Sources of technology failure

A recurring theme in Understanding Society is the topic of technology failure -- air disasters, chemical plant explosions, deep drilling accidents. This diagram is intended to capture several dimensions of failure causes that have been discussed. The categories identified here include organizational dysfunctions, behavioral shortcomings, system failures, and regulatory dysfunctions. Each of these broad categories has contributed to the occurrence of major technology disasters, and often most or all of them are involved.

System failures. 2005 Texas City refinery explosion. A complex technology system involves a dense set of sub-systems that have multiple failure modes and multiple ways of affecting other sub-systems. As Charles Perrow points out, often those system interactions are "tightly coupled", which means that there is very little time in which operators can attempt to diagnose the source of a failure before harmful effects have proliferated to other sub-systems. A pump fails in a cooling loop; an exhaust valve is stuck in the closed position; and nuclear fuel rods are left uncooled for less than a minute before they generate enough heat to boil away the coolant water. Similar to the issue of tight coupling is the feature of complex interactions: A influences B, C, D; B and D influence A; C's change of state further influences unexpected performance by D. The causal chains here are not linear, so once again -- operators and engineers are hard pressed to diagnose the source cause of an anomalous behavior in time to save the system from meltdown or catastrophic failure.

And then there are failures that originate in problems in the original design of the system and its instruments. Nancy Leveson identifies many such design failures in "The Role of Software in Spacecraft Accidents" (link). For example, the explosion at the Texas City refinery (link) occurred in part because the level transmitter instrument for the splitter high tower only measured column height up to the ten-foot maximum permissible height of the column of flammable liquid in the high splitter. Otherwise it only produced an alarm, which was routinely ignored. As a result the operators had no way of knowing that the column had gone up to 80 feet and then to the top of the column, leading to a release and subsequent fire and explosion (CSB Final Report Texas City BP) -- an overflow accident. And sometimes the overall system actually had no formal design process at all; as Andrew Hopkins observes,

Processing plants evolve and grow over time. A study of petroleum refineries in the US has shown that “the largest and most complex refineries in the sample are also the oldest … Their complexity emerged as a result of historical accretion. Processes were modified, added, linked, enhanced and replaced over a history that greatly exceeded the memories of those who worked in the refinery. (Lessons from Longford, 33)

This implies that the whole system is not fully understood by any of the participants -- executives, managers, engineers, or skilled operators.

Organizational dysfunctions. Deepwater Horizon. There is a very wide range of organizational dysfunctions that can be identified in case studies of technology disasters, from refineries to patient safety accidents. These include excessive cost reduction mandated by corporate decisions, inadequate safety culture embodied in leaders, operators, and day-to-day operations; poor inter-unit communications, where one unit concludes that a hazardous operation should be suspended but another unit doesn't get the message; poor training and supervision; and conflicting priorities within the organization. Top managers are subject to production pressures that lead them to resist decisions involving a shutdown of process while anomalies are sorted out; higher-level managers sometimes lack the technical knowledge needed to know when a given signal or alarm may be potentially catastrophic; failures of communications within large companies about known process risks; and inadequate oversight within a large firm of subcontractor performance and responsibilities. Two pervasive problems are identified in a great many case studies: relentless cost containment initiatives to increase efficiency and profitability; and a lack of commitment to (and understanding of) an enterprise-wide culture of safety. In particular, it is common for executives and governing boards of high-risk enterprises to declare that "safety is our number-one priority", where what they focus on is "days-lost" measures of injuries in the workplace. But this conception of safety fails completely to identify system risks. (Andrew Hopkins makes a very persuasive case for the use of "safety case" regulation and detailed HAZOP analysis for a complex operation as a whole; link.)

Behavioral shortcomings. Bhopal toxic gas release, Texas City refinery accident. No organization works like a Swiss watch. Rather, specific individuals occupy positions of work responsibility that may sometimes be only imperfectly performed. A control room supervisor is distracted at the end of his shift and fails to provide critical information for the supervisor on the incoming shift. Process inspectors sometimes take shortcuts and certify processes that in fact contain critical sources of failure; or inspectors yield to management pressure to overlook "minor" deviations from regulations. A maintenance crew deviates from training and protocol in order to complete tasks on time, resulting in a minor accident that leads to a cascade of more serious events. Directors of separate units within a process facility fail to inform each other of anomalies that may affect the safety of other sub-systems. Staff at each level have an incentive to conceal mistakes and "near-misses" that could otherwise be corrected.

Regulatory shortcomings. Longford gas plant, Davis-Besse nuclear plant incidents, East Palestine Norfolk Southern Railway accident. Risky industries plainly require regulation. But regulatory frameworks are often seriously flawed by known dysfunctions (link, link, link): industry capture (nuclear power industry); inadequate resources (NRC); inadequate enforcement tools (Chemical Safety Board); revolving door from industry to regulatory staff to industry; vulnerability to "anti-regulation" ideology expressed by industry and sympathetic legislators; and many of the dysfunctions already mentioned under the categories of organizational and behavioral shortcomings. The system of delegated regulation has been appealing to both industry and government officials. This is a system where central oversight is exercised by the regulatory agency, but the technical experts of the industry itself are called upon to assess critical safety features of the process being regulated. This approach makes government budget support for the regulatory agency much less costly. This system is used by the Federal Aviation Administration in its oversight of airframe safety. However, the experience of the Boeing 737 MAX failures has shown that the system of delegated regulation is vulnerable to distortion by the manufacturing companies that it oversees (link).

Here is Andrew Hopkin's multi-level analysis of the Longford Esso gas plant accident (link). This diagram illustrates each of the categories of failure mentioned here.

Consider this alternative universe. It is a world in which CEOs, executives, directors, and staff in risky enterprises have taken the time to read 4-6 detailed case studies of major technology accidents and have absorbed the complexity of the kinds of dysfunctions that can lead to serious disasters. Instructive case studies might include the Longford Esso gas plant explosion, the 2005 Texas City refinery explosion, the Columbia Space Shuttle disaster, the Boeing 737 MAX failure, the BP Deepwater Horizon disaster, and the Davis-Besse nuclear power plant incidents. These case studies would provide enterprise leaders and staff with a much more detailed understanding of the kinds of organizational and system failure that can be expected to occur in risky enterprises, and leaders and managers would be much better prepared to prevent failures like these in the future. It would be a safer world.

Electronic Health Records and medical mistakes

Electronic Health Record systems (EHRs) have been broadly implemented by hospitals and health systems around the country as a way of increasing the accuracy, availability, and timeliness of patient health status and treatment information. (These systems are also sometimes called "Digital Medical Records" (DMRs).) They are generally regarded as an important forward step in improving the quality of healthcare. Here is a description of the advantages of Electronic Health Record systems, according to Athena Health:

The advantages of electronic health records in the clinical setting are numerous and important. In the 2012 edition of the Physician Sentiment IndexTM, published by athenahealth and Sermo, 81% of physicians said they believe EHRs improve access to clinical data. More than two-thirds said an EHR can actually improve patient care.

The use of an electronic health records system offers these clinical advantages:

• No bulky paper records to store, manage and retrieve
• Easier access to clinical data
• The ability to establish and maintain effective clinical workflows
• Fewer medical errors, improved patient safety and stronger support for clinical decision-making
• Easier participation in Meaningful Use, Patient-Centered Medical Home (PCMH) and other quality programs, with electronic prompts ensuring that required data is recorded at the point of care
• The ability to gather and analyze patient data that enables outreach to discreet populations
• The opportunity to interact seamlessly with affiliated hospitals, clinics, labs and pharmacies

Considering all the advantages of electronic health records, and the rapidly growing electronic interconnectedness of the health care world, even if EHRs had not been mandated by health care reform, their development and eventual ubiquity in the health care industry was inevitable.

And yet, like any software system, EHR systems are capable of creating new errors; and some of those errors can be harmful to patients.

Nancy Leveson is an important expert on software system safety who has written extensively on the challenges of writing highly reliable software in safety-critical applications. Here are a few apt observations from her book Safeware: System Safety and Computers (1995).

Although it might seem that automation would decrease the risk of operator error, the truth is that automation does not remove people from systems -- it merely moves them to maintenance and repair functions and to higher-level supervisory control and decision making. The effects of human decisions and actions can then be extremely serious. At the same time, the increased system complexity makes the decision-making process more difficult. (10)

The increased pace of change lessens opportunity to learn from experience. Small-scale and relatively nonhazardous systems can evolve gradually by trial and error. But learning by trial and error is not possible for many modern products and processes because the pace of change is too fast and the penalties of failure are too great. Design and operating procedures must be right the first time when there is potential for a major fire, explosion, or release of toxic materials. (12)

(To the last statement we might add "or harm to hospital patients through incorrect prescriptions or failed transmission of lab results".)

The safety implications of computers exercising direct control over potentially dangerous processes are obvious. Less obvious are the dangers when ... software generated data is used to make safety-critical decisions, ... software is used in design analysis, ... safety-critical data (such as blood bank data) is stored in computer databases. The FDA has received reports of software errors in medical instruments that led to mixing up patient names and data, as well as reports of incorrect outputs from laboratory and diagnostic instruments (such as patient monitors, electrocardiogram analyzers, and imaging devices". (23)

Automatic control systems [like aircraft autopilots] are designed to cope with the immediate effects of a deviation in the process -- they are feedback loops that attempt to maintain a constant system state, and as such, they mask the occurrence of a problem in its early stages. An operator will be aware of such problems only if adequate information to detect them is provided. That such information is often not provided may be the result of the different mental models of the designers and experienced operators, or it may merely reflect financial pressures on designers due to the cost of providing operators with independent information. (117)

One of the cases examined in detail in Safeware is the Therac-25 radiation-therapy device, which due to a minor software flaw in the treatment-entry plan module began seriously injuring patients with excessive doses of radiation in 1985-87 (515 ff.). It had operated without incident thousands of times before the first accident.

So Leveson gives ample reason to be cautious about the safety implications of DMRs and the "fault pathways" through which their normal functioning might harm patients. What has been the experience so far, now that the healthcare industry has witnessed widespread adoption of DMR systems?

Two specific issues involving EHR errors affecting patient care have been identified in the past several years. The first is in the area of errors in the administration of prescription drugs, and the second is in the area of the handling and routing of medical test results. Both errors have the potential for harming the patient.

Jennifer Bresnick (link) summarizes the results of a report by the Pennsylvania Patient Safety Authority concerning medication errors caused by DMR systems. Medication errors (wrong medication, wrong dose, wrong patient, wrong frequency) can occur at several stages of the clinical process, including prescribing, transcribing, dispensing, and administration. The digital medical record is intended to dramatically reduce all these sources of error, the Pennsylvania study shows that the DMR can also contribute to errors at each of these stages.

While EHRs and other technologies are intended to reduce errors and improve the safe, standardized, and well-documented delivery of care, some stakeholders believe that digital tools can simply serve to swap one set of mistakes for another. Poor implementation and lackluster user training can leave patients just as vulnerable to medication errors as they were when providers used paper charts, commented Staley Lawes, PharmD, BCPS, Patient Safety Analyst, and Matthew Grissinger, RPh, FISMP, FASCP, Manager of Medication Safety Analysis in the brief. (link)

Part of the blame, according to the Pennsylvania report, belongs to the design of the user interface:

For this reason, it is important to design a system with an intuitive user interface to minimize the risk for human error. Users should be able to easily enter and retrieve data and share information with other healthcare professionals.  When systems are designed without these considerations in mind, patients are subject to undue risk. (link)

The report contains several specific design standards that would improve the safety of the DMR system:

The interaction between clinician and software is a key component that is to be taken into consideration when trying to improve the safety of health IT,” the report says. “Incident reports can provide valuable information about the types of HIT-related issues that can cause patient harm, and ongoing HIT system surveillance can help in developing medication safety interventions. (link)

It is clear that ongoing health IT system surveillance and remedial interventions are needed. Efforts to improve health IT safety should include attention to software interoperability, usability, and workflow. The relationship between clinician and software includes complex interactions that must be considered to optimize health IT’s contribution to medication safety.

Yackel and Embi (link) treat the problem of test result management errors in "Unintended errors with EHR-based result management: a case series". Here is their abstract:

Test result management is an integral aspect of quality clinical care and a crucial part of the ambulatory medicine workflow. Correct and timely communication of results to a provider is the necessary first step in ambulatory result management and has been identified as a weakness in many paper-based systems. While electronic health records (EHRs) hold promise for improving the reliability of result management, the complexities involved make this a challenging task. Experience with test result management is reported, four new categories of result management errors identified are outlined, and solutions developed during a 2-year deployment of a commercial EHR are described. Recommendations for improving test result management with EHRs are then given.

They identify test management errors at four stages of the clinical process:

• results not correctly communicated to provider;
• results communicated but never received or reviewed by the provider;
• results reviewed, but appropriate action not recommended by provider;
• appropriate recommendation made by provider, but action not carried out.

They make several key recommendations for improving the performance of DMR systems in managing test results: Develop fault-tolerant systems that automatically report delivery failures; use robust testing to find rare errors that occur both within and between systems; implement tracking mechanisms for critical tests, such as cancer screening and diagnostics; and deliver results directly to patients.

These are just two types of errors that can arise in digital medical record management systems. It is evident that the designers and implementers of DMRs need to take the systems-safety approach described by Nancy Leveson and implement comprehensive safety failure analysis, both in terms of "safety case analysis" (discovery of failure scenarios) and after-event investigation to identify the source of the failure in the software and its human interface.

These examples are not intended to suggest that DMRs are hazardous and should be avoided. On the contrary, the consolidation and convenient presentation of patient information for the provider is clearly an important step forward. But it is crucial that designers and implementers keep safety at the center of their attention, and to have a healthy respect for the ways in which automated systems can incorporate incorrect assumptions, can produce unintended interactions among components, and can be presented in such a confusing way to the human provider that patient care is harmed.

(Here is a case of treatment involving several different errors conveyed through the digital medical record system that involved attaching biopsy and test results to the wrong patient, leading to the wrong treatment for the patient. It is interesting to read because it reflects some of the complexity identified by Leveson in other system failures.) 

O-rings and production pressure

Allan McDonald's Truth, Lies, and O-Rings: Inside the Space Shuttle Challenger Disaster (2009) has given me a somewhat different understanding of the Challenger launch disaster than I've gained from other sources, including Diane Vaughan's excellent book The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. McDonald is a Morton Thiokol (MTI) insider who was present through virtually all aspects of the evolving solid rocket program at NASA in the two years leading up to the explosion in January 1986. He was director of the Space Shuttle Solid Rocket Motor Project during part of this time and he represented MTI at the formal Launch Readiness Review panels (LRRs) for several shuttle launches, including the fateful Challenger launch. He was senior management representative for MTI for the launch of STS-51L Challenger. His account gives a great deal of engineering detail about the Morton Thiokol engineering group's ongoing concerns about the O-rings in the months preceding the Challenger disaster. This serves as a backdrop for a detailed analysis of the dysfunctions in decision-making in both NASA and Morton Thiokol that led to an insufficient priority being given to safety assessments.

It is worth noting that O-rings were a key part of other large solid-fuel rockets, including the Titan rocket. So there was a large base of engineering and test experience with the performance of the O-rings when exposed to the high temperatures and pressures of ignition and firing.

The biggest surprise to me is the level of informed, rigorous, and evidence-based concern that MTI engineers had about the reliability of joint seal afforded by the primary and secondary seals on the solid rocket motors on the Shuttle system. These specialists had a very good and precise understanding of the mechanics of the problem. Further, there was a good engineering understanding of the expected (and required) time-sequence performance of the O-rings during ignition and firing. If the sealing action were delayed by even a few hundredths of a second, hot gas would be able to penetrate past the seal. These were not hypothetical worries, but instead were based on data from earlier launches demonstrating O-ring erosion and soot between the primary and secondary rings showing that super-hot gases had penetrated the primary seal. The worst damage and evidence of blowby had occurred on flight STS-51C January 25, 1985, one year earlier, the lowest-temperature launch yet attempted. And that launch took place when the temperature was 53 degrees.

Launch temperatures for the rescheduled January 28 launch were projected to be extremely cold -- 22-26 degrees was forecast on January 27, roughly 30 degrees colder than the previous January launch. The projected temperatures immediately raised alarm concerning the potential effects on the O-rings with the Utah-based engineering team and with McDonald himself. A teleconference meeting was scheduled for January 27 to receive recommendations from the Utah-based Morton Thiokol engineers who were focused on the O-rings problem about the minimum acceptable temperature for launch (95).

I tried to reach Larry Mulloy at his hotel but failed, so I called Cecil Houston, the NASA/MSFC Resident Manager at KSC. I alerted him of our concerns about the sealing capability of the field-joint O-rings at the predicted cold temperatures and asked him to set up the teleconference. (96)

The teleconference began at 8:30 pm on the evening before the launch. McDonald was present in Cape Canaveral for the Flight Readiness Review panel and participated in the teleconference involving the analysis and recommendations from MTI engineering, leading to a recommendation against launching in the expected cold weather conditions.

Thiokol's engineering presentation consisted of about a dozen charts summarizing the history of the performance of the field-joints, some engineering analysis on the operation of the joints, and some laboratory and full-scale static test data relative to the performance of the O-rings at various temperatures. About half the charts had been prepared by Roger Boisjoly, our chief seal expert on the O-ring Seal Task Force and staff engineer to Jack Kapp, Manager of Applied Mechanics. The remainder were presented by Arnie Thompson, the supervisor of our Structures Section under Jack Kapp, and by Brian Russell, a program manager working for Bob Ebeling. (97)

Boisjoly's next chart showed how cold temperature would reduce all the factors that helped maintain a good seal in the joint: lower O-ring squeeze due to thermal shrinkage of the O-ring; thicker and more viscous grease around the O-ring, making it slower to move across the O-ring groove; and higher O-ring hardness due to low temperature, making it more difficult for the O-ring to extrude dynamically into the gap for proper sealing. All of these things increased the dynamic actuation time, or timing function, of the O-ring, when at the very same time the O-ring could be eroding, creating a situation where the secondary seal might not be able to seal the motor, not if the primary O-ring was sufficiently eroded to prevent sealing in the joint. (99)

Based on their concerns about temperature and effectiveness of the seals in the critical half-second of ignition, MTI engineering staff prepared the foundation for a recommendation to not launch in temperatures lower than 53 degrees. Their conclusion as presented at the January 27 teleconference was unequivocal against launch under these temperature conditions:

The final chart included the recommendations, which resulted in several strong comments and many very surprising reactions from the NASA participants in the teleconference. The first statement on the “Recommendations” chart stated that the O-ring temperature must be equal to or greater than 53° at launch, and this was primarily based upon the fact that SRM-15, which was the best simulation of this condition, worked at 53 °. The chart ended with a statement that we should project the ambient conditions (temperature and wind) to determine the launch time. (102)

NASA lead Larry Mulloy contested the analysis and evidence in the slides and expressed great concern about the negative launch recommendation, and he asserted that the data were "inconclusive" in establishing a relationship between temperature and O-ring failure.

Mulloy immediately said he could not accept the rationale that was used in arriving at that recommendation. Stan Reinartz then asked George Hardy, Deputy Director of Science and Engineering at NASA/MSFC, for his opinion. Hardy said he was “appalled” that we could make such a recommendation, but that he wouldn't fly without Morton Thiokol's concurrence. Hardy also stated that we had only addressed the primary O-ring, and did not address the secondary O-ring, which was in a better position to seal because of the leak-check. Mulloy then shouted, “My God, Thiokol, when do you want me to launch, next April?” He also stated that “the eve of a launch is a helluva time to be generating new launch commit criteria!” Stan Reinartz entered the conversation by saying that he was under the impression that the solid rocket motors were qualified from 40° to 90° and that the 53° recommendation certainly was not consistent with that.” (103)

Joe Kilminster, VP of Space Booster Programs at MTI, then requested a short caucus for the engineering team in Utah to reevaluate the data and consider their response to the skepticism voiced by NASA officials. McDonald did not participate in the caucus, but his reconstruction based on the memories of persons present paints a clear picture. The engineering experts did not change their assessment, and they were overriden by MTI executives Cal Wiggins (VP and General Manager of the Space Division) and Jerry Mason (Senior VP of Wasatch Operations). In opening the caucus discussion, Mason is quoted as saying "we need to make a management decision". Engineers Boisjoly and Thompson reiterated their technical concerns about the functionality of the O-ring seals at low temperature, with no response from the senior executives. No members of the engineering team spoke up to support a decision to launch. Mason polled the senior executives, including Bob Lund (VP of Engineering), and said to Lund, "It's time for you, Bob, to take off your engineering hat and put on your management hat." (111) A positive launch recommendation was then conveyed to NASA, and the process in Florida resumed towards launch.

McDonald spends considerable time indicating the business pressure that MTI was subject to from its largest customer, NASA. NASA was considering creating a second-source option for competing companies for solid fuel motors from MTI and had also delayed signing a large contract (Buy-III fixed cost bid) for the next batch of motors. The collective impact of these actions by NASA could cost MTI over a billion dollars. So MTI management appears to have been under great pressure to accommodate to NASA managers' preferences concerning the launch decision. And it is hard to avoid the conclusion that their decision placed business interests first and the professional judgments of their safety engineers second. In doing so they placed the lives of seven astronauts at risk, with tragic consequences.

And what about NASA? Here the pressures are somewhat less fully developed than in Vaughan's account, but the driving commitment to achieve a 24-launch per year schedule seems to have been a primary motivation. Delayed launches significantly undermined this goal, which threatened both the prestige of NASA, the hope of significant commercial revenue for the program, and the assurance of continuing funding from Congress.

McDonald was not a participant in the caucus conference call. But he provides a reconstruction based on information provided by participants. In his understanding the engineers continued to defend their recommendation based on very concrete concerns about the effectiveness of the O-rings in extreme cold. Senior managers indicated their lack of support for this engineering judgment, and in the end Jerry Mason indicated that this would need to be a management decision. The FRR team was then informed that MTI has reconsidered its negative recommendation concerning launch. McDonald refused to sign the launch recommendation document, which was signed by his boss Joe Kilminster and faxed to the LRR team.

In hindsight it seems clear that both MTI executives and NASA executives deferred to business pressures of their respective organizations in the face of well-supported doubts about the safety of the launch. Is this a case of 20-20 vision after the fact? It distinctly appears not to be. The depth of knowledge, analysis, and rational concern that was present in the engineering group for at least a year prior to the Challenger disaster gave very specific and evidence-based reasons to abort this launch. This was not some intuitive, unspecific set of worries; it was an ongoing research problem that greatly concerned the engineers who were directly involved. And it appears there was no significant disagreement or uncertainty among them.

So it is hard to avoid a rather terrible conclusion, that the Challenger disaster was avoidable and should have been prevented. And the culpability lies with senior NASA and MTI executives who placed production pressures and business interests ahead of normal safety assessment procedures, and ahead of safety itself.

It is worth noting that Diane Vaughan's assessment is directly at odds with this assessment. She writes:

We now return to the eve of the launch. Accounts emphasizing valiant attempts by Thiokol engineers to stop the launch, actions of a few powerful managers who overruled a unanimous engineering position, and managerial failure to pass information about the teleconference to senior NASA administrators, coupled with news of economic strain and production pressure at NASA, led many to suspect that NASA managers had acted as amoral calculators, knowingly violating rules and taking extraordinary risk with human lives in order to keep the shuttle on schedule. However, like the history of decision making, I found that events on the eve of the launch were vastly more complex than the published accounts and media representations of it. From the profusion of information available after the accident, some actions, comments, and actors were brought repeatedly to public attention, finding their way into recorded history. Others, receiving less attention or none, were omitted. The omissions became, for me, details of social context essential for explanation. (LC 6215)

Young, Cook, Boisjoly, and Feynman. Concluding this list of puzzles and contradictions, I found that no one accused any of the NASA managers associated with the launch decision of being an amoral calculator. Although the Presidential Commission report extensively documented and decried the production pressures under which the Shuttle Program operated, no individuals were confirmed or even alleged to have placed economic interests over safety in the decision to launch the Space Shuttle Challenger. For the Commission to acknowledge production pressures and simultaneously fail to connect economic interests and individual actions is, prima facie, extremely suspect. But NASA’s most outspoken critics—Astronaut John Young, Morton Thiokol engineers Al McDonald and Roger Boisjoly, NASA Resource Analyst Richard Cook, and Presidential Commissioner Richard Feynman, who frequently aired their opinions to the media—did not accuse anyone of knowingly violating safety rules, risking lives on the night of January 27 and morning of January 28 to meet a schedule commitment. (kl 1627)

Vaughan's account includes many of the pivot-points of McDonald's narrative, but she assigns a different significance to many of them. She prefers her "normalization of deviance" explanation over the "amoral calculator" explanation.

(The Rogers Commission report and supporting documents are available online. Here is a portion of the hearings transcripts in which senior NASA officials provide testimony; link. This segment is critical to the issues raised in McDonald's account, since it addresses the January 27, 1986 teleconference FRR session in which a recommendation against launch was put forward by MTI engineering and was challenged by NASA senior administrators.)

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.

Flood plains and land use

An increasingly pressing consequence of climate change is the rising threat of flood in coastal and riverine communities. And yet a combination of Federal and local policies have created land use incentives that have led to increasing development in flood plains since the major floods of the 1990s and 2000s (Mississippi River 1993, Hurricane Katrina 2005, Hurricane Sandy 2016, ...), with the result that economic losses from flooding have risen sharply. Many of those costs are born by tax payers through Federal disaster relief and subsidies to the Federal flood insurance program.

Christine Klein and Sandra Zellmer provide a highly detailed and useful review of these issues in their brilliant SMU Law Review article, "Mississippi River Stories: Lessons from a Century of Unnatural Disasters" (link). These arguments are developed more fully in their 2014 book Mississippi River Tragedies: A Century of Unnatural Disaster. Klein and Zellmer believe that current flood insurance policies and disaster assistance policies at the federal level continue to support perverse incentives for developers and homeowners and need to be changed. Projects and development within 100-year flood plains need to be subject to mandatory flood insurance coverage; flood insurance policies should be rated by degree of risk; and government units should have the legal ability to prohibit development in flood plains. Here are their central recommendations for future Federal policy reform:

Substantive requirements for watershed planning and management would effectuate the Progressive Era objective underlying the original Flood Control Act of 1928: treating the river and its floodplain as an integrated unit from source to mouth, "systematically and consistently," with coordination of navigation, flood control, irrigation, hydropower, and ecosystem services. To accomplish this objective, the proposed organic act must embrace five basic principles:

(1) Adopt sustainable, ecologically resilient standards and objectives;
(2) Employ comprehensive environmental analysis of individual and cumulative effects of floodplain construction (including wetlands fill); (3) Enhance federal leadership and competency by providing the Corps with primary responsibility for flood control measures, cabined by clear standards, continuing monitoring responsibilities, and oversight through probing judicial review, and supported by a secure, non-partisan funding source; (4) Stop wetlands losses and restore damaged floodplains by re-establishing natural areas that are essential for floodwater retention; and (5) Recognize that land and water policies are inextricably linked and plan for both open space and appropriate land use in the floodplain. (1535-36)

Here is Klein and Zellmer's description of the US government's response to flood catastrophes in the 1920s:

Flood control was the most pressing issue before the Seventieth Congress, which sat from 1927 to 1929. Congressional members quickly recognized that the problems were two-fold. First, Congressman Edward Denison of Illinois criticized the absence of federal leadership: "the Federal Government has allowed the people. . . to follow their own course and build their own levees as they choose and where they choose until the action of the people of one State has thrown the waters back upon the people of another State, and vice versa." Moreover, as Congressman Robert Crosser of Ohio noted, the federal government's "levees only" policy--a "monumental blunder"--was not the right sort of federal guidance. (1482-83)

In passing the Flood Control Act of 1928, congressional members were influenced by Progressive Era objectives. Comprehensive planning and multiple-use management were hallmarks of the time. The goal was nothing less than a unified, planned society. In the early 1900s, many federal agencies, including the Bureau of Reclamation and the U.S. Geological Survey, had agreed that each river must be treated as an integrated unit from source to mouth. Rivers were to be developed "systematically and consistently," with coordination of navigation, flood control, irrigation, and hydro-power. But the Corps of Engineers refused to join the movement toward watershed planning, instead preferring to conduct river management in a piecemeal fashion for the benefit of myriad local interests. (1484)

But perverse incentives were created by Federal flood policies in the 1920s that persist to the present:

Only a few decades after the 1927 flood, the Mississippi River rose up out of its banks once again, teaching a new lesson: federal structural responses plus disaster relief payouts had incentivized ever more daring incursions into the floodplain. The floodwater evaded federal efforts to control it with engineered structures, and those same structures prevented the river from finding its natural retention areas--wetlands, oxbows, and meanders--that had previously provided safe storage for floodwater. The resulting damage to affected areas was increased by orders of magnitude. The federal response to this lesson was the adoption of a nationwide flood insurance program intended to discourage unwise floodplain development and to limit the need for disaster relief. Both lessons are detailed in this section. (1486)

Paradoxically, navigational structures and floodplain constriction by levees, highway embankments, and development projects exacerbated the flood damage all along the rivers in 1951 and 1952. Flood-control engineering works not only enhanced the danger of floods, but actually contributed to higher flood losses. Flood losses were, in turn, used to justify more extensive control structures, creating a vicious cycle of ever-increasing flood losses and control structures. The mid-century floods demonstrated the need for additional risk-management measures. (1489)

Only five years after the program was enacted, Gilbert White's admonition was validated. Congress found that flood losses were continuing to increase due to the accelerating development of floodplains. Ironically, both federal flood control infrastructure and the availability of federal flood insurance were at fault. To address the problem, Congress passed the Flood Disaster Protection Act of 1973, which made federal assistance for construction in flood hazard areas, including loans from federally insured banks, contingent upon the purchase of flood insurance, which is only made available to participating communities. (1491)

But development and building in the floodplains of the rivers of the United States has continued and even accelerated since the 1990s.

Government policy comes into this set of disasters at several levels. First, climate policy -- the evidence has been clear for at least two decades that the human production of greenhouse gases is creating rapid climate change, including rising temperatures in atmosphere and oceans, severe storms, and rising ocean levels. A fundamental responsibility of government is to regulate and direct activities that create public harms, and the US government has failed abjectly to change the policy environment in ways that substantially reduce the production of CO2 and other greenhouse gases. Second, as Klein and Zellmer document, the policies adopted by the US government in the early part of the twentieth century intended to prevent major flood disasters were ill conceived. The efforts by the US government and regional governments to control flooding through levees, reservoirs, dams, and other infrastructure interventions have failed, and have probably made the problems of flooding along major US rivers worse. Third, the human activities in flood plains -- residences, businesses, hotels and resorts -- have worsened the severity of the consequences of floods by elevating the cost in lives and property because of reckless development in flood zones. Governments have failed to discourage or prevent these forms of development, and the consequences have proven to be extreme (and worsening).

It is evident that storms, floods, and sea-level rise will be vastly more destructive in the decades to come. Here is a projection of the effects on the Florida coastline after a sustained period of sea-level rise resulting from a 2-degree Centigrade rise in global temperature (link):

We seem to have passed the point where it will be possible to avoid catastrophic warming. Our governments need to take strong actions now to ameliorate the severity of global warming, and to prepare us for the damage when it inevitably comes.

The US Chemical Safety Board

The Federal agency responsible for investigating chemical and petrochemical accidents in the United States is the Chemical Safety Board (link). The mission of the Board is described in these terms:

The CSB is an independent federal agency charged with investigating industrial chemical accidents. Headquartered in Washington, DC, the agency’s board members are appointed by the President and confirmed by the Senate.
The CSB’s mission is to “drive chemical safety change through independent investigation to protect people and the environment.”
The CSB’s vision is “a nation safe from chemical disasters.”
The CSB conducts root cause investigations of chemical accidents at fixed industrial facilities. Root causes are usually deficiencies in safety management systems, but can be any factor that would have prevented the accident if that factor had not occurred. Other accident causes often involve equipment failures, human errors, unforeseen chemical reactions or other hazards. The agency does not issue fines or citations, but does make recommendations to plants, regulatory agencies such as the Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA), industry organizations, and labor groups. Congress designed the CSB to be non-regulatory and independent of other agencies so that its investigations might, where appropriate, review the effectiveness of regulations and regulatory enforcement.

CSB was legislatively conceived in analogy with the National Transportation Safety Board, and its sole responsibility is to conduct investigations of major chemical accidents in the United States and report its findings to the public. It is not subordinate to OSHA or EPA, but it collaborates with those (and other) Federal agencies as appropriate (link). It has no enforcement powers; its sole function is to investigate, report, and recommend when serious chemical or petrochemical accidents have occurred.

One of its most important investigations concerned the March 23, 2005 Texas City BP refinery explosion. A massive explosion resulted in the deaths of 15 workers, injuries to over 170 workers, and substantial destruction of the refinery infrastructure. CSB conducted an extensive investigation into the “root causes” of the accident, and assigned substantial responsibility to BP’s corporate management of the facility. Here is the final report of that investigation (link), and here is a video prepared by CSB summarizing its main findings (link).

The key findings of the CSB report focus on the responsibility of BP management for the accident. Here is a summary of the CSB assessment of root causes:

The BP Texas City tragedy is an accident with organizational causes embedded in the refinery’s culture. The CSB investigation found that organizational causes linked the numerous safety system failures that extended beyond the ISOM unit. The organizational causes of the March 23, 2005, ISOM explosion are

• BP Texas City lacked a reporting and learning culture. Reporting bad news was not encouraged, and often Texas City managers did not effectively investigate incidents or take appropriate corrective action.
• BP Group lacked focus on controlling major hazard risk. BP management paid attention to, measured, and rewarded personal safety rather than process safety.
• BP Group and Texas City managers provided ineffective leadership and oversight. BP management did not implement adequate safety oversight, provide needed human and economic resources, or consistently model adherence to safety rules and procedures.
• BP Group and Texas City did not effectively evaluate the safety implications of major organizational, personnel, and policy changes.

Underlying almost all of these failures to manage this complex process with a priority on “process safety” rather than simply personal safety is a corporate mandate for cost reduction:

In late 2004, BP Group refining leadership ordered a 25 percent budget reduction “challenge” for 2005. The Texas City Business Unit Leader asked for more funds based on the conditions of the Texas City plant, but the Group refining managers did not, at first, agree to his request. Initial budget documents for 2005 reflect a proposed 25 percent cutback in capital expenditures, including on compliance, HSE, and capital expenditures needed to maintain safe plant operations.[208] The Texas City Business Unit Leader told the Group refining executives that the 25 percent cut was too deep, and argued for restoration of the HSE and maintenance-related capital to sustain existing assets in the 2005 budget. The Business Unit Leader was able to negotiate a restoration of less than half the 25 percent cut; however, he indicated that the news of the budget cut negatively affected workforce morale and the belief that the BP Group and Texas City managers were sincere about culture change. (176)

And what about corporate accountability? What did BP have to pay in recompense for its faulty management of the Texas City refinery and the subsequent damages to workers and local residents? The answer is, remarkably little. OSHA assessed a fine of $50.6 million for its violations of safety regulations (link, link), and it committed to spend at least $500M to take corrective steps within the plant to protect the safety of workers. This was a record fine at the time; and yet it might very well be seen by BP corporate executives as a modest cost of doing business in this industry. It does not seem to be of the magnitude that would lead to fundamental change of culture, action, and management within the company.

BP commissioned a major review of BP refinery safety in all five of its US-based refineries following release of the CSB report. This study became the Baker Panel REPORT OF THE BP U.S. REFINERIES INDEPENDENT SAFETY REVIEW PANEL (JANUARY 2007) (link). The Baker Panel consisted of fully qualified experts on industrial and technological safety who were in a very good position to assess the safety management and culture of BP in its operations of its five US-based refineries. The Baker Panel was specifically directed to refrain from attempting to analyze responsibility for the Texas City disaster and to focus its efforts on assessing the safety culture and management direction that were currently to be found in BP's five refineries. Here are some central findings:

• Based on its review, the Panel believes that BP has not provided effective process safety leadership and has not adequately established process safety as a core value across all its five U.S. refineries.
• BP has not always ensured that it identified and provided the resources required for strong process safety performance at its U.S. refineries. Despite having numerous staff at different levels of the organization that support process safety, BP does not have a designated, high-ranking leader for process safety dedicated to its refining business.
• The Panel also found that BP did not effectively incorporate process safety into management decision-making. BP tended to have a short-term focus, and its decentralized management system and entrepreneurial culture have delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.
• BP has not instilled a common, unifying process safety culture among its U.S. refineries.
• While all of BP’s U.S. refineries have active programs to analyze process hazards, the system as a whole does not ensure adequate identification and rigorous analysis of those hazards.
• The Panel’s technical consultants and the Panel observed that BP does have internal standards and programs for managing process risks. However, the Panel’s examination found that BP’s corporate safety management system does not ensure timely compliance with internal process safety standards and programs at BP’s five U.S. refineries.
• The Panel also found that BP’s corporate safety management system does not ensure timely implementation of external good engineering practices that support and could improve process safety performance at BP’s five U.S. refineries. (Summary of findings, xii-xiii)

These findings largely validate and support the critical assessment of BP's safety management practices in the CSB report.

It seems clear that an important part of the substantial improvement that has occurred in aviation safety in the past fifty years is the effective investigation and reporting provided by the NTSB. NTSB is an authoritative and respected bureau of experts whom the public trusts when it comes to discovering the causes of aviation disasters. The CSB has a much shorter institutional history -- it was created in 1990 -- but we need to ask a parallel question here as well: Does the CSB provide a strong lever for improving safety practices in the chemical and petrochemical industries through its accident investigations; or are industry actors largely free to continue their poor management practices indefinitely, safe in the realization that large chemical accidents are rare and the costs of occasional liability judgments are manageable?

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.