Disaster by Management:

A key element in contemporary technological accidents and in the September 11th terrorist incidents is the interaction of risk assessment and risk management in complex public organizations. Risk assessment communication moves along the spokes of an organizational hierarchy toward socially and spatially more concentrated hubs of decision-making, each of which makes risk management decisions in politicized contexts peculiar to its own scale. These contexts affect the outcome of a given risk assessment communication: Is the risk managed by an active and effective decision-maker at that level? Is the communication passed along yet another spoke to still another hub in search of an effective decision-maker at a more influential level? Or is the risk assessment suppressed with either no decision taken to alter risk or with sanctions applied to the messengers of risk?

This paper compares the structure of human errors in two disasters with sociogenic causes: the Columbia Shuttle accident and the FBI failure to act on intelligence presaging the 9/11 terrorist attack. In each case, technical information suggesting disaster was weakly transmitted within an elaborate bureaucracy and high-level decision-makers failed to authorize action and, in at least one case, actively overrode actions taken by lower-level decision- makers that may have prevented tragedy. The result was truly "disaster by management."

To analyze risk assessment communication flows along NASA and FBI hierarchies, respectively, this paper integrates several theoretical frameworks: managerialism, organizational theory, functions of government theory, accident theory, risk perception, risk assessment and risk management relations, and the spatiality of NASA and the FBI. Data consist of public documents concerning these two disasters.

The paper concludes that both the Columbia accident and the FBI handling of field office concerns before 9/11 seem to validate normal accident theory. Communication about risks appear to have been hog-tied in complex bureaucracies. Unpredictable external constraints acted on both agencies and led to a shift in risk managers' perception of the relative importance of the precautionary principle and the opportunity costs its application can impose. In NASA's case, the failure in communication can be traced to its external political environment and funding base, its geographically ornate and hierarchical structure, and the lower status and timidity of risk assessors compared with managers. In the FBI's case, the most consequential failure of communication was between the most senior levels of the Bureau and the lower- ranked personnel there at Headquarters, which affected their decision-making concerning the distant field offices.

In both agencies, there were, additionally, parallel chains of command and communication. At NASA, individuals may find themselves wearing hats as engineers, as technical staff within the Shuttle Program, and as employees within the line structure of a NASA center, and it may not be clear to them which chain they should jerk to call attention to a safety-of-flight issue. At the FBI, intelligence and criminal investigation functions have been kept strictly separated and compartmentalized.

The consequence of these barriers to communication along hierarchies, between chains of command, and across space was an imbalanced focus on the managerialist concerns of efficiency, budget, scheduling, and rules and regulations, instead of on the risk to human life. Managers had normalized anomaly and resisted data that contradicted their biases in perception, leading to what one NASA engineer called "worlds of pain."

This paper compares the structure of human errors in two disasters with sociogenic causes: the Columbia Shuttle accident and the FBI failure to act on intelligence presaging the 9/11 terrorist attack. In each case, technical information suggesting disaster was weakly transmitted within an elaborate bureaucracy and high-level decision-makers failed to authorize action that may have prevented tragedy. The result was truly "disaster by management."

Themes from prior literature relevant to these case studies include:

• managerialism in the public sector -- application of "scientific" management to public sector agencies
• organizational theory -- mechanistic vs. organic, hierarchical and stable vs. flexible teamwork and unstable milieu
• O'Connor's analysis of government functions -- accumulation agencies vs. legitimatization agencies
• accident theory -- normal accident theory vs. high reliability theory
• risk perception and behavior -- normalizing anomaly and reïnforcement of biases in viewing risk
• the risk analysis and risk management relationship -- Type I vs. Type II errors, precautionary principle vs. opportunity costs
• the rôle of geography as a silent agent -- friction of (psychological) distance in communication and hierarchies in space

Information on the Shuttle disaster came from the Columbia Accident Investigation Board report, while information on the FBI treatment of field office communications comes from testimony given to the Congressional Joint Investigation into September 11th and the Boston Globe.

On January 16th, the Columbia Shuttle was struck during launch by a large piece of insulation foam at a relative velocity of several hundred km/hr, leading to the breakup of the shuttle during descent on February 1st, killing all 7 astronauts.

The Columbia Accident Investigation Board (CAIB) attributed the accident more to NASA's internal organization and history and Congressional and White House pressures on the agency than to the specific mechanisms that led to failure.

Nixon ended most of NASA's post-Apollo space exploration plans. NASA salvaged the Shuttle by promising it would be a self-supporting launch vehicle and scientific platform.

The first shuttle (Columbia) was launched in 1981.

Reagan declared this experimental vehicle "fully operational" in 1981, so Reagan and Congress found Shuttle cost overruns and schedule delays inexplicable and unacceptable.

Such managerialist pressures led to a lethal decision to launch Challenger in January 1986 over the concerns of engineers.

The Rogers Commission indicted NASA's managerialism for normalizing anomaly to meet tighter schedules and budgets.

NASA implemented many reforms in the Rogers Report and returned to flight in 1988, but the Shuttle Program was now part of the Human Space Flight Initiative, along with the ISS.

Managerialist pressures resumed in 1994 with an OMB directive that ISS cost overruns be confined to the HSFI, meaning the moneys would be taken from the Shuttle.

From 1993 to 2003, the Shuttle budget was hacked 40% and its labor force 42%: "Faster, cheaper, better"?

Faced with a $4 billion ISS cost overrun in 2001 and White House pressure, the US contribution was limited to completing a node allowing other nations' modules to dock with the ISS. An arbitrary date was set for node completion: February 2004.

The deadline imposed intense schedule pressure on the Shuttle, which led to managerial concerns about delays on a tight sequence of launches.

The consequences of missing deadlines caused managers to require virtually ironclad proof of impending mission failure before approving delays or mission aborts.

Routine examination of launch videos revealed the strike by a suitcase-sized piece of foam insulation.

The Intercenter Photo Working Group asked Kennedy Shuttle Management to get Defense Department imagery, which the Kennedy manager tried to do.

NASA & Boeing engineers formed a Debris Assessment Team.

Boeing engineers asked their Houston office to run "Crater," a program for simulating popcorn-sized debris impacts on the Shuttle. Crater had never been used by the Houston staff.

The model predicted the foam had ruptured the wing. The Houston staff did not trust the model's results but did not consult with the California Crater developers about them.

The Debris Assessment Team, however, was worried enough to request DoD imagery separately from the KSM request, via Johnson Space Flight Center engineering management.

The Chair of the Mission Management Team, thinking the DAT had gone around her to Johnson and the DoD, contacted DoD to cancel the imagery request. DoD canceled both requests.

The Chair knew a particularly bad debris strike had happened on the previous launch, without a mission abort (or accident). Normalization of anomaly made her decision comfortable.

The DAT accepted her decision as a final order due to the mechanistic and hierarchical nature of NASA management.

With no DoD imagery and just the odd results of Crater to go on, the DAT could make only a weak presentation justifying emergency rescue, which could have saved the crew's lives.

Management found nothing in their talk to compel concern about safety-of- flight over their natural inclination to worry more about mission costs and schedule. And the rest is history.

The second analysis focusses on 4 cases of FBI Headquarters' response to the anxieties of field officers and a HQ translator about odd behavior by certain Middle Easterners in the US.

These 4 examples of failed communication took place at a time of extremely heightened concern at the highest echelons of the Federal government about impending al-Qaeda attacks, e.g.,

• On July 5th, Richard Clarke told a White House gathering of senior officials from the FBI and other Federal agencies about a "really spectacular," imminent al-Qaeda attack.

• On August 6th, the CIA's President's Daily Brief, "Bin Ladin Determined to Strike in US," was given to President Bush.

For some reason, that urgent concern was not communicated down the hierarchy at FBI Headquarters, much less diffused out to the field offices around the country.

In light of that failure, the behavior of Headquarters analysts and operations specialists before the attacks makes sense.

Both the Columbia accident and the FBI handling of field office concerns before 9/11 seem to validate normal accident theory.

• Risk communication foundered in complex bureaucracies.

• Unpredictable external constraints acted on both agencies, shifting risk managers' perception of the proper balance between the precautionary principle and the opportunity costs its application can impose.

In NASA's case, the failure in communication reflects:

• its vulnerability as a legitimatization agency to external political and funding conditions

• its geographically ornate and hierarchical structure

• lower status and timidity of risk assessors compared with managers in its mechanistic and hierarchical organization

In the FBI's case, the worst failure of communication was from the top levels to the lower-ranked personnel there at HQ:

• This affected HQ's response to the distant field offices.

• It also created resistance to upwards communications post 9/11 from translators and agents at HQ, hindering the learning behavior seen in high reliability organizations.

Both agencies have parallel chains of command and communication:

• At NASA, individuals may serve as engineers, technical staff within the Shuttle Program, and employees within a NASA center's line structure: It may not be clear to them which chain they should jerk about a safety-of-flight issue.

• At the FBI, intelligence and criminal investigation functions were kept strictly separated and compartmentalized to protect intelligence sources.

Both NASA and the FBI contain endemic barriers to communication:

• along hierarchies
• between chains of command
• across geographical and psychological space

A severe cut in Shuttle funding and labor force had been imposed on NASA, along with calls for better management of budget and scheduling; the FBI was under DoJ investigation of its practices and in transition between directors.

The result was an imbalanced focus on the managerialist concerns of efficiency, budget, scheduling, and rules and regulations, instead of on the risk to human life.

Managers had normalized anomaly and resisted data that contradicted their biases in perception, leading to what one NASA engineer called "worlds of pain."

Columbia Accident Investigation Board report is available at:

http://www.spaceflight.nasa.gov/shuttle/investigation/index.html

Congressional testimony about 9/11 is collected at:

http://www.fas.org/irp/congress/2002_hr/

The post-9/11 issue of the translator's problems on reporting suspicious behavior of another translator comes from:

Kornblut, Anne E. 2004. Translator in eye of storm on retroactive classification. The Boston Globe (5 July). Temporarily available from: http://www.boston.com/news/nation/articles/2004/07/05/ translator_in_eye_of_storm_on_retroactive_classification/

This paper is available at:

https://home.csulb.edu/~rodrigue/disbymgt/boulder04.html