What the Dog Saw [119]
What NASA had created was a closed culture that, in her words, “normalized deviance” so that to the outside world, decisions that were obviously questionable were seen by NASA’s management as prudent and reasonable. It is her depiction of this internal world that makes her book so disquieting: when she lays out the sequence of decisions that led to the launch — each decision as trivial as the string of failures that led to the near disaster at TMI — it is difficult to find any precise point where things went wrong or where things might be improved next time. “It can truly be said that the Challenger launch decision was a rule-based decision,” she concludes. “But the cultural understandings, rules, procedures, and norms that always had worked in the past did not work this time. It was not amorally calculating managers violating rules that were responsible for the tragedy. It was conformity.”
4.
There is another way to look at this problem, and that is from the standpoint of how human beings handle risk. One of the assumptions behind the modern disaster ritual is that when a risk can be identified and eliminated, a system can be made safer. The new booster joints on the shuttle, for example, are so much better than the old ones that the overall chances of a Challenger-style accident’s ever happening again must be lower, right? This is such a straightforward idea that questioning it seems almost impossible. But that is just what another group of scholars has done, under what is called the theory of risk homeostasis. It should be said that within the academic community, there are huge debates over how widely the theory of risk homeostasis can and should be applied. But the basic idea, which has been laid out brilliantly by the Canadian psychologist Gerald Wilde in his book Target Risk, is quite simple: under certain circumstances, changes that appear to make a system or an organization safer in fact don’t. Why? Because human beings have a seemingly fundamental tendency to compensate for lower risks in one area by taking greater risks in another.
Consider, for example, the results of a famous experiment conducted several years ago in Germany. Part of a fleet of taxicabs in Munich was equipped with antilock brake systems (ABS), a technological innovation that vastly improves braking, particularly on slippery surfaces. The rest of the fleet was left alone, and the two groups — which were otherwise perfectly matched — were placed under careful and secret observation for three years. You would expect the better brakes to make for safer driving. But that is exactly the opposite of what happened. Giving some drivers ABS made no difference at all in their accident rate; in fact, it turned them into markedly inferior drivers. They drove faster. They made sharper turns. They showed poorer lane discipline. They braked harder. They were more likely to tailgate. They didn’t merge as well, and they were involved in more near misses. In other words, the ABS systems were not used to reduce accidents; instead, the drivers used the additional element of safety to enable them to drive faster and more recklessly without increasing their risk of getting into an accident. As economists would say, they consumed the risk reduction, they didn’t save it.
Risk homeostasis doesn’t happen all the time. Often — as in the case of seat belts, say — compensatory behavior only partly offsets the risk reduction of a safety measure. But it happens often enough that it must be given serious consideration. Why are more pedestrians killed crossing the street at marked crosswalks than at unmarked crosswalks? Because they compensate for the “safe