Saving human lives : lessons in management ethics vol. 21

TABLE OF CONTENTS CHAPTER 1 ACCIDENTS, TRAGEDIES AND DISASTERS.....................1 THE RULE OF ACCIDENTAL ..........................................3 THE EXPLANATION OF HUMAN ERROR......................3 THE EXPLANATION OF A BREAKDOWN OF A MATERIAL OR TECHNICAL COMPONENT AND ITS COROLLARY, RISKY TECHNOLOGY ..................3 RISKY OR UNRULY TECHNOLOGY?.............................4 THE EXPLANATION OF ORGANIZATIONAL INERTIA OR BUREAUCRATIC DRIFT............................6 ACCIDENTS WILL HAPPEN .............................................7 THE WORD ‘ACCIDENT’ ..................................................8 THE BELIEF IN MONOCAUSALITY............................ 12 MULTI-CAUSALITY AND MULTIPLE RESPONSIBILITY .............................................................14 FAULT FINDING AND THE SCAPEGOAT....................15 WARNINGS AND ETHICS...............................................17 FREEDOM AND ETHICS..................................................18 NOTES ................................................................................19 CHAPTER 2 THE INTERNAL RELATIONSHIP BETWEEN ETHICS AND BUSINESS......................................................21 ETHICS AS INVOLVED IN THE GOALS OF AN ORGANIZATION...............................................................22 ETHICS AND THE CONDUCT OF BUSINESS ENTERPRISE.................................................................. 33 ix .... “ ” ETHICS AND THE INFRASTRUCTURE OF A BUSINESS ORGANIZATION...........................................33 THE WILL TO COMMUNICATE: FORMAL AND INFORMAL REPORTING CHANNELS.................34 THE UNDERLYING PRINCIPLE OF ETHICAL COMMUNICATION: RESPECT FOR PERSONS............34 ETHICS AND INFORMAL CHANNELS OF COMMUNICATION ..........................................................36 ETHICS AND FORMAL REPORTING CHANNELS........................................................................37 THE ARGUMENT FOR THE EQUIVALENCE IN EFFECT OF COMPETING NORMATIVE ETHICAL JUSTIFICATIONS..............................................................39 NOTES ................................................................................46 CHAPTER 3 THE BUCK STOPS HERE AND IT STOPS EVERYWHERE ELSE AS WELL......................................................................48 THE BUCK STOPS HERE.................................................48 THE WILL TO COMMUNICATE................................. 50 THE MANAGER’S TASK .................................................52 THE MANAGER AS EDUCATOR AND FACILITATOR OF GOOD WILL.................................................................53 NOTES ................................................................................55 CHAPTER 4 CRISIS MANAGEMENT AND DISASTER PREVENTION MANAGEMENT ....................................................................60 CRISIS MANAGEMENT: THE “BAND-AID” APPROACH........................................................................60 x TABLE OF CONTENTS .... CONCEPTUAL PREPAREDNESS....................................64 THE EXPLICIT PRIORITIZATION OF A SAFETY ETHOS ......................................................66 THE INDEPENDENTLY FUNDED SAFETY BOARD WITH FULL VETO POWERS OVER OPERATIONAL DECISIONS ...........................................67 NOTES ................................................................................68 CHAPTER 5 THE VASA DISASTER ...................................................71 THE CONSTRUCTION OF THE VASA ............................72 THE STABILITY TEST ................................................. 73 THE QUESTION OF BALLAST .......................................74 THE WIND PRESSURE ON THE SAILS .........................75 THE VASA’S CENTER OF GRAVITY..............................76 WHY THE VASA CAPSIZED.............................................76 CONCLUSIONS .................................................................82 NOTES ................................................................................82 CHAPTER 6 THE TITANIC DISASTER......................................................84 METAPHYSICAL BELIEF SYSTEMS .............................84 LOSS OF LIFE....................................................................87 REPORT OF THE COURT (BRITISH REPORT) .............87 THE COLLISION ...............................................................87 CAUSES OF THE DISASTER...........................................88 WARNINGS........................................................................88 WARNINGS TO PASSENGERS .......................................91 ....... TABLE OF CONTENTS xi .... SPEED OF THE SHIP.........................................................92 WEATHER..........................................................................92 CAUSES OF DEATHS .......................................................92 PREVENTED? ....................................................................92 THE SAILING ORDERS....................................................93 RELEVANT DESIGN FEATURES ...................................94 RIVETS ...............................................................................94 THE INADEQUACY OF THE HUMAN ERROR HYPOTHESIS.....................................................................96 LIFEBOATS.................................................................... 97 THIRD-CLASS PASSENGERS .........................................98 NEARBY RESCUE POSSIBILITIES ................................99 THE RESCUE BY THE S.S. “CARPATHIA”................. 99 S.S. “CALIFORNIAN”.........................................................99 FINDINGS OF THE COURT ...........................................101 LOOK-OUT.......................................................................101 SPEED...............................................................................102 RECOMMENDATIONS............................................... 102 NOTES .......................................................................... 104 CHAPTER 7 THE SPACE SHUTTLE CHALLENGER DISASTER.........107 A BRIEF SYNOPSIS ........................................................108 KEY WORDS....................................................................109 THE WORD ‘ACCIDENT’ ..............................................109 CAUSE AND CONTRIBUTING CAUSE .......................112 DECISION MAKING .......................................................115 xii TABLE OF CONTENTS .... .... .... HOW ELSE COULD THE TITANIC DISASTER BEEN .... THE ATMOSPHERE OF THE DECISION MAKING PROCESS.........................................................115 THE DECISION MUST BE MADE UNDER PRESSURE........................................................................117 A FIXED DEADLINE MUST BE MET...........................118 AWRONG DECISION WILL HAVE GRAVE CONSEQUENCES............................................................119 THE PRESENCE OF IRREGULARITIES. ..................120 ABBREVIATED CHRONOLOGY OF EVENTS LEADING TO CHALLENGER LAUNCH.......................121 (a.) THE LACK OF ANY CLEAR UNIFORM GUIDELINES AS TO MORAL CRITERIA ....................123 (b.) A FORMULA FOR THE ATTRIBUTION OF THE RESPONSIBILITY FOR THE BURDEN OF PROOF IN AN ARGUMENT.....................................124 (c.) WHAT WOULD COUNT AS SUFFICIENT JUSTIFICATION FOR CONCLUSIONS ........................126 (d.) THE LACK OF UNDERSTANDING OF WHAT INPUT IS RELEVANT TO A DECISION.......................126 THE LACK OF A SPELLED OUT DECISION MAKING MECHANISM .................................................130 MANAGEMENT STRUCTURE......................................131 THE LANGUAGE OF COMMUNICATION ..................134 RESPONSIBILITY: BOTTOM UP ..................................137 TOP DOWN RESPONSIBILITY ................................. 139 DORMANT STAGE .........................................................139 THE WILL TO COMMUNICATE............................... 141 NOTES ..............................................................................143 TABLE OF CONTENTS xiii CHAPTER 8 POST-CHALLENGER INVESTIGATIONS.........................154 THE WORD ‘ACCIDENT’ ..............................................154 THE CONFLATION OF GENERAL UNKNOWN RISK OF SPACE TRAVEL WITH THE SPECIFICALLY FOREKNOWN RISK OF THE O-RINGS ...........................................................................155 SAFETY PRIORITY.........................................................157 DECISION MAKING .......................................................157 SAFETY FIRST?...............................................................158 IS THERE A GREATER SENSE OF RESPONSIBILITY NOW? ...............................................162 WERE MIDDLE MANAGERS SIMPLY FOLLOWING POLICY? ...........................................................................163 WERE THE MIDDLE MANAGERS MORAL?.......... 164 WAS THE CHALLENGER DISASTER A MISTAKE?...165 WAS THE DISASTER AN ACCIDENT? .....................................................................165 WAS THE CHALLENGER DISASTER THE INEVITABLE OUTCOME OF CULTURAL DETERMINISM? AND, WAS MORAL CHOICE AND MORAL RESPONSIBILITY THEREFORE IRRELEVANT AS AN EXPLANATION? ................................................166 THE HISTORY OF O-RING EROSION..........................168 NORMALIZED DECISIONS? .........................................170 LINKS BETWEEN TEMPERATURE AND EROSION...................................................................... 170 TRUSTING ESTABLISHED PATTERNS OF DEVIANCE? .....................................................................173 xiv TABLE OF CONTENTS CHALLENGER FAITH IN THE SECONDARY SEAL? ...........................173 DID ENGINEERS BELIEVE THAT THE CHALLENGER WAS SAFE TO FLY?.............................176 WERE THE ENGINEERS UNAWARE OF WHAT WAS A PROBABLE OUTCOME?.....................178 THE QUESTION OF “HARD DATA” ............................180 ETHICAL DECISION MAKING.....................................181 CONCLUSION..................................................................182 NOTES ..............................................................................183 CHAPTER 9 THE HERALD OF FREE ENTERPRISE DISASTER .........198 THE IMMEDIATE CAUSE OF THE DISASTER AND MULTI-RESPONSIBILITY ......................................... 199 THE ORDERS............................................................... 202 BOTTOMUP RESPONSIBILITY ............................... 204 TOP DOWN RESPONSIBILITY ................................ 208 A DYSFUNCTIONAL MANAGEMENT.................... 209 THE LACK OF A CLEAR ATTRIBUTION OF DOMAINS OF RESPONSIBILITY FOR OFFICERS.....210 THE LACK OF THE ISSUANCE OF CLEAR INSTRUCTIONS ..............................................................210 TECHNICAL COMPONENT...........................................212 THE CLOSING OF THE DOORS....................................213 THE WILL TO COMMUNICATE .............................. 213 CONCLUSIONS OF THE COURT..................................218 NOTES ..............................................................................220 TABLE OF CONTENTS xv .... .... ... ... ... ... CHAPTER 10 THE KING’S CROSS UNDERGROUND FIRE ............. 223 EPISTEMOLOGICAL FRAMEWORKS COMPARED ................................................................ 224 FENNELL’S EPISTEMOLOGICAL FRAMEWORK.....227 THE USE OF WORDS .....................................................228 THE CAUSE OF THE FIRE.............................................230 RESPONSIBILITY FOR THE FIRE: TOP DOWN.........233 RESPONSIBILITY: BOTTOM UP ..................................235 THE IMPORTANCE OF A SAFETY ETHOS ............. 246 THE ROLE OF MANAGEMENT STRUCTURE IN BLOCKING THE FLOW OF INFORMATION ..............247 FENNELL’S RECOMMENDATIONS: THE PRIMACY OF SAFETY...................................................249 PHILOSOPHICAL UNDERPINNINGS...........................251 NOTES ..............................................................................252 CHAPTER 11 THE DISASTER ON MT. EREBUS ....................................256 A SHORT HISTORY OF THE DISASTER.....................258 THE CHIPPINDALE REPORT........................................258 JUSTICE MAHON’S CRITIQUE OF THE CHIPPINDALE REPORT.................................................259 THE EVIDENCE FROM THE FLIGHT-DECK TAPES...............................................................................260 VETTE’S TEXT................................................................265 MACFARLANE’S NOTES ON VETTE’S TEXT...........265 .... xvi TABLE OF CONTENTS MACFARLANE’S REPLY TO 1. (THAT THE CHANGE IN COMPUTER FLIGHT PATH DID NOT MISLEAD THE CREW)..................................266 MACFARLANE’S REPLY TO 2. (THAT PILOTS VIOLATED INSTRUCTIONS NOT TO DESCEND BELOW 16,000 FEET) .....................................................268 MACFARLANE’S REPLY TO 3. (THAT THE CREW WERE UNCERTAIN OF THEIR POSITION) ....270 MACFARLANE’S REPLY TO 4. (THAT RADAR WOULD HAVE SHOWN EREBUS AHEAD) ................271 TAKING A PHENOMENOLOGICAL VIEW.................272 PHENOMENOLOGICAL APPROACH: TAPES............274 THE COHERENCE THEORY OF TRUTH.....................276 MISMANAGEMENT .......................................................278 THE CAUSE OF THE DISASTER ..................................280 DEFECTS IN ADMINISTRATIVE STRUCTURE .........283 DEFECTS IN ADMINISTRATIVE COMMUNICATIONS SYSTEM .....................................284 SUMMARY OF MANAGEMENT DEFECTS ................285 THE LACK OF ANY SAFETY ETHOS..........................287 TOP DOWN RESPONSIBILITY .....................................287 NOTES ..............................................................................289 APPENDIX ONE ..............................................................313 APPENDIX TWO .............................................................316 APPENDIX THREE..........................................................320 APPENDICES TO CHAPTER 11 ......................................313 xvii THE WHITEOUT PHENOMENON............................ .272 TABLE OF CONTENTS ... NOTES ..............................................................................320 CHAPTER 12 MORAL RESPONSIBILITY AND TECHNO-ORGANIZATION ...............................................322 NOTES..............................................................................332 BIBLIOGRAPHY..................................................................334 INDEX...................................................................................347