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{{First Name | My friend}},

Anton Valukas was a former federal prosecutor. In 2014, GM's board commissioned him to investigate why it took the company more than a decade to recall vehicles with a defective ignition switch now linked to at least 13 deaths.

His finding was precise.

"While the issue of the ignition switch passed through numerous hands at GM, from engineers to investigators to lawyers, nobody raised the problem to the highest levels of the company. As a result, those in the best position to demand quick answers did not know questions needed to be asked."¹

The finding pointed to something specific: a gap between where the information existed and where it needed to go. This gap persisted across a decade during which millions of vehicles with the defective switch reached consumers.

The Valukas Report described a company operating in silos. Engineers in one part of the organization didn't know what engineers elsewhere were seeing. The ignition switch defect was classified as a "customer convenience" issue, something annoying but not a safety concern. This meant it triggered a process designed for customer convenience issues, not one designed to surface a cross-functional safety risk to the people with the authority to act on it.²

Bottom line: group after group and committee after committee reviewed the issue. Yet, nobody assembled the pieces into an enterprise-level risk and carried it to the executive team.

The congressional investigation that followed confirmed what the Valukas Report documented. Rep. Fred Upton, chair of the House Energy and Commerce Subcommittee on Oversight and Investigations, described "a maddening and deadly breakdown over a decade plagued by missed opportunities and disconnects."³

I understand why the common diagnosis of this case focuses on silos. It’s a valid observation. That said, my experience shows this diagnosis stops one layer short.

Why? Because silos can be a reflection of different factors: culture, strategy, organizational design. The report findings, however, show the concerns failed to surface for structural reasons. Effort and intent were present. The path was not. As a result, a unified risk picture was never assembled and presented at the executive level.

The "customer convenience" categorization is the clearest illustration of this. It was the category that fit the process available. But that process had no defined route to the executive leadership team. Consequently, the categorization drove what happened next, which was no change in direction for over a decade.

If you narrow your focus prematurely to the silo issue, you risk missing something critical about the GM escalation failure. You miss what happened (or didn’t) at the decision layer.

What's worth examining is how the absence of a defined escalation path allowed silos to persist and deepen over time. GM illustrates this through the documentation of concern that existed in fragments across engineering, legal, and investigative functions simultaneously. Yet, there was no path designed to assemble those fragments and carry them to the executive level as a unified picture.

Each function held its piece, but no decision architecture existed to require those pieces to come together and travel upward.

A defined escalation path is one of the structural conditions decision architecture puts in place. Doing this creates the conditions for cross-functional concerns to surface and travel to the right level. As a byproduct of that design, it becomes structurally harder for functions to operate in isolation, because the path itself requires them to surface what they are carrying.

When a defined escalation path exists at the executive level that accounts for how concerns crossing functional boundaries get assembled, elevated, and acted upon, it creates those structural conditions. When it doesn't exist, each function more readily operates within its own lane.

That pattern runs through the GM record from beginning to end. It serves as a powerful reminder that what is absent can still govern, and without the intentional development of decision architecture, it may announce itself in consequences that compound quietly.

When a concern exists across more than one function in your organization, does your decision architecture create a defined path for it to reach the leaders who need to act on it?

If you’re ready for a conversation, you can schedule time directly here.

Until Next Sunday,

Shawnette Rochelle, MBA, PCC
Founder, Excellence Unbounded
Executive Decision Systems That Drive Organizational Momentum

If you’re curious to learn more about my work with executive teams, you can find it here.