Systems accidents, blaming, and policy

As a student of disasters in the policy process, I am interested in what Charles Perrow has called "normal accidents." Normal accidents are events--also known as system accidents--that occur when complex systems interact in unusual ways. In the New York Times today we learn that a number of pre-flight errors contributed to the crash of Continental Connection (that is, Colgan Air) flight 3407 on approach to Buffalo last February.

Perhaps a better example of a system accident was the 2000 crash of a Concorde flight. At least one of the plane's engines failed catastrophically on takeoff from Paris Charles de Gaulle airport, whereupon the plane failed to gain altitude and crashed into a hotel, killing all aboard and several on the ground. Continental Airlines and five individuals are on trial in France on manslaughter charges; the French authorities determined that the proximate cause of the crash was a strip of metal that had fallen off a Continental Airlines DC-10 that had departed just before the Concorde took off. The claim is that the metal strip shed by the DC-10 damaged the tires on the landing gear of the Concorde, causing a large chunk of rubber to strike the wing, thereby rupturing the fuel tank. But, as the BBC noted this morning, there were other factors involved, including the apparent fact that the fuel tanks were filled higher than recommended, thereby allowing the rubber to create a shock wave in the full tank, compounding damage and leading to the rupture and fire.

What is interesting about these cases is the fundamental question of blame attribution? Whose fault are these accidents? In the Colgan case, arguments have been made that the pilot showed poor skills, the co-pilot had a cold and was inattentive due to lack of sleep, and that, in the end, the pilot failed to fully increase power before lifting the nose of the plane, thereby precipitating a stall that led to loss of control and the crash. But the Times story suggests other causes, including conflicting data being entered into the plane's computers. In the Concorde case, should a piece of debris have been able to so badly damage the plane's tires? Should a piece of rubber be able to damage the wing? Should the fuel tank have been designed to be so vulnerable to shock?

These seem like highly technical arguments, but they really come down to different models of blame attribution that Deborah Stone has written about. And such blame attribution can matter in regulation, and in the investigation and prosecution of those considered responsible.

Reviews of Deborah Stone's Policy Paradox

One of the best ways to truly understand a complex book is to read the book reviews to see what struck reviewers as the most important theme of the book. With that in mind, I was able to find reviews of Deborah Stone's Policy Paradox,  through JSTOR--one of the finest databases for peer-reviewed research across many disciplines. These links will take you directly to the reviews if you are viewing this on a campus that subscribes to JSTOR, or if you can authenticate your student status.


B. Guy Peters's review, in the American Political Science Review (1989): http://www.jstor.org/stable/1956482


Janice Thomas's review in Public Administration Review (1989): http://www.jstor.org/stable/976580

For Gates’s Aides, No More Fatigues at Work - NYTimes.com

This article in the New York Times shows how symbolic acts--like deciding what sort of uniforms military officers should wear at the Pentagon--can seem "merely" symbolic, but have real substantive policy effects.

8 Qualities of Powerful Writing - Stepcase Lifehack

Students in my courses know that I am pretty strict about writing. With that in mind, I will post links to interesting articles about writing, the writing process, and the like. Here's an interesting article that I find a bit abstract, but it does contain some really important ideas--including the idea that writing should be driven by one's passion for the subject and by a goal.

8 Qualities of Powerful Writing - Stepcase Lifehack

Martin Luther King Birthday and the Civil Rights Movement

In my Public Policy textbook I cite the civil rights movement as perhaps the most important social movement of the 20th century. With that in mind, this interesting article from the Raleigh News and Observer provides some context in North Carolina. These sort of stories are, of course, very common around the Martin Luther King Jr. Holiday, but the accumulation of these stories is a worthwhile way for younger people to learn about this movement, and for older people to remember their roles, however big or small, in that movement.

Indeed, the struggle to make MLK's birthday a national holiday would, itself, be an interesting case study. I will see if I can find a good treatment of this debate.

Why most journalism is poor evidence

In most cases, I don't accept newspapers as sources in my students' analytic work. This article from Slate, on the Washington Post's coverage of the local drug problem, reveals why. I would accept journalism as an example of how journalism tends to dramatize problems with little or no context, but, as this Slate article suggests, most daily journalism is not a reliable source of actual facts or data. It is said that "journalism is the rough draft of history," but in this Washington Post case, it's very rough indeed. Of course, I would accept this Post article as an example of the problems of daily journalism.