| Cases
Here is a sample of cases from the book.
Space Shuttle Columbia
From the first viewing of Columbia's launch films, NASA knew that there might be problems from the foam debris that hit the spacecraft, damaging the fragile heat-resisting tiles that protect it from the fearsome heat of reentry. Unfortunately, the severity of such problems could not be determined from the information they had.
Chapter 1 examines the Columbia tragedy by focusing on Rodney Rocha, a well-respected and dedicated long-term NASA engineer who tried to get the agency's top brass to determine the true risk to Columbia. Despite Rodney's determination, he eventually gave up when his concerns were ignored, even remaining silent at an important meeting where speaking out might have made a difference. Rodney thus transformed from being an advocate to being an "organizational bystander," a desperately concerned but nevertheless passive observer to tragedy.
This is Rodney's story -- and it might well be yours.
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Space Shuttle Columbia (NASA)
| Hurricane Katrina
As it roared in from the Gulf, Hurricane Katrina appeared to be the "big one": the storm that many had feared would sink the city and perhaps render it uninhabitable. Despite extensive warnings by scientists, government officials and journalists, flood preparations were inadequate, and the city's levees dangerously weak in places.
The mystery of Katrina is why so little was done when there appeared to be such good warnings. Did people misunderstand the risks? Was it actually cheaper to rebuild than to protect, irrespective of the human costs?
Chapter 3 digs into these issues.
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People wading to safety near the I-10 offramp to S. Claiborne on Aug. 31, 2005. Taken near Stanislaus Hall, the old Delgado Nursing dormatory. Photo: Jh12. (Wikipedia Commons) | Space Shuttle Challenger
Christa McAuliff was the “teacher in space,” one of the best recognized people in America as she and her crew-mates launched aboard the Space Shuttle Challenger on January 28th, 1986.
As practically everybody knows, Challenger exploded just seconds after launch in an explosive fireball seen on TV sets around the world. All the astronauts perished.
The infamous O-rings that failed that cold January morning had a long history of problems. Chapter 4 looks at the reasons such problems were ignored, and the more immediate reasons why Challenger had to be launched on that day and at that time over the objections of many experts. Even if you are familiar with the Challenger story, you may be surprised by what you learn.
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Crew of Challenger mission STS-51-L. Back row (L-R): Ellison Onizuka, Christa McAuliffe, Gregory Jarvis, Judith Resnik. Front row (L-R): Michael J. Smith, Francis "Dick" Scobee, Ronald McNair. Photo: NASA
| Chernobyl
The explosion of the nuclear power plant at Chernobyl, Ukraine, not far from Kiev and the border with nearby Belarus, spewed more radioactivity into the atmosphere than the Hiroshima bomb. This catastrophic accident was the result of a dangerous design, poor staff training, and irresponsible government action. But finger-pointing cannot take away the decimation of the land -- a "dead zone" considered uninhabitable for 600 years -- or the harm done to a generation of children who are plagued with thyroid and other cancers arising from the contaminated food and milk they consumed in the days and weeks after the accident while the government did little to help them.
Ironically, the accident at Chernobyl occurred during the test of new safety equipment. But the test was high risk, although the employees that were conducting it almost certainly did not understand the danger. To make matters worse, production pressures raised the stakes, encouraging employees to shut down a variety of safety systems to avoid having the postpone the test for another year.
Why would anyone take such risks?
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Chernobyl Monument in Ternivka, Dnipropetrovsk Oblast, Ukraine. Photo: Leonid Dzhepko (Wikipedia Commons)
| Vioxx
According to the Senate testimony of Dr. David Graham, an FDA scientist, Vioxx may have caused nearly as many American deaths as the Vietnam war, as well as perhaps many tens of thousands of unnecessary heart attacks and strokes. Vioxx also damaged Merck & Company, its maker, by depressing its stock price for several years, thereby destroying 10 years of growth.
The Vioxx story focuses on why Merck did not let the public know the risks that its own scientists had identified, why it relentlessly persecuted scientists in the U.S. and abroad that tried to expose the drug's risks, and why the FDA was largely passive in following up the growing evidence of Vioxx's dangers.
We also raise the mystery why no one at Merck spoke up while thousands died, all of them ordinary people in search of relief from pain.
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Celebration Vioxx cake
| Arthur Andersen
Arthur Andersen collapsed in the wake of the Enron scandal as a result of their conviction on obstruction of justice charges brought against the firm by the U.S. government. Although Andersen's conviction was later dismissed as a result of improper jury instructions, many accounts make clear that Andersen's liberal accounting judgments facilitated misleading the public by obscuring the true nature of Enron's complex (and sometimes illegal) financial transactions.
The Andersen story focuses on the role of the firm's culture in its demise, particularly how the most straighlaced member of the accounting community could, over time, become so “overly aggressive” in the pursuit of client interests. Some of the largest bankruptcies in American history were Andersen clients with accounting problems.
Andersen's apparent ethical transformation appears to be related to the fierce internal “sibling rivalry” with Andersen Consulting, its more successful sister firm, although some problems do appear to predate the actual breakup of the firms. The Andersen case provides a window into how greed, rivalry, and desire to please one's client at any cost can lead to the destruction of a once great firm, while contributing to the demise of Enron, one of the most spectacular business meltdowns of all time.
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Arthur Andersen
| Sovereign Bankruptcies
Countries, like people, go bankrupt when they run out of money, although the special type of money in the case of countries is called “hard currency,” usually U.S. dollars.
In the middle to late 1990s, a series of countries went bankrupt -- including Mexico, Thailand, South Korea, Indonesia, Russia, and Brazil. The financial collapses represented as much a failure of the promise of international globalization as they were failures of local financial management and ill-conceived rescue plans.
This is the story of these disasters came about, and their parallels to the current subprime crisis and implications for the future.
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| Easter Island
When discovered by Europeans in 1722, explorers could not understand how Easter was ever colonized, or how its inhabitants had created the giant statues, called moai, that greeted them. The island's watercraft consisted of just a few leaky canoes, and there was no sign of the forests, other raw materials, and infrastructure needed to construct the vast totems, or transport them throughout the island.
Many mysteries surround Easter Island, but its greatest is perhaps how its flowering, millennium-long civilization came to a rapid end. Many consider it a parable for our modern challenges of energy and climate change.
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Moai from Easter island (Prof. Terry Hunt, Univ. Hawaii)
| BP Texas City
At British Petroleum's Texas City refinery, someone had died every 18 months for nearly thirty years. It was a dangerous place to work -- more dangerous than many other BP facilities.
Workers reported in an employee survey that people were at the bottom of the list in management's eyes, and that “making money” was at the top. Not surprisingly, investigators found after the accident that a cocern for “process safety,” the modern term for preventing accidents before they occur, should be high on the list of reforms.
It appears that concern about profits dominated management's attention at BP Texas City despite the fact that the oil industry was going through a boom time with windfall profits and a shortage of refining capacity. Maintenance and upgrades at the refinery were seriously delayed, and safety guidelines -- such as not driving motor vehicles in explosion prone areas -- were not observed. It was one such vehicle that probably caused the spark that caused the explosion that killed 15 and injured 180 when a dangerous vapor cloud ignited during a restart procedure. Such dangers had arisen before, many times before, in fact, but management was unwilling to fix the known problems.
The BP case tells the story of the pressure for profits, the denial of danger, and a culture that knowingly puts ordinary employees in harms way.
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Computer Simulation of BP Explosion
U.S. Chemical Safety Board
| When Leaders Are The Problem
In many organizations, leaders work tirelessly to ensure that their customers, employees, and the communities they serve remain free from harm. That is not always the case, however. In his afterword, Daniel Ellsberg addresses those situations in which leaders are tempted to enrich or protect themselves at the expense of others.
The United States Constitution, in the creation of the separation of powers, recognizes the need for tempering the power of those at the top with others of equal power.
Ellsberg's concluding thoughts remind us that our ultimate freedom sometimes requires bringing leaders to task and this, in turn, requires the protection of those who might expose their misdeeds.
We might wish that it be otherwise, but the temptations of power make whistleblowers necessary.
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The "Big Board" from Dr. Strangelove (1964)
Produced and directed by Stanley Kubrick, cinematography
by Gilbert Taylor, production design by Ken Adam,
art direction by Peter Murton
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