When public services fail: leadership, accountability and the cost of poor management

Lisbon’s City Council woke up to a harsh reality in the wake of a cable car tragedy that killed 16 and injured 22 last year. The lesson? Expanding public services without strengthening leadership and management capacity is a dangerous illusion. Complexity cannot be solved with more laws, more organisations or grander promises.

Text: Rui Ramos-Pinto Coelho; Photos: Rodrigo Amado/Chris Graeme/Lusa

At 6:04 pm on September 3, 2025, the Glória Elevator descended out of control down Lisbon’s steep Calçada da Glória. It reached 60 km/h, derailed on a curve, and slammed into a building. Sixteen people were killed and 22 injured. A tragedy.

Five Portuguese nationals (including the operator), three Britons, two Canadians, two South Koreans, one Swiss, one Ukrainian, one American and one French citizen were in the wrong place at the wrong time. They all lost their lives in an instant. The question that inevitably follows is: why?

Machines have no feelings

Machines have no feelings. When they fail, there is always a logical, material explanation: a flaw in design, manufacturing, maintenance or operation, or some form of external interference, such as sabotage or a natural disaster. Understanding what went wrong is essential, not only to assign responsibility, but to ensure it does not happen again.

In serious accidents, failure is rarely singular. Machines are typically equipped with redundant safety systems designed to prevent catastrophe when one component fails. In this case, according to publicly available information, the cable holding the elevator snapped and the safety brake then failed. A sequence of failures, not a single fault.

Experts quickly ruled out external interference, although, in today’s climate, every incident tends to raise suspicions of sabotage. Responsibility therefore appears to lie with Carris, the company that owns, operates and contracted the maintenance of the elevator.

The wrong cable

Months after the accident, at the time of writing, the final investigation report has yet to be published. Interim findings, however, indicate that the cable that snapped was not certified for the transport of people. If this is confirmed, two questions remain: why did the safety brake fail, and who was responsible for the decisions – or omissions – that led to this chain of events?

Those responsible should be held accountable, not out of revenge, but out of justice. Accountability also serves a broader purpose: it sends a clear signal to those across many organisations who design, maintain or operate machines and systems capable of causing harm. Responsibility must be real, and consequences must exist.

This case is an extreme example, but it is not an isolated one. It reflects deeper and more systemic problems affecting public services. Unfortunately, Lisbon’s public transport is not alone in underperforming.

Poor justice and deficient public services

Justice may be the most troubling example. It functions poorly, and that failure corrodes society as a whole. Justice, in practice, often feels unjust. There is a widespread perception – indeed, a certainty – that those with money can delay decisions until cases expire. A system that punishes those who steal small sums yet struggles to hold white-collar criminals who steal millions to account.

In education, teaching sometimes fails because there are no teachers. At other times, because there is no discipline. Without either, effective learning is nearly impossible.

In defence, it is enough to recall that an ammunition depot was looted, not by a foreign elite force, but by a group of common criminals.

In healthcare, the situation of geographically variable emergency services is indefensible. Ambulances are left uncertain about where to go, creating confusion, discomfort and, in some cases, fatal delays for patients in urgent need of care.

At Lisbon Airport, long queues lasting hours await passengers arriving from outside the Schengen Area. For a country that has invested almost all its strategies on tourism, this is a baffling way to treat its most valuable customers.

Meanwhile, hundreds – perhaps thousands – of publicly owned buildings have been left vacant and deteriorating for decades. On my own street, a Tax Office branch has been closed for more than 25 years.

The list could continue, but the point is clear: Carris is not alone in providing deficient public services.

Why public services fail

The critical question is not whether public services fail, but why they do – and how failure can be prevented.

I recently read an article in the Financial Times (because public services do not function poorly only in Portugal) with the thesis that developed countries have never had so many public services, and that the sheer scale and complexity inevitably lead to failures, and that we should be less shocked when things go wrong.

The reasoning is sound, to a point. The expansion of services does increase complexity, and complexity increases the likelihood of defects.

Citizens also grow accustomed to services working well, until one day they suddenly do not. Taken to its logical extreme, however, this argument becomes absurd: when there were no services, there were no failures.

Elevators did not derail because there were no elevators. With only one hospital, there was no doubt about where to take the injured.

Quality services at zero cost unachievable

That line of reasoning does little to solve today’s problems, unless the proposed solution is to dismantle public services altogether. What it does highlight, however, is the impossibility of endlessly expanding services – offering everything to everyone, 24 hours a day, 365 days a year – while simultaneously expecting flawless quality. The recent ambition to make almost everything “free” (healthcare, education, transport, housing) only intensifies this contradiction.

High quality, universal, failure-free services at zero cost are simply not achievable

The underlying truth is far simpler. Public services are delivered by organisations, and organisations deliver quality only when they are well managed. Just as machines must be properly designed, built, operated and maintained, organisations require sound management to function effectively.

The meaning of public service

Unlike machines, however, organisations are made up of people – and people are far more complex. They need training, evaluation, career paths, incentives and sanctions. Above all, they need motivation. In Portugal, we say people must “wear the organisation’s jersey”.

People have ambitions, expectations, frustrations and personal lives. They take holidays, fall ill, care for families, fall in love, retire… When motivated and aligned with organisational goals, they are capable of extraordinary effort, creativity and even heroism.

Do employees in public service organisations truly understand what is expected from them? Do they grasp the meaning of public service?

Over time, especially in very old institutions, organisations can lose sight of what matters most. The Portuguese army forgot the fundamental priority of safeguarding its weapons. Carris appears to have forgotten that passenger safety must take precedence over cost savings, whether by purchasing uncertified equipment or failing to modernise safety systems on an ageing elevator.

Omelettes without eggs

Portugal has long prided itself on making “omelettes without eggs” – managing through improvisation and resourcefulness. We celebrate our ability to ‘desenrascar’. But improvisation is not a management strategy. It usually signals a failure to plan, implement, evaluate and correct—basic principles of good management.

Political leaders often respond to media pressure by creating new organisations, rather than strengthening those that already exist. This creates the illusion of action while generating confusion for the public and demoralisation within existing institutions.
Time and resources are wasted on building new structures instead of improving the capacity of current ones. The result is predictable: organisations become increasingly under-resourced and unmotivated, reinforcing a vicious cycle.

Lack of leadership and legislative overload

Leadership – or the absence of it – is another root cause. Ministers and senior public-sector leaders frequently lack deep sector knowledge or management experience. Appointments are often based on political or personal affinities rather than competence. It is unrealistic to expect effective leadership under such conditions, or to motivate capable subordinates who know they will never reach the top and must endure poor decisions.

A further chronic problem is legislative overload. When an issue arises, a new law is passed. This is not inherently wrong – unless the law is poorly drafted, ambiguous, retroactive or unaccompanied by proper regulation. In these situations, the result is confusion, inconsistent interpretation and bureaucratic paralysis.

Neglected training

Finally, there is the persistent neglect of training. It is far more attractive to announce the purchase of a new equipment than to invest in developing people. Yet many employees lack even a basic understanding of organisational objectives, public service values, expectations, empathy toward citizens or the operational specifics of their roles.

Ultimately, the performance of public services is the result of leadership choices. Well-managed organisations rely on clear objectives, capable leadership, accountability, adequate resources and motivated people. When public services fail, the cost is not abstract – it is measured in trust, safety and human lives. Improving them is therefore not merely a technical challenge, but a leadership imperative.

At the heart of every public service are people. When they understand the mission, feel accountable for results and are led by credible leaders, services work – even under constraints. When they are demotivated, poorly led and shielded from consequences, systems eventually fail.

Expanding public services without strengthening leadership and management capacity is a dangerous illusion. Complexity cannot be solved with more laws, more organisations or grander promises. It can only be addressed through better governance, clearer accountability and leadership capable of aligning people, resources and purpose. Without this, failures will continue – and society will continue to pay the price.