Organizational culture

It is of both intellectual and practical interest to understand how organizations function and how the actors within them choose the actions that they pursue. A common answer to these questions is to refer to the rules and incentives of the organization, and then to attempt to understand the actor's choices through the lens of rational preference theory. However, it is now increasingly clear that organizations embody distinctive "cultures" that significantly affect the actions of the individuals who operate within their scope. Edgar Schein is a leading expert on the topic of organizational culture. Here is how he defines the concept in Organizational Culture and Leadership. Organizational culture, according to Schein, consists of a set of "basic assumptions about the correct way to perceive, think, feel, and behave, driven by (implicit and explicit) values, norms, and ideals" (Schein, 1990).

Culture is both a dynamic phenomenon that surrounds us at all times, being constantly enacted and created by our interactions with others and shaped by leadership behavior, and a set of structures, routines, rules, and norms that guide and constrain behavior. When one brings culture to the level of the organization and even down to groups within the organization, one can see clearly how culture is created, embedded, evolved, and ultimately manipulated, and, at the same time, how culture constrains, stabilizes, and provides structure and meaning to the group members. These dynamic processes of culture creation and management are the essence of leadership and make one realize that leadership and culture are two sides of the same coin. (3rd edition, p. 1)

According to Schein, there is a cognitive and affective component of action within an organization that has little to do with rational calculation of interests and more to do with how the actors frame their choices. The values and expectations of the organization help to shape the actions of the participants. And one crucial aspect of leaders, according to Schein, is the role they play in helping to shape the culture of the organizations they lead.

It is intriguing that several pressing organizational problems have been found to rotate around the culture of the organization within which behavior takes place. The prevalence of sexual and gender harassment appears to depend a great deal on the culture of respect and civility that an organization has embodied -- or has failed to embody. The ways in which accidents occur in large industrial systems seems to depend in part on the culture of safety that has been established within the organization. And the incidence of corrupt and dishonest practices within businesses seems to be influenced by the culture of integrity that the organization has managed to create. In each instance experience seems to demonstrate that "good" culture leads to less socially harmful behavior, while "bad" culture leads to more such behavior.

Consider first the prominence that the idea of safety culture has come to play in the nuclear industry after Three Mile Island and Chernobyl. Here are a few passages from a review document authored by the Advisory Committee on Reactor Safeguards (link).

There also seems to be a general agreement in the nuclear community on the elements of safety culture. Elements commonly included at the organization level are senior management commitment to safety, organizational effectiveness, effective communications, organizational learning, and a working environment that rewards identifying safety issues. Elements commonly identified at the individual level include personal accountability, questioning attitude, and procedural adherence. Financial health of the organization and the impact of regulatory bodies are occasionally identified as external factors potentially affecting safety culture. 

The working paper goes on to consider two issues: has research validated the causal relationship between safety culture and safe performance? And should the NRC create regulatory requirements aimed at observing and enhancing the safety culture in a nuclear plant? They note that current safety statistics do not permit measurement of the association between safety culture and safe performance, but that experience in the industry suggests that the answers to both questions are probably affirmative:

On the other hand, even at the current level of industry maturity, we are confronted with events such as the recent reactor vessel head corrosion identified so belatedly at the Davis-Besse Nuclear Power Plant. Problems subsequently identified in other programmatic areas suggest that these may not be isolated events, but the result of a generally degraded plant safety culture. The head degradation was so severe that a major accident could have resulted and was possibly imminent. If, indeed, the true cause of such an event proves to be degradation of the facility's safety culture, is it acceptable that the reactor oversight program has to wait for an event of such significance to occur before its true root cause, degraded culture, is identified? This event seems to make the case for the need to better understand the issues driving the culture of nuclear power plants and to strive to identify effective performance indicators of resulting latent conditions that would provide leading, rather than lagging, indications of future plant problems. (7-8)

Researchers in the area of sexual harassment have devoted quite a bit of attention to the topic of workplace culture as well. This theme is emphasized in the National Academy study on sexual and gender harassment (link); the authors make the point that gender harassment is chiefly aimed at expressing disrespect towards the target rather than sexual exploitation. This has an important implication for institutional change. An institution that creates a strong core set of values emphasizing civility and respect is less conducive to gender harassment. They summarize this analysis in the statement of findings as well:

Organizational climate is, by far, the greatest predictor of the occurrence of sexual harassment, and ameliorating it can prevent people from sexually harassing others. A person more likely to engage in harassing behaviors is significantly less likely to do so in an environment that does not support harassing behaviors and/or has strong, clear, transparent consequences for these behaviors. (50)

Ben Walsh is representative of this approach. Here is the abstract of a research article by Walsh, Lee, Jensen, McGonagle, and Samnani on workplace incivility (link):

Scholars have called for research on the antecedents of mistreatment in organizations such as workplace incivility, as well as the theoretical mechanisms that explain their linkage. To address this call, the present study draws upon social information processing and social cognitive theories to investigate the relationship between positive leader behaviors—those associated with charismatic leadership and ethical leadership—and workers’ experiences of workplace incivility through their perceptions of norms for respect. Relationships were separately examined in two field studies using multi- source data (employees and coworkers in study 1, employees and supervisors in study 2). Results suggest that charismatic leadership (study 1) and ethical leadership (study 2) are negatively related to employee experiences of workplace incivility through employee perceptions of norms for respect. Norms for respect appear to operate as a mediating mechanism through which positive forms of leadership may negatively relate to workplace incivility. The paper concludes with a discussion of implications for organizations regarding leader behaviors that foster norms for respect and curb uncivil behaviors at work.

David Hess, an expert on corporate corruption, takes a similar approach to the problem of corruption and bribery by officials of multinational corporations (link). Hess argues that bribery often has to do with organizational culture and individual behavior, and that effective steps to reduce the incidence of bribery must proceed on the basis of an adequate analysis of both culture and behavior. And he links this issue to fundamental problems in the area of corporate social responsibility.

Corporations must combat corruption. By allowing their employees to pay bribes they are contributing to a system that prevents the realization of basic human rights in many countries. Ensuring that employees do not pay bribes is not accomplished by simply adopting a compliance and ethics program, however. This essay provided a brief overview of why otherwise good employees pay bribes in the wrong organizational environment, and what corporations must focus on to prevent those situations from arising. In short, preventing bribe payments must be treated as an ethical issue, not just a legal compliance issue, and the corporation must actively manage its corporate culture to ensure it supports the ethical behavior of employees.

As this passage emphasizes, Hess believes that controlling corrupt practices requires changing incentives within the corporation while equally changing the ethical culture of the corporation; he believes that the ethical culture of a company can have effects on the degree to which employees engage in bribery and other corrupt practices.

What is in common among each of these examples -- and other examples are available as well -- is that intangible features of the work environment are likely to influence behavior of the actors in that environment, and thereby affect the favorable and unfavorable outcomes of the organization's functioning as well. Moreover, if we take the lead offered by Schein and work on the assumption that leaders can influence culture through their advocacy for the values that the organization embodies, then leadership has a core responsibility to facilitate a work culture that embodies these favorable outcomes. Work culture can be cultivated to encourage safety and to discourage bad outcomes like sexual harassment and corruption.

Testing the NRC

Serious nuclear accidents are rare but potentially devastating to people, land, and agriculture. (It appears that minor to moderate nuclear accidents are not nearly so rare, as James Mahaffey shows in Atomic Accidents: A History of Nuclear Meltdowns and Disasters: From the Ozark Mountains to Fukushima.) Three Mile Island, Chernobyl, and Fukushima are disasters that have given the public a better idea of how nuclear power reactors can go wrong, with serious and long-lasting effects. Reactors are also among the most complex industrial systems around, and accidents are common in complex, tightly coupled industrial systems. So how can we have reasonable confidence in the safety of nuclear reactors?

One possible answer is that we cannot have reasonable confidence at all. However, there are hundreds of large nuclear reactors in the world, and 98 active nuclear reactors in the United States alone. So it is critical to have highly effective safety regulation and oversight of the nuclear power industry. In the United States that regulatory authority rests with the Nuclear Regulatory Commission. So we need to ask the question: how good is the NRC at regulating, inspecting, and overseeing the safety of nuclear reactors in our country?

One would suppose that there would be excellent and detailed studies within the public administration literature that attempt to answer this question, and we might expect that researchers within the field of science and technology studies might have addressed it as well. However, this seems not to be the case. I have yet to find a full-length study of the NRC as a regulatory agency, and the NRC is mentioned only twice in the 600-plus page Oxford Handbook of Regulation. However, we can get an oblique view of the workings of the NRC through other sources. One set of observers who are in a position to evaluate the strengths and weaknesses of the NRC are nuclear experts who are independent of the nuclear industry. For example, publications from the Bulletin of the Atomic Scientists include many detailed reports on the operations and malfunctions of nuclear power plants that permit a degree of assessment of the quality of oversight provided by the NRC (link). And a detailed (and scathing) report by the General Accounting Office on the near-disaster at the Davis-Besse nuclear power plant is another expert assessment of NRC functioning (link).

David Lochbaum, Edwin Lyman, and Susan Stranahan fit the description of highly qualified independent scientists and observers, and their detailed case history of the Fukushima disaster provides a degree of insight into the workings of the NRC as well as the Japanese nuclear safety agency. Their book, Fukushima: The Story of a Nuclear Disaster, is jointly written by the authors under the auspices of the Union of Concerned Scientists, one of the best informed networks of nuclear experts we have in the United States. Lochbaum is director of the UCS Nuclear Safety Project and author of Nuclear Waste Disposal Crisis. The book provides a careful and scientific treatment of the unfolding of the Fukushima disaster hour by hour, and highlights the background errors that were made by regulators and owners in the design and operation of the Fukushima plant as well. The book makes numerous comparisons to the current workings of the NRC which permit a degree of assessment of the US regulatory agency.

In brief, Lochbaum and his co-authors appear to have a reasonably high opinion of the technical staff, scientists, and advisors who prepare recommendations for NRC consideration, but a low opinion of the willingness of the five commissioners to adopt costly recommendations that are strongly opposed by the nuclear industry. The authors express frustration that the nuclear safety agencies in both countries appear to have failed to have learned important lessons from the Fukushima disaster:

“The [Japanese] government simply seems in denial about the very real potential for another catastrophic accident.... In the United States, the NRC has also continued operating in denial mode. It turned down a petition requesting that it expand emergency evacuation planning to twenty-five miles from nuclear reactors despite the evidence at Fukushima that dangerous levels of radiation can extend at least that far if a meltdown occurs. It decided to do nothing about the risk of fire at over-stuffed spent fuel pools. And it rejected the main recommendation of its own Near-Term Task Force to revise its regulatory framework. The NRC and the industry instead are relying on the flawed FLEX program as a panacea for any and all safety vulnerabilities that go beyond the “design basis.” (kl 117)

They believe that the NRC is excessively vulnerable to influence by the nuclear power industry and to elected officials who favor economic growth over hypothetical safety concerns, with the result that it tends to err in favor of the economic interests of the industry.

Like many regulatory agencies, the NRC occupies uneasy ground between the need to guard public safety and the pressure from the industry it regulates to get off its back. When push comes to shove in that balancing act, the nuclear industry knows it can count on a sympathetic hearing in Congress; with millions of customers, the nation’s nuclear utilities are an influential lobbying group. (36)

They note that the NRC has consistently declined to undertake more substantial reform of its approach to safety, as recommended by its own panel of experts. The key recommendation of the Near-Term Task Force (NTTF) was that the regulatory framework should be anchored in a more strenuous standard of accident prevention, requiring plant owners to address "beyond-design-basis accidents". The Fukushima earthquake and tsunami events were "beyond-design-basis"; nonetheless, they occurred, and the NTTF recommended that safety planning should incorporate consideration of these unlikely but possible events.

The task force members believed that once the first proposal was implemented, establishing a well-defined framework for decision making, their other recommendations would fall neatly into place. Absent that implementation, each recommendation would become bogged down as equipment quality specifications, maintenance requirements, and training protocols got hashed out on a case-by-case basis. But when the majority of the commissioners directed the staff in 2011 to postpone addressing the first recommendation and focus on the remaining recommendations, the game was lost even before the opening kickoff. The NTTF’s Recommendation 1 was akin to the severe accident rulemaking effort scuttled nearly three decades earlier, when the NRC considered expanding the scope of its regulations to address beyond-design accidents. Then, as now, the perceived need for regulatory “discipline,” as well as industry opposition to an expansion of the NRC’s enforcement powers, limited the scope of reform. The commission seemed to be ignoring a major lesson of Fukushima Daiichi: namely, that the “fighting the last war” approach taken after Three Mile Island was simply not good enough. (kl 253)

As a result, "regulatory discipline" (essentially the pro-business ideology that holds that regulation should be kept to a minimum) prevailed, and the primary recommendation was tabled. The issue was of great importance, in that it involved setting the standard of risk and accident severity for which the owner needed to plan. By staying with the lower standard, the NRC left the door open to the most severe kinds of accidents.

The NTTF task force also addressed the issue of "delegated regulation" (in which the agency defers to the industry in many issues of certification and risk assessment) (Here is the FAA's definition of delegated regulation; link.)

The task force also wanted the NRC to reduce its reliance on industry voluntary initiatives, which were largely outside of regulatory control, and instead develop its own “strong program for dealing with the unexpected, including severe accidents.” (252)

Other more detail-oriented recommendations were refused as well -- for example, a requirement to install reliable hardened containment vents in boiling water reactors, with a requirement that these vents should incorporate filters to remove radioactive gas before venting. 

But what might seem a simple, logical decision—install a $15 million filter to reduce the chance of tens of billions of dollars’ worth of land contamination as well as harm to the public—got complicated. The nuclear industry launched a campaign to persuade the NRC commissioners that filters weren’t necessary. A key part of the industry’s argument was that plant owners could reduce radioactive releases more effectively by using FLEX equipment.... In March 2013, they voted 3–2 to delay a requirement that filters be installed, and recommended that the staff consider other alternatives to prevent the release of radiation during an accident. (254)

The NRC voted against including the requirement of filters on containment vents, a decision that was based on industry arguments that the cost of the filters was excessive and unnecessary.

The authors argue that the NRC needs to significantly rethink its standards of safety and foreseeable risk.

What is needed is a new, commonsense approach to safety, one that realistically weighs risks and counterbalances them with proven, not theoretical, safety requirements. The NRC must protect against severe accidents, not merely pretend they cannot occur. (257)

Their recommendation is to make use of an existing and rigorous plan for reactor safety incorporating the results of "severe accident mitigation alternatives" (SAMA) analysis already performed -- but largely disregarded.

However, they are not optimistic that the NRC will be willing to undertake these substantial changes that would significantly enhance safety and make a Fukushima-scale disaster less likely. Reporting on a post-Fukushima conference sponsored by the NRC, they write:

But by now it was apparent that little sentiment existed within the NRC for major changes, including those urged by the commission’s own Near-Term Task Force to expand the realm of “adequate protection.”

Lochbaum and his co-authors also make an intriguing series of points about the use of modeling and simulation in the effort to evaluate safety in nuclear plants. They agree that simulation methods are an essential part of the toolkit for nuclear engineers seeking to evaluate accident scenarios; but they argue that the simulation tools currently available (or perhaps ever available) fall far short of the precision sometimes attributed to them. So simulation tools sometimes give a false sense of confidence in the existing safety arrangements in a particular setting.

Even so, the computer simulations could not reproduce numerous important aspects of the accidents. And in many cases, different computer codes gave different results. Sometimes the same code gave different results depending on who was using it. The inability of these state-of-the-art modeling codes to explain even some of the basic elements of the accident revealed their inherent weaknesses—and the hazards of putting too much faith in them. (263)

In addition to specific observations about the functioning of the NRC the authors identify chronic failures in the nuclear power system in Japan that should be of concern in the United States as well. Conflict of interest, falsification of records, and punishment of whistleblowers were part of the culture of nuclear power and nuclear regulation in Japan. And these problems can arise in the United States as well. Here are examples of the problems they identify in the Japanese nuclear power system; it is a valuable exercise to attempt to determine whether these issues arise in the US regulatory environment as well.

Non-compliance and falsification of records in Japan

Headlines scattered over the decades built a disturbing picture. Reactor owners falsified reports. Regulators failed to scrutinize safety claims. Nuclear boosters dominated safety panels. Rules were buried for years in endless committee reviews. “Independent” experts were financially beholden to the nuclear industry for jobs or research funding. “Public” meetings were padded with industry shills posing as ordinary citizens. Between 2005 and 2009, as local officials sponsored a series of meetings to gauge constituents’ views on nuclear power development in their communities, NISA encouraged the operators of five nuclear plants to send employees to the sessions, posing as members of the public, to sing the praises of nuclear technology. (46)

The authors do not provide evidence about similar practices in the United States, though the history of the Davis-Besse nuclear plant in Ohio suggests that similar things happen in the US industry. Charles Perrow treats the Davis-Besse near-disaster in a fair amount of detail; link. Descriptions of the Davis-Besse nuclear incident can be found here, here, here, and here.
Conflict of interest

Shortly after the Fukushima accident, Japan’s Yomiuri Shimbun reported that thirteen former officials of government agencies that regulate energy companies were currently working for TEPCO or other power firms. Another practice, known as amaagari, “ascent to heaven,” spins the revolving door in the opposite direction. Here, the nuclear industry sends retired nuclear utility officials to government agencies overseeing the nuclear industry. Again, ferreting out safety problems is not a high priority.

Punishment of whistle-blowers

In 2000, Kei Sugaoka, a nuclear inspector working for GE at Fukushima Daiichi, noticed a crack in a reactor’s steam dryer, which extracts excess moisture to prevent harm to the turbine. TEPCO directed Sugaoka to cover up the evidence. Eventually, Sugaoka notified government regulators of the problem. They ordered TEPCO to handle the matter on its own. Sugaoka was fired. (47)

There is a similar story in the Davis-Besse plant history.

Factors that interfere with effective regulation

In summary: there appear to be several structural factors that make nuclear regulation less effective than it needs to be.

First is the fact of the political power and influence of the nuclear industry itself. This was a major factor in the background of the Chernobyl disaster as well, where generals and party officials pushed incessantly for rapid completion of reactors; Serhii Plokhy, Chernobyl: The History of a Nuclear Catastrophe. Lochbaum and his collaborators demonstrate the power that TEPCO had in shaping the regulations under which it built the Fukushima complex, including the assumptions that were incorporated about earthquake risk and tsunami risk. Charles Perrow demonstrates a comparable ability by the nuclear industry in the United States to influence the rules and procedures that govern their use of nuclear power as well (link). This influence permits the owners of nuclear power plants to influence the content of regulation as well as the systems of inspection and oversight that the agency adopts.

A related factor is the set of influences and lobbying points that come from the needs of the economy and the production pressures of the energy industry. (Interestingly enough, this was also a major influence on Soviet decision-making in choosing the graphite-moderated light water reactor for use at Chernobyl and numerous other plants in the 1960s; Serhii Plokhy, Chernobyl: The History of a Nuclear Catastrophe.)

Third is the fact emphasized by Charles Perrow that the NRC is primarily governed by Congress, and legislators are themselves vulnerable to the pressures and blandishments of the industry and demands for a low-regulation business environment. This makes it difficult for the NRC to carry out its role as independent guarantor of the health and safety of the public. Here is Perrow's description of the problem in The Next Catastrophe: Reducing Our Vulnerabilities to Natural, Industrial, and Terrorist Disasters (quoting Lochbaum from a 2004 Union of Concerned Scientists report):

With utilities profits falling when the NRC got tough after the Time story, the industry not only argued that excessive regulation was the problem, it did something about what it perceived as harassment. The industry used the Senate subcommittee that controls the agency’s budget, headed by a pro-nuclear Republican senator from New Mexico, Pete Domenici. Using the committee’s funds, he commissioned a special study by a consulting group that was used by the nuclear industry. It recommended cutting back on the agency’s budget and size. Using the consultant’s report, Domenici “declared that the NRC could get by just fine with a $90 million budget cut, 700 fewer employees, and a greatly reduced inspection effort.” (italics supplied) The beefed-up inspections ended soon after the threat of budget cuts for the agency. (Mangels 2003) And the possibility for public comment was also curtailed, just for good measure. Public participation in safety issues once was responsible for several important changes in NRC regulations, says David Lochbaum, a nuclear safety engineer with the Union of Concerned Scientists, but in 2004, the NRC, bowed to industry pressure and virtually eliminated public participation. (Lochbaum 2004) As Lochbaum told reporter Mangels, “The NRC is as good a regulator as Congress permits it to be. Right now, Congress doesn’t want a good regulator.”  (The Next Catastrophe, kl 2799)

A fourth important factor is a pervasive complacency within the professional nuclear community about the inherent safety of nuclear power. This is a factor mentioned by Lochbaum:

Although the accident involved a failure of technology, even more worrisome was the role of the worldwide nuclear establishment: the close-knit culture that has championed nuclear energy—politically, economically, socially—while refusing to acknowledge and reduce the risks that accompany its operation. Time and again, warning signs were ignored and near misses with calamity written off. (kl 87)

This is what we might call an ideological or cultural factor, in that it describes a mental framework for thinking about the technology and the public. It is very real factor in decision-making, both within the industry and in the regulatory world. Senior nuclear engineering experts at major research universities seem to share the view that the public "fear" of nuclear power is entirely misplaced, given the safety record of the industry. They believe the technical problems of nuclear power generation have been solved, and that a rational society would embrace nuclear power without anxiety. For rebuttal to this complacency, see Rose and Sweeting's report in the Bulletin of the Atomic Scientists, "How safe is nuclear power? A statistical study suggests less than expected" (link). Here is the abstract to their paper:

After the Fukushima disaster, the authors analyzed all past core-melt accidents and estimated a failure rate of 1 per 3704 reactor years. This rate indicates that more than one such accident could occur somewhere in the world within the next decade. The authors also analyzed the role that learning from past accidents can play over time. This analysis showed few or no learning effects occurring, depending on the database used. Because the International Atomic Energy Agency (IAEA) has no publicly available list of nuclear accidents, the authors used data compiled by the Guardian newspaper and the energy researcher Benjamin Sovacool. The results suggest that there are likely to be more severe nuclear accidents than have been expected and support Charles Perrow’s “normal accidents” theory that nuclear power reactors cannot be operated without major accidents. However, a more detailed analysis of nuclear accident probabilities needs more transparency from the IAEA. Public support for nuclear power cannot currently be based on full knowledge simply because important information is not available.

Lee Clarke's book on planning for disaster on the basis of unrealistic models and simulations is relevant here. In Mission Improbable: Using Fantasy Documents to Tame Disaster Clarke argues that much of the planning currently in place for largescale disasters depends upon models, simulations, and scenario-building tools in which we should have very little confidence.

The complacency about nuclear safety mentioned here makes safety regulation more difficult and, paradoxically, makes the safe use of nuclear power more unlikely. Only when the risks are confronted with complete transparency and honesty will it be possible to design regulatory systems that do an acceptable job of ensuring the safety and health of the public.

In short, Lochbaum and his co-authors seem to provide evidence for the conclusion that the NRC is not in a position to perform its primary function: to establish a rational and scientifically well grounded set of standards for safe reactor design and operation. Further, its ability to enforce through inspection seems impaired as well by the power and influence the nuclear industry can deploy through Congress to resist its regulatory efforts. Good expert knowledge is canvassed through the NRC's processes; but the policy recommendations that flow from this scientific analysis are all too often short-circuited by the ability of the industry to fend off new regulatory requirements. Lochbaum's comment quoted by Perrow above seems all too true: “The NRC is as good a regulator as Congress permits it to be. Right now, Congress doesn’t want a good regulator.” 

It is very interesting to read the transcript of a 2014 hearing of the Senate Committee on Environment and Public Works titled "NRC'S IMPLEMENTATION OF THE FUKUSHIMA NEAR-TERM TASK FORCE RECOMMENDATIONS AND OTHER ACTIONS TO ENHANCE AND MAINTAIN NUCLEAR SAFETY" (link). Senator Barbara Boxer, California Democrat and chair of the committee, opened the meeting with these words:

Although Chairman Macfarlane said, when she announced her resignation, she had assured that ‘‘the agency implemented lessons learned from the tragic accident at Fukushima.’’ She said, ‘‘the American people can be confident that such an accident will never take place here.’’

I say the reality is not a single one of the 12 key safety recommendations made by the Fukushima Near-Term Task Force has been implemented. Some reactor operators are still not in compliance with the safety requirements that were in place before the Fukushima disaster. The NRC has only completed its own action 4 of the 12 task force recommendations.

This is an alarming assessment, and one that is entirely in accord with the observations made by Lochbaum above.

The 737 MAX disaster as an organizational failure

The topic of the organizational causes of technology failure comes up frequently in Understanding Society. The tragic crashes of two Boeing 737 MAX aircraft in the past year present an important case to study. Is this an instance of pilot error (as has occasionally been suggested)? Is it a case of engineering and design failures? Or are there important corporate and regulatory failures that created the environment in which the accidents occurred, as the public record seems to suggest?

The formal accident investigations are not yet complete, and the FAA and other air safety agencies around the world have not yet approved the aircraft for flight following the suspension of certification following the second crash. There will certainly be a detailed and expert case study of this case at some point in the future, and I will be eager to read the resulting book. In the meantime, though, it is  useful to bring the perspectives of Charles Perrow, Diane Vaughan, and Andrew Hopkins to bear on what we can learn about this case from the public media sources that are available. The preliminary sketch of a case study offered below is a first effort and is intended simply to help us learn more about the social and organizational processes that govern the complex technologies upon which we depend. Many of the dysfunctions identified in the safety literature appear to have had a role in this disaster.

I have made every effort to offer an accurate summary based on publicly available sources, but readers should bear in mind that it is a preliminary effort.

The key conclusions I've been led to include these:

The updated flight control system of the aircraft (MCAS) created the conditions for crashes in rare flight conditions and instrument failures.

• Faults in the AOA sensor and the MCAS flight control system persisted through the design process 
• pilot training and information about changes in the flight control system were likely inadequate to permit pilots to override the control system when necessary  

There were fairly clear signs of organizational dysfunction in the development and design process for the aircraft:

• Disempowered mid-level experts (engineers, designers, software experts)
• Inadequate organizational embodiment of safety oversight
• Business priorities placing cost savings, timeliness, profits over safety
• Executives with divided incentives
• Breakdown of internal management controls leading to faulty manufacturing processes 

Cost-containment and speed trumped safety. It is hard to avoid the conclusion that the corporation put cost-cutting and speed ahead of the professional advice and judgment of the engineers. Management pushed the design and certification process aggressively, leading to implementation of a control system that could fail in foreseeable flight conditions.

The regulatory system seems to have been at fault as well, with the FAA taking a deferential attitude towards the company's assertions of expertise throughout the certification process. The regulatory process was "outsourced" to a company that already has inordinate political clout in Congress and the agencies.

• Inadequate government regulation
• FAA lacked direct expertise and oversight sufficient to detect design failures. 
• Too much influence by the company over regulators and legislators

Here is a video presentation of the case as I currently understand it (link). 

See also this earlier discussion of regulatory failure in the 737 MAX case (link). Here are several experts on the topic of organizational failure whose work is especially relevant to the current case:

Charles Perrow, Normal Accidents: Living with High-Risk Technologies
Diane Vaughan, The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, Enlarged Edition
Andrew Hopkins, Lessons from Longford: The ESSO Gas Plant Explosion

Theorizing about organizations

The fields of organizational studies and organizational sociology originated in the early twentieth century but flourished in the post-war period. This makes a certain amount of historical sense. The emergence in the nineteenth century of large, complex organizations in business and government became a factor in modern society that dwarfed the impact of the organizations of the past -- universities, religious societies, and guilds. There was therefore a new sociological topic that demanded study. How do corporations and large government departments work? What concepts permit insightful analysis of large, complex organizations? Max Weber's theory of bureaucracy provided a beginning, but organizations proved to have greater variety and more perplexing features than Weber's ideas could account for.

Large, complex organizations are the most pervasive social structure in the modern world. They structure the food we eat, the ways we work, the compensation we receive for our labors, the technologies that inform our daily lives, the ways that wars occur, and the modes through which governments function. And, as any observant person will recognize, large organizations create some of the most important dysfunctions that our modern society confronts. So it is enormously important to have a better idea of what a large organization is and how it works. We need to understand the variety, structures, and dynamics of large organizations if we are to have realistic ideas about how to make a more humane world.

Charles Perrow has been one of the most insightful contributors to organizational sociology since the 1960s. His research on the topic of safety within high-risk industries (space, nuclear power, marine transport, chemicals) has been highly influential, including especially his 1984 book, Normal Accidents: Living with High-Risk Technologies.

In 1972 Perrow published Complex Organizations: A Critical Essay, which was released in its third edition in 2014. The book is a masterful synthesis of the schools of thought that have emerged in organizational sociology since 1945. Perrow describes the human relations school, the neo-Weberian school, the institutional tradition, the technology [contingency] approach, the economic interpretation, and the "power" interpretation of organizations. The book therefore provides a valuable map of the geography of the field today, and the intellectual origins of current research. But more than that, the book is an important and original presentation of how organizations work, in Perrow's view. Perrow takes a "structural" view of organizations, which amounts fundamentally to the idea that the most important questions have to do with the internal processes of various organizations and the relationships the organization has to powerful external forces. (Perrow quotes March and Simon on organizational structure: "those aspects of the pattern of behavior in the organization that are relatively stable and that change only slowly"; (124). This contrasts with the "human relations" school, which holds that the important properties of organizations derive from features of behavior associated with the individuals who make them up, including leaders, managers, and workers.

An idea that emerges as particularly important in Perrow's account is the idea of bounded rationality and the limits on rational planning and decision-making within an organization. This part of Perrow's treatment depends heavily on the theories of Herbert Simon and James March (March and Simon, Organizations and Simon, Administrative Behavior).

Bounded rationality, however, is visited upon the elites as well. Their position is always insecure, for their information, understanding, and goals are never fully rational. This allows for occasional resistance and subtle changes by the controlled. In fact, bounded rationality, by elites or their subjects, creates a great deal of change, for it permits unexpected interactions, new discoveries, serendipities, and new goals and values. (123)

Perrow emphasizes the inherent diversity of goals and purposes that are operative within an organization at any given point. He describes the "garbage can" theory of organizational goal-setting and problem-setting (135). Executives, managers, and other decision-makers are portrayed as unavoidably opportunistic, in the sense that they address one set of problems rather than another without a compelling reason for thinking that this is the best path forward for the organization.

Goals may thus emerge in a rather fortuitous fashion, as when the organization seems to back into a new line of activity or into an external alliance in a fit of absentmindedness. (135)

Associated with this idea is the idea advanced by March and Simon that plans and goals are often adopted retrospectively rather than in advance of action.

No coherent, stable goal guided the total process, but after the fact a coherent stable goal was presumed to have been present. It would be unsettling to see it otherwise. (135) 

This recognition of the multiplicity and sketchiness of organizational goals casts profound doubt on the functionalism that observers sometimes bring to organizations (the idea that organizations possess the structures and goals they need to optimize the achievement of their goals). Perrow specifically endorses these doubts:

For those doing case studies of organizations it is also indispensable, checking the tendency of social scientists to find reason, cause, and function in all behavior, and emphasizing instead the accidental, temporary, shifting, and fluid nature of all social life.... Garbage can theory provides the tools to examine the process and not be taken in by functional explanations. The decision process must be seen as involving a shifting set of actors with unpredictable entrances and exits from the "can" (or the decision mechanism), the often unrelated problems these actors have on their agendas, the solutions of some that are looking for problems they can apply them to, the accidental availability of external candidates that then bring new solutions and problems to the decision process, and finally the necessity of "explaining" the outcomes as rational and intended. (136, 137) 

Typology and classification of organizations has been a preoccupation of organizational theory for a century. Perrow believes that we do not yet have a satisfactory basis for classifying organizations, but in his discussion of safety and disaster he provides a typology that has a lot going for it. The scheme sorts organizational tasks along two dimensions: the nature of interactions within the functioning of the organization (linear / complex) and the nature of the coupling of events and processes that exists (loose / tight coupling). His analysis of accidents finds that organizations involving high complexity and tight coupling are most vulnerable to disasters; so nuclear plants, the handling of nuclear weapons, the operations of aircraft, military early warning systems, chemical plants, and genetic research fall in the high-risk category. Motor-vehicle departments, community colleges, assembly-line factories, and post offices fall in the "linear, loose coupling" category and present the lowest risk. The intriguing question that arises here is whether there are organizational features that are best suited to safe and efficient functioning in the four quadrants.

Also interesting is Perrow's treatment of the institutionalist school, represented here by Philip Selznick's Leadership in Administration: A Sociological Interpretation and Selznick's study of the Tennessee Valley Authority. This approach is grounded in structuralist-functionalist sociological theory.

Perrow's considered theory or organizations is offered in the final chapter of the book. He advocates for an interpretation of organizations as vehicles of power through which some individuals control the behavior and products of others.

In my scheme, power is the ability of persons or groups to extract for themselves valued outputs from a system in which other persons or groups either seek the same outputs for themselves or would prefer to expend their effort toward other outputs. Power is exercised to alter the initial distribution of outputs, to establish an unequal distribution, or to change the outputs. (259)

Two specific examples illustrate this approach. Corporations influence consumers' palate for products, and they do this in ways that serve the interests of one group in society over another. And corporations and industrial bureaucracies have fundamentally shaped the practices and culture of "work" in ways that fundamentally serve the interests of one group over another. Both are examples of the "social construction" of important categories of social life; and corporations (business organizations) are actively involved in this process of social construction. (This is essentially the approach to the definition of "labor" and "work" offered by Bowles and Gintis in Schooling In Capitalist America: Educational Reform and the Contradictions of Economic Life.) This approach to organizations is mirrored in Perrow's book about the emergence of the business corporation in the United States in the nineteenth century, Organizing America: Wealth, Power, and the Origins of Corporate Capitalism.

In short, Complex Organizations is an excellent overview of organizational theory today, and it provides many of the conceptual and theoretical tools that help to make sense of these extended and pervasive social constructions that so fundamentally shape our modern experience.

Organizations and dysfunction

A recurring theme in recent months in Understanding Society is organizational dysfunction and the organizational causes of technology failure. Helmut Anheier's volume When Things Go Wrong: Organizational Failures and Breakdowns is highly relevant to this topic, and it makes for very interesting reading. The volume includes contributions by a number of leading scholars in the sociology of organizations.

And yet the volume seems to miss the mark in some important ways. For one thing, it is unduly focused on the question of "mortality" of firms and other organizations. Bankruptcy and organizational death are frequent synonyms for "failure" here. This frame is evident in the summary the introduction offers of existing approaches in the field: organizational aspects, political aspects, cognitive aspects, and structural aspects. All bring us back to the causes of extinction and bankruptcy in a business organization. Further, the approach highlights the importance of internal conflict within an organization as a source of eventual failure. But it gives no insight into the internal structure and workings of the organization itself, the ways in which behavior and internal structure function to systematically produce certain kinds of outcomes that we can identify as dysfunctional.

Significantly, however, dysfunction does not routinely lead to death of a firm. (Seibel's contribution in the volume raises this possibility, which Seibel refers to as "successful failures"). This is a familiar observation from political science: what looks dysfunctional from the outside may be perfectly well tuned to a different set of interests (for example, in Robert Bates's account of pricing boards in Africa in Markets and States in Tropical Africa: The Political Basis of Agricultural Policies). In their introduction to this volume Anheier and Moulton refer to this possibility as a direction for future research: "successful for whom, a failure for whom?" (14).

The volume tends to look at success and failure in terms of profitability and the satisfaction of stakeholders. But we can define dysfunction in a more granular way by linking characteristics of performance to the perceived "purposes and goals" of the organization. A regulatory agency exists in order to effectively project the health and safety of the public. In this kind of case, failure is any outcome in which the agency flagrantly and avoidably fails to prevent a serious harm -- release of radioactive material, contamination of food, a building fire resulting from defects that should have been detected by inspection. If it fails to do so as well as it might then it is dysfunctional.

Why do dysfunctions persist in organizations? It is possible to identify several possible causes. The first is that a dysfunction from one point of view may well be a desirable feature from another point of view. The lack of an authoritative safety officer in a chemical plant may be thought to be dysfunctional if we are thinking about the safety of workers and the public as a primary goal of the plant (link). But if profitability and cost-savings are the primary goals from the point of view of the stakeholders, then the cost-benefit analysis may favor the lack of the safety officer.

Second, there may be internal failures within an organization that are beyond the reach of any executive or manager who might want to correct them. The complexity and loose-coupling of large organizations militate against house cleaning on a large scale.

Third, there may be powerful factions within an organization for whom the "dysfunctional" feature is an important component of their own set of purposes and goals. Fligstein and McAdam argue for this kind of disaggregation with their theory of strategic action fields (link). By disaggregating purposes and goals to the various actors who figure in the life cycle of the organization – founders, stakeholders, executives, managers, experts, frontline workers, labor organizers – it is possible to see the organization as a whole as simply the aggregation of the multiple actions and purposes of the actors within and adjacent to the organization. This aggregation does not imply that the organization is carefully adjusted to serve the public good or to maximize efficiency or to protect the health and safety of the public. Rather, it suggests that the resultant organizational structure serves the interests of the various actors to the fullest extent each actor is able to manage.

Consider the account offered by Thomas Misa of the decline of the steel industry in the United States in the first part of the twentieth century in A Nation of Steel: The Making of Modern America, 1865-1925. Misa's account seems to point to a massive dysfunction in the steel corporations of the inter-war period, a deliberate and sustained failure to invest in research on new steel technologies in metallurgy and production. Misa argues that the great steel corporations -- US Steel in particular -- failed to remain competitive in their industry in the early years of the twentieth century because management persistently pursued short-term profits and financial advantage for the company through domination of the market at the expense of research and development. It relied on market domination instead of research and development for its source of revenue and profits.

In short, U.S. Steel was big but not illegal. Its price leadership resulted from its complete dominance in the core markets for steel.... Indeed, many steelmakers had grown comfortable with U.S. Steel's overriding policy of price and technical stability, which permitted them to create or develop markets where the combine chose not to compete, and they testified to the court in favor of the combine. The real price of stability ... was the stifling of technological innovation. (255)

The result was that the modernized steel industries in Europe leap-frogged the previous US advantage and eventually led to unviable production technology in the United States.

At the periphery of the newest and most promising alloy steels, dismissive of continuous-sheet rolling, actively hostile to new structural shapes, a price leader but not a technical leader: this was U.S. Steel. What was the company doing with technological innovation? (257)

 Misa is interested in arriving at a better way of understanding the imperatives leading to technical change -- better than neoclassical economics and labor history. His solution highlights the changing relationships that developed between industrial consumers and producers in the steel industry.

We now possess a series of powerful insights into the dynamics of technology and social change. Together, these insights offer the realistic promise of being better able, if we choose, to modulate the complex process of technical change. We can now locate the range of sites for technical decision making, including private companies, trade organizations, engineering societies, and government agencies. We can suggest a typology of user-producer interactions, including centralized, multicentered, decentralized, and direct-consumer interactions, that will enable certain kinds of actions while constraining others. We can even suggest a range of activities that are likely to effect technical change, including standards setting, building and zoning codes, and government procurement. Furthermore, we can also suggest a range of strategies by which citizens supposedly on the "outside" may be able to influence decisions supposedly made on the "inside" about technical change, including credibility pressure, forced technology choice, and regulatory issues. (277-278)

In fact Misa places the dynamic of relationship between producer and large consumer at the center of the imperatives towards technological innovation:

In retrospect, what was wrong with U.S. Steel was not its size or even its market power but its policy of isolating itself from the new demands from users that might have spurred technical change. The resulting technological torpidity that doomed the industry was not primarily a matter of industrial concentration, outrageous behavior on the part of white- and blue-collar employees, or even dysfunctional relations among management, labor, and government. What went wrong was the industry's relations with its consumers. (278)

This relative "callous treatment of consumers" was profoundly harmful when international competition gave large industrial users of steel a choice. When US Steel had market dominance, large industrial users had little choice; but this situation changed after WWII. "This favorable balance of trade eroded during the 1950s as German and Japanese steelmakers rebuilt their bombed-out plants with a new production technology, the basic oxygen furnace (BOF), which American steelmakers had dismissed as unproven and unworkable" (279). Misa quotes a president of a small steel producer: "The Big Steel companies tend to resist new technologies as long as they can ... They only accept a new technology when they need it to survive" (280).

***

Here is an interesting table from Misa's book that sheds light on some of the economic and political history in the United States since the post-war period, leading right up to the populist politics of 2016 in the Midwest. This chart provides mute testimony to the decline of the rustbelt industrial cities. Michigan, Illinois, Ohio, Pennsylvania, and western New York account for 83% of the steel production on this table. When American producers lost the competitive battle for steel production in the 1980s, the Rustbelt suffered disproportionately, anad eventually blue collar workers lost their places in the affluent economy.

Social ontology of government

I am currently writing a book on the topic of the "social ontology of government". My goal is to provide a short treatment of the social mechanisms and entities that constitute the workings of government. The book will ask some important basic questions: what kind of thing is "government"? (I suggest it is an agglomeration of organizations, social networks, and rules and practices, with no overriding unity.) What does government do? (I simplify and suggest that governments create the conditions of social order and formulate policies and rules aimed at bringing about various social priorities that have been selected through the governmental process.) How does government work -- what do we know about the social and institutional processes that constitute its metabolism? (How do government entities make decisions, gather needed information, and enforce the policies they construct?)

In my treatment of the topic of the workings of government I treat the idea of "dysfunction" with the same seriousness as I do topics concerning the effective and functional aspects of governmental action. Examples of dysfunctions include principal-agent problems, conflict of interest, loose coupling of agencies, corruption, bribery, and the corrosive influence of powerful outsiders. It is interesting to me that this topic -- ontology of government -- has unexpectedly crossed over with another of my interests, the organizational causes of largescale accidents.

If there are guiding perspectives in my treatment, they are eclectic: Neil Fligstein and Doug McAdam, Manuel DeLanda, Nicos Poulantzas, Charles Perrow, Nancy Leveson, and Lyndon B. Johnson, for example.

In light of these interests, I find the front page of the New York Times on March 28, 2019 to be a truly fascinating amalgam of the social ontology of government, with a heavy dose of dysfunction. Every story on the front page highlights one feature or another of the workings and failures of government. Let's briefly name these features. (The item numbers flow roughly from upper right to lower left.)

Item 1 is the latest installment of the Boeing 737 MAX story. Failures of regulation and a growing regime of "collaborative regulation" in which the FAA delegates much of the work of certification of aircraft safety to the manufacturer appear at this early stage to be a part of the explanation of this systems failure. This was the topic of a recent post (link).

Items 2 and 3 feature the processes and consequences of failed government -- the social crisis in Venezuela created in part by the breakdown of legitimate government, and the fundamental and continuing inability of the British government and its prime minister to arrive at a rational and acceptable policy on an issue of the greatest importance for the country. Given that decision-making and effective administration of law are fundamental functions of government, these two examples are key contributions to the ontology of government. The Brexit story also highlights the dysfunctions that flow from the shameful self-dealing of politicians and leaders who privilege their own political interests over the public good. Boris Johnson, this one's for you!

Item 4 turns us to the  dynamics of presidential political competition. This item falls on the favorable side of the ledger, illustrating the important role that a strong independent press has in helping to inform the public about the past performance and behavior of candidates for high office. It is an important example of depth journalism and provides the public with accurate, nuanced information about an appealing candidate with a policy history as mayor that many may find unpalatable. The story also highlights the role that non-governmental organizations have in politics and government action, in this instance the ACLU.

Item 5 brings us inside the White House and gives the reader a look at the dynamics and mechanisms through which a small circle of presidential advisors are able to determine a particular approach to a policy issue that they favor. It displays the vulnerability the office of president shows to the privileged insiders' advice concerning policies they personally favor. Whether it is Mick Mulvaney, acting chief of staff to the current president, or Robert McNamara's advice to JFK and LBJ leading to escalation in Vietnam, the process permits ideologically committed insiders to wield extraordinary policy power.

Item 6 turns to the legislative process, this time in the New Jersey legislature, on the topic of the legalization of marijuana. This story too falls on the positive side of the "function-dysfunction" spectrum, in that it describes a fairly rational and publicly visible process of fact-gathering and policy assessment by a number of New Jersey legislators, leading to the withdrawal of the legislation.

Item 7 turns to the mechanisms of private influence on government, in a particularly unsavory but revealing way. The story reveals details of a high-end dinner "to pa tribute to the guest of honor, Gov. Andrew M. Cuomo." The article writes, "Lobbyists told their clients that the event would be a good thing to go to", at a minimum ticket price of $25,000 per couple. This story connects the dots between private interest and efforts to influence governmental policy. In this case the dots are not very far apart.

With a little effort all these items could be mapped onto the diagram of the interconnections within and across government and external social groups provided above.

Regulatory failure and the 737 MAX disasters

The recent crashes of two Boeing 737 MAX aircraft raise questions about the safety certification process through which this modified airframe was certified for use by the FAA. Recent accounts of the design and manufacture of the aircraft demonstrate an enormous pressure for speed and great pressure to reduce costs. Attention has focused on a software system, MCAS, which was a feature needed to adapt to the aerodynamics created by repositioning of larger engines on the existing 737 body. The software was designed to automatically intervene to prevent stall if a single sensor in the nose indicated unacceptable angle of ascent. The crash investigations are not complete, but current suspicions are that the pilots in the two aircraft were unable to control or disable the nose-down response of the system in the roughly 40 seconds they had to recover control of the aircraft. (James Fallows provides a good and accessible account of the details of the development of the 737 MAX in a story in the Atlantic; link.)

The question here concerns the regulatory background of the aircraft: was the certification process through which the 737 MAX was certified to fly a sufficiently rigorous and independent one?

Thomas Kaplan details in a New York Times article the division of responsibility that has been created in the certification process over the past several decades between the FAA and the manufacturer (NYT 3/27/19). Under this program, the FAA delegates a substantial part of the work of certification evaluation to the manufacturer and its engineering staff. Kaplan writes:

In theory, delegating much of the day-to-day regulatory work to Boeing allows the FAA to focus its limited resources on the most critical safety work, taps into existing industry technical expertise at a time when airliners are becoming increasingly complex, and allows Boeing in particular to bring out new planes faster at a time of intense global competition with its European rival Airbus.

However, it is apparent to both outsiders and insiders that this creates the possibility of impairing the certification process by placing crucial parts of the evaluation in the hands of experts whose interests and careers lie in the hands of the corporation whose product they are evaluating. This is an inherent conflict of interest for the employee, and it is potentially a critical flaw in the process from the point of view of safety. (See an earlier post on the need for an independent and empowered safety officer within complex and risky processes; link.)

Senator Richard Blumenthal (Connecticut) highlighted this concern when he wrote to the inspector general last week: "The staff responsible for regulating aircraft safety are answerable to the manufacturers who profit from cutting corners, not the American people who may be put at risk."

A 2011 audit report from the Transportation Department's inspector general's office highlighted exactly this kind of issue: "The report cited an instance where FAA engineers were concerned about the 'integrity' of an employee acting on the agency's behalf at an unnamed manufacturer because the employee was 'advocating a position that directly opposed FAA rules on an aircraft fuel system in favor of the manufacturer'." The article makes the point that Congress has encouraged this program of delegation in order to constrain budget requirements for the federal agency.

Kaplan notes that there is also a worrisome degree of exchange of executive staff between the FAA and the airline industry, raising the possibility that the industry's priorities about cost and efficiency may unduly influence the regulatory agency:

The part of the FAA under scrutiny, the Transport Airplane Directorate, was led at the time by an aerospace engineer names Ali Bahrami. The next year, he took a job at the Aerospace Industries Association, a trade group whose members include Boeing. In that position, he urged his former agency to allow manufacturers like Boeing to perform as much of the work of certifying new planes as possible. Mr. Bahrami is now back at the FAA as its top safety official.

This episode illustrates one of the key dysfunctions of organizations that have been highlighted elsewhere here: the workings of conflict of commitment and interest within an organization, and the ability that the executives of an organization have to impose behavior and judgment on their employees that are at odds with the responsibilities these individuals have to other important social goods, including airline safety. The episode has a lot in common with the sequence of events leading to the launch of Space Shuttle Challenger (Vaughan, The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA).

Charles Perrow has studied system failure extensively since publication of his important book, Normal Accidents: Living with High-Risk Technologies and extending through his 2011 book The Next Catastrophe: Reducing Our Vulnerabilities to Natural, Industrial, and Terrorist Disasters. In a 2015 article, "Cracks in the 'regulatory state'" (link), he summarizes some of his concerns about the effectiveness of the regulatory enterprise. The abstract of the article shows its relevance to the current case:

Over the last 30 years, the U.S. state has retreated from its regulatory responsibility over private-sector economic activities. Over the same period, a celebratory literature, mostly in political science, has developed, characterizing the current period as the rise of the regulatory state or regulatory capitalism. The notion of regulation in this literature, however, is a perverse one—one in which regulators mostly advise rather than direct, and industry and firm self- regulation is the norm. As a result, new and potentially dangerous technologies such as fracking or mortgage backed derivatives are left unregulated, and older necessary regulations such as prohibitions are weakened. This article provides a joint criticism of the celebratory literature and the deregulation reality, and strongly advocates for a new sociology of regulation that both recognizes and documents these failures. (203)

The 2015 article highlights some of the precise sources of failure that seem to be evident in the 737 MAX case. "Government assumes a coordinating rather than a directive role, in this account, as regulators draw upon industry best practices, its standard-setting proclamations, and encourage self-monitoring" (203). This is precisely what current reporting demonstrates about the FAA relationship to the manufacturers.

One of the key flaws of self-monitoring is the lack of truly independent inspectors:

Part of the problem stems from the failure of firms to select truly independent inspectors. Firms can, in fact, select their own inspectors—for example, firemen or police from the local areas who are quite conscious of the economic power of the local chemical firm they are to inspect. (205)

Here again, the Boeing 737 MAX certification story seems to illustrate this defect as well.
How serious are these "cracked regulatory institutions"? According to Perrow they are deadly serious. Here is Perrow's summary assessment about the relationship between regulatory failure and catastrophe:

Almost every major industrial accident in recent times has involved either regulatory failure or the deregulation demanded by business and industry. For more examples, see Perrow (2011). It is hard to make the case that the industries involved have failed to innovate because of federal regulation; in particular, I know of no innovations in the safety area that were stifled by regulation. Instead, we have a deregulated state and deregulated capitalism, and rising environmental problems accompanied by growing income and wealth inequality. (210)

In short, we seem to be at the beginning of an important reveal of the cost of neoliberal efforts to minimize regulation and to pass the responsibility for safety significantly to the manufacturer.

(Baldwin, Cave, and Lodge provide a good exposure to current thinking about government regulation in Understanding Regulation: Theory, Strategy, and Practice, 2nd Edition. Their Oxford Handbook of Regulation also provides excellent resources on this topic.)

Nuclear power plant siting decisions

Readers may be skeptical about the practical importance of the topic of nuclear power plant siting decisions, since very few new nuclear plants have been proposed or approved in the United States for decades. However, the topic is one for which there is an extensive historical record, and it is a process that illuminates the challenge for government to balance risk and benefit, private gain and public cost.  Moreover, siting inherently brings up issues that are both of concern to the public in general (throughout a state or region of the country) and to the citizens who live in close proximity to the recommended site. The NIMBY problem is unavoidable -- it is someone's backyard, and it is a worrisome neighbor. So this is a good case in terms of which to think creatively about the responsibilities of government for ensuring the public good in the face of risky private activity, and the detailed institutions of regulation and oversight that would work to make wise public outcomes more likely.

I've been thinking quite a bit recently about technology failure, government regulation, and risky technologies, and there is a lot to learn about these subjects by looking at the history of nuclear power in the United States. Two books in particular have been interesting to me. Neither is particularly recent, but both shed valuable light on the public-policy context of nuclear decision-making. The first is Joan Aron's account of the processes that led to the cancellation of the Shoreham nuclear power plant on Long Island in the 1970s (Licensed To Kill?: The Nuclear Regulatory Commission and the Shoreham Power Plant) and the second is Donald Stever, Jr.'s account of the licensing process for the Seabrook nuclear power plant in Seabrook and The Nuclear Regulatory Commission: The Licensing of a Nuclear Power Plant. Both are fascinating books and well worthy of study as a window into government decision-making and regulation. Stever's book is especially interesting because it is a highly capable analysis of the licensing process, both at the state level and at the level of the NRC, and because Stever himself was a participant. As an assistant attorney general in New Hampshire he was assigned the role of Counsel for the Public throughout the process in New Hampshire.

Joan Aron’s 1997 book Licensed to Kill? is a detailed case study the effort to establish the Shoreham nuclear power plant on Long Island in the 1980s. LILCO had proposed the plant to respond to rising demand for electricity on Long Island as population and energy use rose. And Long Island is a long, narrow island on which traffic congestion at certain times of day is legendary. Evacuation planning was both crucial and in the end, perhaps impossible.

This is an intriguing story, because it led eventually to the cancellation of the operating license for the plant by the NRC after completion of the plant. And the cancellation resulted largely from the effectiveness of public opposition and interest-group political pressure. Aron provides a detailed account of the decisions made by the public utility company LILCO, the AEC and NRC, New York state and local authorities, and citizen activist groups that led to the costliest failed investment in the history of nuclear power in the United States.

In 1991 the NRC made the decision to rescind the operating license for the Shoreham plant, after completion at a cost of over $5 billion but before it had generated a kilowatt of electricity.

Aron’s basic finding is that the project collapsed in costly fiasco because of a loss of trust among the diverse stakeholders: LILCO, the Long Island public, state and local agencies and officials, scientific experts, and the Nuclear Regulatory Commission. The Long Island tabloid Newsday played a role as well, sensationalizing every step of the process and contributing to public distrust of the process. Aron finds that the NRC and LILCO underestimated the need for full analysis of safety and emergency preparedness issues raised by the plant’s design, including the issue of evacuation from a largely inaccessible island full of two million people in the event of disaster. LILCO’s decision to upscale the capacity of the plant in the middle of the process contributed to the failure as well. And the occurrence of the Three Mile Island disaster in 1979 gave new urgency to the concerns experienced by citizens living within fifty miles of the Shoreham site about the risks of a nuclear plant.

As we have seen, Shoreham failed to operate because of intense public opposition, in which the governor played a key role, inspired in part by the utility’s management incompetence and distrust of the NRC. Inefficiencies in the NRC licensing process were largely irrelevant to the outcome. The public by and large ignored NRC’s findings and took the nonsafety of the plant for granted. (131)

The most influential issue was public safety: would it be possible to perform an orderly evacuation of the population near the plant in the event of a serious emergency? Clarke and Perrow (included in Helmut Anheier, ed., When Things Go Wrong: Organizational Failures and Breakdowns) provide an extensive analysis of the failures that occurred during tests of the emergency evacuation plan designed by LILCO. As they demonstrate, the errors that occurred during the evacuation test were both “normal” and potentially deadly.

One thing that comes out of both books is the fact that the commissioning and regulatory processes are far from ideal examples of the rational development of sound public policy. Rather, business interests, institutional shortcomings, lack of procedural knowledge by committee chairs, and dozens of other factors lead to outcomes that appear to fall far short of what the public needs. But in addition to ordinary intrusions into otherwise rational policy deliberations, there are other reasons to believe that decision-making is more complicated and less rational than a simple model of rational public policy formation would suggest. Every decision-maker brings a set of “framing assumptions” about the reality concerning which he or she is deliberating. These framing assumptions impose an unavoidable kind of cognitive bias into collective decision-making. A business executive brings a worldview to the question of regulation of risk that is quite different from that of an ecologist or an environmental activist. This is different from the point often made about self-interest; our framing assumptions do not feel like expressions of self-interest, but rather simply secure convictions about how the world works and what is important in the world. This is one reason why the work of social scientists like Scott Page (The Difference: How the Power of Diversity Creates Better Groups, Firms, Schools, and Societies) on the value of diversity in problem-solving and decision-making is so important: by bringing multiple perspectives and cognitive frames to a problem, we are more likely to get a balanced decision that gives appropriate weight to the legitimate interests and concerns of all involved.

Here is an interesting concrete illustration of cognitive bias (with a generous measure of self-interest as well) in Stever’s discussion of siting decisions for nuclear power plants:

From the time a utility makes the critical in-house decision to choose a site, any further study of alternatives is necessarily negative in approach. Once sufficient corporate assets have been sunk into the chosen site to produce data adequate for state site review, the company's management has a large enough stake in it to resist suggestions that a full study of site alternatives be undertaken as a part of the state (or for that matter as a part of the NEPA) review process. hence, the company's methodological approach to evaluating alternates to the chosen site will always be oriented toward the desired conclusion that the chosen site is superior. (Stever 1980 : 30)

This is the bias of sunk costs, both inside the organization and in the cognitive frames of independent decision makers in state agencies.

Stever’s central point here is a very important one: the pace of site selection favors the energy company’s choices over the concerns and preferences of affected groups because the company is in a position to have dedicated substantial resources to development of the preferred site proposal. Likewise, scientific experts have a difficult time making their concerns about habitat or traffic flow heard in the context.

But here is a crucial thing to observe: the siting decision is only one of dozens in the development of a new power plant, which is itself only one of hundreds of government / business decisions made every year. What Stever describes is a structural bias in the regulatory process, not a one-off flaw. At its bottom, this is the task that government faces when considering the creation of a new nuclear power plant: “to assess the various public and private costs and benefits of a site proposed by a utility” (32); and Stever’s analysis makes it doubtful that existing public processes do this in a consistent and effective way. Stever argues that government needs to have more of a role in site selection, not less, as pro-market advocates demand: “The kind of social and environmental cost accounting required for a balanced initial assessment of, and development of, alternative sites should be done by a public body acting not as a reviewer of private choices, but as an active planner” (32).

Notice how this scheme shifts the pace and process from the company to the relevant state agency. The preliminary site selection and screening is done by a state site planning agency, with input then invited from the utilities companies, interest groups, and a formal environmental assessment. This places the power squarely in the hands of the government agency rather than the private owner of the plant -- reflecting the overriding interest the public has in ensuring health, safety, and environmental controls.

Stever closes a chapter on regulatory issues with these cogent recommendations (38-39):

1. Electric utility companies should not be responsible for decisions concerning early nuclear-site planning.
2. Early site identification, evaluation, and inventorying is a public responsibility that should be undertaken by a public agency, with formal participation by utilities and interest groups, based upon criteria developed by the state legislature.
3. Prior to the use of a particular site, the state should prepare a complete environmental assessment for it, and hold adjudicatory hearings on contested issues.
4. Further effort should be made toward assessing the public risk of nuclear power plant sites.
5. In areas like New England, characterized by geographically small states and high energy demand, serious efforts should be made to develop regional site planning and evaluation.
6. Nuclear licensing reform should focus on the quality of decision-making.
7. There should be a continued federal presence in nuclear site selection, and the resolution of environmental problems should not be delegated entirely to the states. 

(It is very interesting to me that I have not been able to locate a full organizational study of the Nuclear Regulatory Commission itself.)