Organizational Causes of Largescale Technology Failure
Elective course in masters of public policy program
Daniel Little, University of Michigan-Dearborn
Course description
Gas plants explode, planes crash, and nuclear power plants suffer meltdowns. Human beings make mistakes and complex technologies fail in unexpected ways. Often unrecognized in accidents and disasters are the organizational features that made these disasters possible or likely. This course examines the organizational features, system defects, and bureaucratic dysfunctions that contribute to large technology failures. Organizations affect the occurrence of accidents at every level. Internal characteristics like poor communication, loose coupling, and principal-agent problems lead to accidents. External factors like ineffective regulation and enforcement likewise contributes to disaster. Through case studies, sociological analysis, and organizational study this course will help students think more fully about safety and accident in our technologically complex world.
Learning will occur through study of detailed real-world case studies as well as social-scientific analysis of the workings of various organizations and agencies. Teams of students will take on a particular accident or failure in order to analyze the incident; identify causes and dysfunctions; and recommend remedies for reducing risk through public policy and corporate organizational change. Examples may include: Katrina disaster relief process, 2011 Mississippi River flooding, the Morandi Bridge collapse in Genoa, Fermi I meltdown, Davis-Besse nuclear power plant near-miss, New England Compounding Center meningitis contamination case, the Boeing 737 Max, persistent police misconduct, and sexual predation scandals at Penn State or MSU.
Assignments
Work in the course is organized around a group project developing a case study of a significant event and an individual policy brief based on the same case. Team members will collaborate in development of a case-study treatment of the event, including organizational, technical, regulatory, and external factors. The case study will make recommendations for organizational policies and changes that would serve to reduce risk, including both internal policies and public policies when appropriate. Teams will make 20-minute presentations during class in the final eight weeks of the semester. The work product from the team project should be a jointly-authored case report and a slide presentation suitable for a 20-minute presentation of the essentials of the final findings, including policy recommendations based on the case. Each student will write a reflective individual policy brief of about 2,000 words on the case you studied in your group project. This will not require additional research but I will expect you to make use of the learning you have done from the readings and discussions of the course to write your own assessment of causes and “lessons learned” from the case on which you collaborated.
Course Objectives
- deepen understanding of organizational dysfunction in large organizations
- examine regulatory regimes in nuclear, chemical, and food industries; identify goals and shortcomings
- gain facility in policy analysis with respect to the management and regulation of large technologies
- gain experience working on multi-disciplinary research team
Key texts
- Charles Perrow, Normal Accidents
- Diane Vaughan, The Challenger Launch Decision
- Weick and Sutcliffe, Managing the Unexpected
- Scott Sagan, The Limits of Safety
- Andrew Hopkins, Lessons from Longford
- Walker and Wellock, A Short History of Nuclear Regulation, 1946-2009
- David Lochbaum et al, Fukushima: The Story of a Nuclear Disaster
- Earl Boebert, James Blossom, Deepwater Horizon: A Systems Analysis of the Macondo Disaster
Course topics and readings
Section 1. Theoretical resources
Week 1.
Introduction to the problem: organizational and regulatory causes of large failure
Discussion of case-study projects
VIDEO: Anatomy of a Disaster Texas City refinery explosion (YouTube 55 mins) (link)
Week 2.
Organizational causes of accidents: Normal accidents
Perrow, Normal Accidents (intro, chaps. 1-3,5)
Clarke and Perrow, “Prosaic Organizational Failure” (PDF)
Hopkins, “Lessons from Esso’s Gas Plant Explosion at Longford” (PDF)
Week 3.
Normalization of deviance
Case: Challenger Space Shuttle disaster
Diane Vaughan, The Challenger Launch Decision (preface to 2016 edition; chapters 1-6)
Selections from Allan McDonald, Truth, Lies, and O-Rings (PDF)
Rogers Commission report on Challenger disaster, Chapter V (PDF)
Week 4.
System safety: the engineering approach
Case: Spacecraft accidents
Nancy Leveson, “Technical and Managerial Factors in the NASA Challenger and Columbia Losses: Looking Forward to the Future” (PDF)
Nancy Leveson, “The Role of Software in Spacecraft Accidents” (PDF)
Bonaca and Powers, “Safety Culture in the Nuclear Industry” (PDF)
RESOURCE Nancy Leveson, System Safety Engineering (Part I) (PDF)
Week 5.
High reliability organizations
Large high-risk loosely coupled organizations
Case: Esso Gas Plant explosion, Longford, Australia, 1998
Cantu, Jaime et al, “High Reliability Organization (HRO) systematic literature review” PDF
Scott Sagan, The Limits of Safety (introduction; chapters 1-4, 6)
VIDEO: Longford Gas plant, Andrew Hopkins, Lesson from Longford (link)
Week 6.
Managing the unexpected
Weick and Sutcliffe, Managing the Unexpected (all)
Week 7.
The sources of dysfunction in organizations and government
D. Little, A New Social Ontology of Government (chaps. 1, 4-6)
GAO Study of Davis-Besse Nuclear Reactor Incident (PDF)
RESOURCE Walker and Wellock, A Short History of Nuclear Regulation, 1946-2009
Week 8.
Regulatory agencies and safety
Little, A New Social Ontology of Government (chaps. 8-10)
Charles Perrow, “Cracks in the “Regulatory State” (PDF)
Hopkins, “Explaining Safety Case Regulation”
Brookings, “Boeing crisis illustrates risks of delegated regulatory authority” PDF
Little Prezi slides, Boeing 737 Max disaster
Section 2. Lessons from complex failures in the real world
Week 9.
Corporate, management, and regulatory failures 1
Case: Deepwater Horizon
Boebert and Blossom, Deepwater Horizon: A Systems Analysis of the Macondo Disaster (chaps. 1-15)
Hopkins, “Management Walk-Arounds: Lessons from the Gulf of Mexico Oil Well Blowout” (PDF)
Week 10.
Corporate, management, and regulatory failures 2
Wrapping up Deepwater Horizon
Vaughan, D. “The Dark Side of Organization: Mistakes, Misconduct, and Disaster” (PDF)
Charles Perrow, “Cracks in the “Regulatory State” (PDF)
National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling
US Chemical Safety Board Investigation Report
Week 11.
State agencies, revolving doors, and poor “worst case” planning
Case: Fukushima nuclear disaster
Lochbaum et al, Fukushima: The Story of a Nuclear Disaster (selected chapters)
World Nuclear Association Fukushima Report (web)
Charles Perrow, “Fukushima and the inevitability of accidents” (PDF)
Charles Perrow, “Five Assessments of the Fukushima Disaster” (Bulletin of the Atomic Scientists 3/10/14) (web)
Lochbaum’s testimony on “lessons learned from Fukushima” (Union of Concerned Scientists) (https://youtu.be/7FBmfseoKeg)
Section 3. Chronic problems resisting reform
Week 12.
Patterns of sexual and gender harassment and misconduct in universities and laboratories
NASEM Report on Sexual and Gender Harassment (PDF)
David Hess, “Corporate Culture and Corporate Compliance Programs” (PDF)
Week 13.
Patient and hospital safety
National Academy of Science, Engineering and Medicine, To Err is Human: Building a Safer Health System (executive summary and chapter 3) PDF
Nancy Leveson, “A Systems Approach to Analyzing and Preventing Hospital Adverse Events” PDF
James Bagian, “Patient safety: lessons learned” PDF
James Bagian, “RCA2: Improving Root Cause Analyses and Actions to Prevent Harm” PDF
Week 14.
Reforming police departments – racial profiling and excessive use of force
Klemko, “Why Police Reform is Hard”
Human Rights Watch, “A Roadmap for Reform”
Brookings, “A Better Path Forward”
Alpert, “Police Use of Force: Organizational Characteristics”
Bell, “Police Reform”
Week 15.
Assessment of Normal Accident theory, HRO theory, regulatory failure theory
Perrow, Normal Accidents (chapter 9)
Nancy Leveson, “Moving beyond normal accidents and high-reliability organizations” (PDF)
Joseph Stiglitz, “Regulation and Failure”
Brookings Report on Delegated Regulation re Boeing 737 Max
Week 16.
Wrapup of course
Dan Little Research Page 