means to or not. The book asks three questions: Who can warn? Who can try? And who pays first when something goes wrong? This post is about the first one. When warning is expensive for the person who gives it and ignoring a warning is cheap for the person who decides, the news arrives late, and the damage arrives with it.

“Take off your engineering hat”

The United States learned the same lesson in public. In July 1985, Roger Boisjoly, an engineer at Morton Thiokol, wrote that a failure of the booster’s joint seals could lead to “a catastrophe of the highest order.” On the night of January 27, 1986, Thiokol’s engineers recommended against launching the space shuttle Challenger in the cold. NASA pushed back, and Thiokol’s managers went into a private caucus. According to Boisjoly’s testimony, senior executive Jerry Mason asked the company’s vice president of engineering, Bob Lund, to “take off his engineering hat and put on his management hat.” Thiokol reversed its recommendation. Challenger broke apart 73 seconds after liftoff the next morning, and all seven crew members died.

The Rogers Commission found that Thiokol’s management had reversed its position, against the views of its engineers, “in order to accommodate a major customer.” Boisjoly paid for having been right. He was ostracized by colleagues at Morton Thiokol, and one of them told him, “If you wreck this company, I’m going to put my kids on your doorstep.” He left the company and spent years lecturing on engineering ethics.

Making honesty cheaper

America also offers the opposite example. Since 1976, NASA has run the Aviation Safety Reporting System, where pilots, controllers and mechanics can confidentially report safety problems, including their own mistakes. A pilot who promptly reports an inadvertent violation can, under strict conditions, avoid an FAA penalty. The program has received more than two million reports. Aviation did not make people more honest. It made honesty cheaper.

“Is TÜV SÜD going to sign or not?”

Brazil paid for the expensive version. On January 25, 2019, a tailings dam owned by the mining company Vale collapsed in Brumadinho, in the state of Minas Gerais, killing 270 people. According to Reuters, an internal Vale report from October 2018 had placed the dam in an “attention zone,” with an annual probability of failure about twice the company’s own maximum tolerable level. A month earlier, the German certifier TÜV SÜD had signed a declaration of the dam’s stability. One of its engineers later told the Federal Police that a Vale executive had asked him, “Is TÜV SÜD going to sign or not?”, which he described as pressure. The executive denied pressuring him. The criminal proceedings over the collapse are still under way, with no criminal conviction so far in the principal case. Whatever the outcome, the record shows that risk assessments raising concerns about the dam existed alongside a declaration certifying its stability. Why those concerns did not produce adequate preventive action remains the central question.

In Israel, a lieutenant’s warnings stopped one level up. In America, an engineer suffered professional retaliation after opposing a launch. In Brazil, a dam was certified as stable despite documented warning signs, and an engineer later described feeling pressured during the certification. In all three cases, warning signs existed before the disaster, and the people who received them did not turn them into adequate preventive action. The consequences were borne by soldiers on two fronts, seven astronauts and 270 people in a Brazilian mining town.

Cheap to warn, expensive to ignore

No organization will ever eliminate error. The question is what it charges for bringing it to light. Israel’s answer after 1973 was to make dissent part of the job. Aviation’s answer was to make honest reporting safer than silence. The lesson for companies, from start-ups in Tel Aviv to mining giants in Brazil, is the same. Make it cheap to warn. Make it expensive to ignore a warning. And when a decision goes wrong, the person who made it should be the first to answer for it.

Amplianism puts it in one line: no one above error, no one below a fresh start. A lieutenant at Southern Command should never be below the right to be heard, and no general, executive or certifier should be above the duty to listen.