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Sources of technology failure



A recurring theme in Understanding Society is the topic of technology failure -- air disasters, chemical plant explosions, deep drilling accidents. This diagram is intended to capture several dimensions of failure causes that have been discussed. The categories identified here include organizational dysfunctions, behavioral shortcomings, system failures, and regulatory dysfunctions. Each of these broad categories has contributed to the occurrence of major technology disasters, and often most or all of them are involved.


System failures. 2005 Texas City refinery explosion. A complex technology system involves a dense set of sub-systems that have multiple failure modes and multiple ways of affecting other sub-systems. As Charles Perrow points out, often those system interactions are "tightly coupled", which means that there is very little time in which operators can attempt to diagnose the source of a failure before harmful effects have proliferated to other sub-systems. A pump fails in a cooling loop; an exhaust valve is stuck in the closed position; and nuclear fuel rods are left uncooled for less than a minute before they generate enough heat to boil away the coolant water. Similar to the issue of tight coupling is the feature of complex interactions: A influences B, C, D; B and D influence A; C's change of state further influences unexpected performance by D. The causal chains here are not linear, so once again -- operators and engineers are hard pressed to diagnose the source cause of an anomalous behavior in time to save the system from meltdown or catastrophic failure.

And then there are failures that originate in problems in the original design of the system and its instruments. Nancy Leveson identifies many such design failures in "The Role of Software in Spacecraft Accidents" (link). For example, the explosion at the Texas City refinery (link) occurred in part because the level transmitter instrument for the splitter high tower only measured column height up to the ten-foot maximum permissible height of the column of flammable liquid in the high splitter. Otherwise it only produced an alarm, which was routinely ignored. As a result the operators had no way of knowing that the column had gone up to 80 feet and then to the top of the column, leading to a release and subsequent fire and explosion (CSB Final Report Texas City BP) -- an overflow accident. And sometimes the overall system actually had no formal design process at all; as Andrew Hopkins observes,

Processing plants evolve and grow over time. A study of petroleum refineries in the US has shown that “the largest and most complex refineries in the sample are also the oldest … Their complexity emerged as a result of historical accretion. Processes were modified, added, linked, enhanced and replaced over a history that greatly exceeded the memories of those who worked in the refinery. (Lessons from Longford, 33)

This implies that the whole system is not fully understood by any of the participants -- executives, managers, engineers, or skilled operators.

Organizational dysfunctions. Deepwater Horizon. There is a very wide range of organizational dysfunctions that can be identified in case studies of technology disasters, from refineries to patient safety accidents. These include excessive cost reduction mandated by corporate decisions, inadequate safety culture embodied in leaders, operators, and day-to-day operations; poor inter-unit communications, where one unit concludes that a hazardous operation should be suspended but another unit doesn't get the message; poor training and supervision; and conflicting priorities within the organization. Top managers are subject to production pressures that lead them to resist decisions involving a shutdown of process while anomalies are sorted out; higher-level managers sometimes lack the technical knowledge needed to know when a given signal or alarm may be potentially catastrophic; failures of communications within large companies about known process risks; and inadequate oversight within a large firm of subcontractor performance and responsibilities. Two pervasive problems are identified in a great many case studies: relentless cost containment initiatives to increase efficiency and profitability; and a lack of commitment to (and understanding of) an enterprise-wide culture of safety. In particular, it is common for executives and governing boards of high-risk enterprises to declare that "safety is our number-one priority", where what they focus on is "days-lost" measures of injuries in the workplace. But this conception of safety fails completely to identify system risks. (Andrew Hopkins makes a very persuasive case for the use of "safety case" regulation and detailed HAZOP analysis for a complex operation as a whole; link.)

Behavioral shortcomings. Bhopal toxic gas release, Texas City refinery accident. No organization works like a Swiss watch. Rather, specific individuals occupy positions of work responsibility that may sometimes be only imperfectly performed. A control room supervisor is distracted at the end of his shift and fails to provide critical information for the supervisor on the incoming shift. Process inspectors sometimes take shortcuts and certify processes that in fact contain critical sources of failure; or inspectors yield to management pressure to overlook "minor" deviations from regulations. A maintenance crew deviates from training and protocol in order to complete tasks on time, resulting in a minor accident that leads to a cascade of more serious events. Directors of separate units within a process facility fail to inform each other of anomalies that may affect the safety of other sub-systems. Staff at each level have an incentive to conceal mistakes and "near-misses" that could otherwise be corrected.

Regulatory shortcomings. Longford gas plant, Davis-Besse nuclear plant incidents, East Palestine Norfolk Southern Railway accident. Risky industries plainly require regulation. But regulatory frameworks are often seriously flawed by known dysfunctions (link, link, link): industry capture (nuclear power industry); inadequate resources (NRC); inadequate enforcement tools (Chemical Safety Board); revolving door from industry to regulatory staff to industry; vulnerability to "anti-regulation" ideology expressed by industry and sympathetic legislators; and many of the dysfunctions already mentioned under the categories of organizational and behavioral shortcomings. The system of delegated regulation has been appealing to both industry and government officials. This is a system where central oversight is exercised by the regulatory agency, but the technical experts of the industry itself are called upon to assess critical safety features of the process being regulated. This approach makes government budget support for the regulatory agency much less costly. This system is used by the Federal Aviation Administration in its oversight of airframe safety. However, the experience of the Boeing 737 MAX failures has shown that the system of delegated regulation is vulnerable to distortion by the manufacturing companies that it oversees (link).

Here is Andrew Hopkin's multi-level analysis of the Longford Esso gas plant accident (link). This diagram illustrates each of the categories of failure mentioned here.


Consider this alternative universe. It is a world in which CEOs, executives, directors, and staff in risky enterprises have taken the time to read 4-6 detailed case studies of major technology accidents and have absorbed the complexity of the kinds of dysfunctions that can lead to serious disasters. Instructive case studies might include the Longford Esso gas plant explosion, the 2005 Texas City refinery explosion, the Columbia Space Shuttle disaster, the Boeing 737 MAX failure, the BP Deepwater Horizon disaster, and the Davis-Besse nuclear power plant incidents. These case studies would provide enterprise leaders and staff with a much more detailed understanding of the kinds of organizational and system failure that can be expected to occur in risky enterprises, and leaders and managers would be much better prepared to prevent failures like these in the future. It would be a safer world.

Sources of technology failure



A recurring theme in Understanding Society is the topic of technology failure -- air disasters, chemical plant explosions, deep drilling accidents. This diagram is intended to capture several dimensions of failure causes that have been discussed. The categories identified here include organizational dysfunctions, behavioral shortcomings, system failures, and regulatory dysfunctions. Each of these broad categories has contributed to the occurrence of major technology disasters, and often most or all of them are involved.


System failures. 2005 Texas City refinery explosion. A complex technology system involves a dense set of sub-systems that have multiple failure modes and multiple ways of affecting other sub-systems. As Charles Perrow points out, often those system interactions are "tightly coupled", which means that there is very little time in which operators can attempt to diagnose the source of a failure before harmful effects have proliferated to other sub-systems. A pump fails in a cooling loop; an exhaust valve is stuck in the closed position; and nuclear fuel rods are left uncooled for less than a minute before they generate enough heat to boil away the coolant water. Similar to the issue of tight coupling is the feature of complex interactions: A influences B, C, D; B and D influence A; C's change of state further influences unexpected performance by D. The causal chains here are not linear, so once again -- operators and engineers are hard pressed to diagnose the source cause of an anomalous behavior in time to save the system from meltdown or catastrophic failure.

And then there are failures that originate in problems in the original design of the system and its instruments. Nancy Leveson identifies many such design failures in "The Role of Software in Spacecraft Accidents" (link). For example, the explosion at the Texas City refinery (link) occurred in part because the level transmitter instrument for the splitter high tower only measured column height up to the ten-foot maximum permissible height of the column of flammable liquid in the high splitter. Otherwise it only produced an alarm, which was routinely ignored. As a result the operators had no way of knowing that the column had gone up to 80 feet and then to the top of the column, leading to a release and subsequent fire and explosion (CSB Final Report Texas City BP) -- an overflow accident. And sometimes the overall system actually had no formal design process at all; as Andrew Hopkins observes,

Processing plants evolve and grow over time. A study of petroleum refineries in the US has shown that “the largest and most complex refineries in the sample are also the oldest … Their complexity emerged as a result of historical accretion. Processes were modified, added, linked, enhanced and replaced over a history that greatly exceeded the memories of those who worked in the refinery. (Lessons from Longford, 33)

This implies that the whole system is not fully understood by any of the participants -- executives, managers, engineers, or skilled operators.

Organizational dysfunctions. Deepwater Horizon. There is a very wide range of organizational dysfunctions that can be identified in case studies of technology disasters, from refineries to patient safety accidents. These include excessive cost reduction mandated by corporate decisions, inadequate safety culture embodied in leaders, operators, and day-to-day operations; poor inter-unit communications, where one unit concludes that a hazardous operation should be suspended but another unit doesn't get the message; poor training and supervision; and conflicting priorities within the organization. Top managers are subject to production pressures that lead them to resist decisions involving a shutdown of process while anomalies are sorted out; higher-level managers sometimes lack the technical knowledge needed to know when a given signal or alarm may be potentially catastrophic; failures of communications within large companies about known process risks; and inadequate oversight within a large firm of subcontractor performance and responsibilities. Two pervasive problems are identified in a great many case studies: relentless cost containment initiatives to increase efficiency and profitability; and a lack of commitment to (and understanding of) an enterprise-wide culture of safety. In particular, it is common for executives and governing boards of high-risk enterprises to declare that "safety is our number-one priority", where what they focus on is "days-lost" measures of injuries in the workplace. But this conception of safety fails completely to identify system risks. (Andrew Hopkins makes a very persuasive case for the use of "safety case" regulation and detailed HAZOP analysis for a complex operation as a whole; link.)

Behavioral shortcomings. Bhopal toxic gas release, Texas City refinery accident. No organization works like a Swiss watch. Rather, specific individuals occupy positions of work responsibility that may sometimes be only imperfectly performed. A control room supervisor is distracted at the end of his shift and fails to provide critical information for the supervisor on the incoming shift. Process inspectors sometimes take shortcuts and certify processes that in fact contain critical sources of failure; or inspectors yield to management pressure to overlook "minor" deviations from regulations. A maintenance crew deviates from training and protocol in order to complete tasks on time, resulting in a minor accident that leads to a cascade of more serious events. Directors of separate units within a process facility fail to inform each other of anomalies that may affect the safety of other sub-systems. Staff at each level have an incentive to conceal mistakes and "near-misses" that could otherwise be corrected.

Regulatory shortcomings. Longford gas plant, Davis-Besse nuclear plant incidents, East Palestine Norfolk Southern Railway accident. Risky industries plainly require regulation. But regulatory frameworks are often seriously flawed by known dysfunctions (link, link, link): industry capture (nuclear power industry); inadequate resources (NRC); inadequate enforcement tools (Chemical Safety Board); revolving door from industry to regulatory staff to industry; vulnerability to "anti-regulation" ideology expressed by industry and sympathetic legislators; and many of the dysfunctions already mentioned under the categories of organizational and behavioral shortcomings. The system of delegated regulation has been appealing to both industry and government officials. This is a system where central oversight is exercised by the regulatory agency, but the technical experts of the industry itself are called upon to assess critical safety features of the process being regulated. This approach makes government budget support for the regulatory agency much less costly. This system is used by the Federal Aviation Administration in its oversight of airframe safety. However, the experience of the Boeing 737 MAX failures has shown that the system of delegated regulation is vulnerable to distortion by the manufacturing companies that it oversees (link).

Here is Andrew Hopkin's multi-level analysis of the Longford Esso gas plant accident (link). This diagram illustrates each of the categories of failure mentioned here.


Consider this alternative universe. It is a world in which CEOs, executives, directors, and staff in risky enterprises have taken the time to read 4-6 detailed case studies of major technology accidents and have absorbed the complexity of the kinds of dysfunctions that can lead to serious disasters. Instructive case studies might include the Longford Esso gas plant explosion, the 2005 Texas City refinery explosion, the Columbia Space Shuttle disaster, the Boeing 737 MAX failure, the BP Deepwater Horizon disaster, and the Davis-Besse nuclear power plant incidents. These case studies would provide enterprise leaders and staff with a much more detailed understanding of the kinds of organizational and system failure that can be expected to occur in risky enterprises, and leaders and managers would be much better prepared to prevent failures like these in the future. It would be a safer world.

New public administration 1968-2002

Image: org chart, Housing and Urban Development (9,500 staff)

Herbert Simon's important contribution to the study of administrative organizations appeared in 1947, with the title Administrative Behavior: A Study of Decision-Making Processes in Administrative Organizations. It is a remarkably sophisticated book in the social scientific study of bureaucracy and large organizations. (Here is an earlier discussion of some of the main lines of thought in the book (link).) Simon provides a treatment of four of what he takes to be the key mechanisms underlying the operations of large organizations: authority, communications, efficiency, and "organizational identification". These mechanisms contribute to the ability of leaders to coordinate the actions of subordinates in pursuit of goals and plans articulated on behalf of the organization and its division. The book is still worth reading carefully.

In the 1960s there was a flurry of discussion and debate within the field of public administration about how thinking in the field ought to be reconceived. Much of this thinking was summarized in a volume edited by Frank Marini with the title Toward a New Public Administration: The Minnowbrook Perspective. It is now worth asking whether that burst of disciplinary energy lead to new insights about the workings of public agencies. Unhappily, it appears that it did not.

H. George Frederickson's contribution to the Marini volume provided a substantive synthesis of the field at that time. Frederickson was a leader in the field of public administration, and he was a pivotal figure in reconvening the Minnowbrook Conference in 1988 to assess progress since the first Minnowbrook Conference in 1968. Frederickson summarizes the thrust of "New Public Administration" in these terms (included in Shafritz and Hyde, Classics of Public Administration (3rd ed.)).

New Public Administration adds social equity to the classic objectives and rationale. Conventional or classic Public Administration seeks to answer either of these questions: (1) How can we offer more or better services with available resources (efficiency)? or (2) how can we maintain our level of services while spending less money (economy)? New Public Administration adds this question: Does this service enhance social equity? (369)

He observes that specific emphasis on social equity is needed because ...

Pluralistic government systematically discriminates in favor of established stable bureaucracies and their established minority clientele (the Department of Agriculture and large farmers as an example) and against those minorities (farm laborers, both migrant and permanent, as an example) who lack political and economic resources.... Social equity, then, includes activities designed to enhance the political power and economic well-being of these minorities. 369

This realization within the profession of academic public administration represents a recognition of the fact that agencies work within an environment of private actors, and some of those actors have substantially greater power through which to influence agency choices. Agencies are to some extent "open systems". This is the feature of "industry capture" that arises in the case of regulatory agencies. And it is certainly a good thing that the field of academic public administration was encouraged to shift its focus towards equity, not just efficiency and cost-cutting.

What the New Public Administration literature seems not to have addressed is the need for a meso-level analysis of the internal workings of agencies (and firms). This is a virtue of Simon's book, but it seems not to have carried over as a central focus into the paradigms of the New Public Administration. The only meso-level analysis offered in Frederickson's summary of the field concerns the topic of hierarchy. And his observations about "hierarchy" within governmental organizations come into dialogue with Simon's views. Here are a few passages:

Authority hierarchies are the primary means by which the work of persons in publicly administered organizations is coordinated. The formal hierarchy is the most obvious and easiest-to-identify part of the permanent and on-going organization. Administrators are seen as persons taking roles in the hierarchy and performing tasks that are integrated through the hierarchies to constitute a cohesive goal-seeking whole. The public administrator has customarily been regarded as the one who builds and maintains the organization through the hierarchy. He attempts to understand formal-informal relationships, status, politics, and power in authority hierarchies. The hierarchy environment is at once an ideal design and a hospitable for the person who wishes to manage, control, or direct the work of large numbers of people.

The counterproductive characteristics of hierarchies are now well known. New Public Administration is probably best understood as advocating modified hierarchic systems. Several means both in theory and practice are utilized to modify traditional hierarchies. The first and perhaps the best known is the project or matrix technique. The project is, by definition, temporary. (374)

Frederickson considers several alternatives to the authority hierarchies described here.

The search for less structured, less formal, and less authoritative integrative techniques in publicly administered organizations is only beginning. The preference for these types of organizational modes implies first a relative tolerance for variation.... The second problem [with less formal methods] is in the inherent conflict between higher-and lower-level administrators in less formal, integrative systems.... (375)

This passage suggests the conflict of priorities emphasized by Fligstein and McAdam in their treatment of organizations as strategic action fields (link).

This short discussion of the role and effectiveness of hierarchy is the only example I can find of efforts within the program of new public administration to open up the black box of the workings of a public agency, and this is a blindspot for the discipline.

Decades later Frederickson and Todd R. LaPorte published an article of interest to readers of Understanding Society, "Airport Security, High Reliability, and the Problem of Rationality" (link). (LaPorte is a major contributor to the literature on high-reliability organizations (link).) The establishment of the Transportation Security Administration following the September 11 attacks is the central example. The article reflects some new thinking for public administration from the twenty-first century. The primary new contribution is incorporation of the emerging literature on high-reliability organizations, and the authors' treatment of air safety from that perspective. The authors also give a nod to normal-accident theory, without working out the implications of Perrow's theory in the case of air safety organizations.

And in fact, Frederickson and LaPorte offer enough information about the air safety system to make us very dubious that it constitutes a "high-reliability organization" at all. Consider this relatively detailed description of the air safety system:

With the passage of the Aviation Security Act, the formal governance of the air passenger and baggage security system becomes the responsibility of the TSA, an agency in the Department of Transportation. Under the direction of the secretary of transportation, the TSA has dotted-line responsibilities to other executive agencies such as the Office of Management and Budget and now the Office of Homeland Security. Just as important, however, are contemporary patterns of congressional comanagement and the dotted-line relationships of the TSA to the Senate and House Committees on Transportation and Infrastructure, and, of course, to the appropriations committees and sub- committees (Gilmour and Halley 1994). The complex horizontal, lateral, and vertical network of participants in the air travel security system is still in place, augmented now by the coordinating role of the Office of Homeland Security (Moynihan and Roberts 2002). While the establishment of the TSA concentrates air passenger and baggage responsibility directly in governmental hands and provides a system of finance that is independent of the air carriers, it does not reduce the system's overall fragmentation and complexity. Much of the contemporary debate over whether the Office of Homeland Security should have more than just coordinating responsibilities has to do with perceived disarticulation between the fragmented components of the air security system. (39)

This is exactly the kind of complexity and tight coupling that Charles Perrow identifies as a potent source of "normal" accidents. It is not at all hard to see how this "complex ... network of participants" can lead to miscommunication, conflicting priorities, principal-agent problems, and the other sources of organizational dysfunction that lead to disaster. "Fragmentation and complexity" are exactly the attributes that have led to major failures, from intelligence failures leading up to the September 11 attacks to the lack of coordination between principal and contractors in the Deepwater Horizon disaster (link).

It would appear, then, that the field of public administration has not made a lot of progress in incorporating and extending the insights of organizational sociology to permit a better understanding of success and failure in government agencies. More case studies are needed to allow us to better understand the workings (and failures) of government agencies, and a more focused attention to the findings of the sociology of organizational failure would be a very welcome infusion.


New public administration 1968-2002

Image: org chart, Housing and Urban Development (9,500 staff)

Herbert Simon's important contribution to the study of administrative organizations appeared in 1947, with the title Administrative Behavior: A Study of Decision-Making Processes in Administrative Organizations. It is a remarkably sophisticated book in the social scientific study of bureaucracy and large organizations. (Here is an earlier discussion of some of the main lines of thought in the book (link).) Simon provides a treatment of four of what he takes to be the key mechanisms underlying the operations of large organizations: authority, communications, efficiency, and "organizational identification". These mechanisms contribute to the ability of leaders to coordinate the actions of subordinates in pursuit of goals and plans articulated on behalf of the organization and its division. The book is still worth reading carefully.

In the 1960s there was a flurry of discussion and debate within the field of public administration about how thinking in the field ought to be reconceived. Much of this thinking was summarized in a volume edited by Frank Marini with the title Toward a New Public Administration: The Minnowbrook Perspective. It is now worth asking whether that burst of disciplinary energy lead to new insights about the workings of public agencies. Unhappily, it appears that it did not.

H. George Frederickson's contribution to the Marini volume provided a substantive synthesis of the field at that time. Frederickson was a leader in the field of public administration, and he was a pivotal figure in reconvening the Minnowbrook Conference in 1988 to assess progress since the first Minnowbrook Conference in 1968. Frederickson summarizes the thrust of "New Public Administration" in these terms (included in Shafritz and Hyde, Classics of Public Administration (3rd ed.)).

New Public Administration adds social equity to the classic objectives and rationale. Conventional or classic Public Administration seeks to answer either of these questions: (1) How can we offer more or better services with available resources (efficiency)? or (2) how can we maintain our level of services while spending less money (economy)? New Public Administration adds this question: Does this service enhance social equity? (369)

He observes that specific emphasis on social equity is needed because ...

Pluralistic government systematically discriminates in favor of established stable bureaucracies and their established minority clientele (the Department of Agriculture and large farmers as an example) and against those minorities (farm laborers, both migrant and permanent, as an example) who lack political and economic resources.... Social equity, then, includes activities designed to enhance the political power and economic well-being of these minorities. 369

This realization within the profession of academic public administration represents a recognition of the fact that agencies work within an environment of private actors, and some of those actors have substantially greater power through which to influence agency choices. Agencies are to some extent "open systems". This is the feature of "industry capture" that arises in the case of regulatory agencies. And it is certainly a good thing that the field of academic public administration was encouraged to shift its focus towards equity, not just efficiency and cost-cutting.

What the New Public Administration literature seems not to have addressed is the need for a meso-level analysis of the internal workings of agencies (and firms). This is a virtue of Simon's book, but it seems not to have carried over as a central focus into the paradigms of the New Public Administration. The only meso-level analysis offered in Frederickson's summary of the field concerns the topic of hierarchy. And his observations about "hierarchy" within governmental organizations come into dialogue with Simon's views. Here are a few passages:

Authority hierarchies are the primary means by which the work of persons in publicly administered organizations is coordinated. The formal hierarchy is the most obvious and easiest-to-identify part of the permanent and on-going organization. Administrators are seen as persons taking roles in the hierarchy and performing tasks that are integrated through the hierarchies to constitute a cohesive goal-seeking whole. The public administrator has customarily been regarded as the one who builds and maintains the organization through the hierarchy. He attempts to understand formal-informal relationships, status, politics, and power in authority hierarchies. The hierarchy environment is at once an ideal design and a hospitable for the person who wishes to manage, control, or direct the work of large numbers of people.

The counterproductive characteristics of hierarchies are now well known. New Public Administration is probably best understood as advocating modified hierarchic systems. Several means both in theory and practice are utilized to modify traditional hierarchies. The first and perhaps the best known is the project or matrix technique. The project is, by definition, temporary. (374)

Frederickson considers several alternatives to the authority hierarchies described here.

The search for less structured, less formal, and less authoritative integrative techniques in publicly administered organizations is only beginning. The preference for these types of organizational modes implies first a relative tolerance for variation.... The second problem [with less formal methods] is in the inherent conflict between higher-and lower-level administrators in less formal, integrative systems.... (375)

This passage suggests the conflict of priorities emphasized by Fligstein and McAdam in their treatment of organizations as strategic action fields (link).

This short discussion of the role and effectiveness of hierarchy is the only example I can find of efforts within the program of new public administration to open up the black box of the workings of a public agency, and this is a blindspot for the discipline.

Decades later Frederickson and Todd R. LaPorte published an article of interest to readers of Understanding Society, "Airport Security, High Reliability, and the Problem of Rationality" (link). (LaPorte is a major contributor to the literature on high-reliability organizations (link).) The establishment of the Transportation Security Administration following the September 11 attacks is the central example. The article reflects some new thinking for public administration from the twenty-first century. The primary new contribution is incorporation of the emerging literature on high-reliability organizations, and the authors' treatment of air safety from that perspective. The authors also give a nod to normal-accident theory, without working out the implications of Perrow's theory in the case of air safety organizations.

And in fact, Frederickson and LaPorte offer enough information about the air safety system to make us very dubious that it constitutes a "high-reliability organization" at all. Consider this relatively detailed description of the air safety system:

With the passage of the Aviation Security Act, the formal governance of the air passenger and baggage security system becomes the responsibility of the TSA, an agency in the Department of Transportation. Under the direction of the secretary of transportation, the TSA has dotted-line responsibilities to other executive agencies such as the Office of Management and Budget and now the Office of Homeland Security. Just as important, however, are contemporary patterns of congressional comanagement and the dotted-line relationships of the TSA to the Senate and House Committees on Transportation and Infrastructure, and, of course, to the appropriations committees and sub- committees (Gilmour and Halley 1994). The complex horizontal, lateral, and vertical network of participants in the air travel security system is still in place, augmented now by the coordinating role of the Office of Homeland Security (Moynihan and Roberts 2002). While the establishment of the TSA concentrates air passenger and baggage responsibility directly in governmental hands and provides a system of finance that is independent of the air carriers, it does not reduce the system's overall fragmentation and complexity. Much of the contemporary debate over whether the Office of Homeland Security should have more than just coordinating responsibilities has to do with perceived disarticulation between the fragmented components of the air security system. (39)

This is exactly the kind of complexity and tight coupling that Charles Perrow identifies as a potent source of "normal" accidents. It is not at all hard to see how this "complex ... network of participants" can lead to miscommunication, conflicting priorities, principal-agent problems, and the other sources of organizational dysfunction that lead to disaster. "Fragmentation and complexity" are exactly the attributes that have led to major failures, from intelligence failures leading up to the September 11 attacks to the lack of coordination between principal and contractors in the Deepwater Horizon disaster (link).

It would appear, then, that the field of public administration has not made a lot of progress in incorporating and extending the insights of organizational sociology to permit a better understanding of success and failure in government agencies. More case studies are needed to allow us to better understand the workings (and failures) of government agencies, and a more focused attention to the findings of the sociology of organizational failure would be a very welcome infusion.


Philosophy of public administration?

 

Philosophy has well-developed theories about the foundations of government — the moral principles that underlie the legitimacy of government; the nature of rights and duties of citizens; the limits of government authority; and so on for a large number of issues. These debates take place within social and political philosophy, a field whose lineage extends back to the ancient Greek philosophers, through Hobbes, Locke, Rousseau, Kant, Hegel, Marx, and Mill, and into the twentieth century in the writings of people like Rawls, Habermas, van Parijs, and Nozick.

What does not yet exist is a discipline that treats the workings of government itself as a philosophical subject. This field could be called “the philosophy of public administration.” This subject matter invites us to focus on the “social ontology” of government — the mechanisms of governments as concrete human institutions and the logic of interaction that these constituents produce. How do governments, as extended social entities, perform the functions we attribute to them — knowledge gathering, belief formation, policy and priority setting, legislation, regulation, and enforcement? Governments are not unified entities; they are extended networks of agencies, organizations, alliances, interests, and actors, and it is worth careful philosophical investigation to consider how this kind of entity can be purposive, intentional, and calculating. A philosophical reflection on these questions would focus on issues about mechanisms, order, and dysfunction within government, through attention to the actors, institutions, and organizations that constitute it.

The topics of dysfunction and imperfect functionality run throughout these discussions — not because government is an especially defective kind of social organization, but because all extended social collectivities confront the sources of dysfunction mentioned at many points in Understanding Society. Principal-agent problems, conflicts of interest within individuals and between groups of individuals, multiple understandings of the setting of organizational action and the means that are available, conflicting priorities across agencies and groups involved in coordinated activity — all of these features of social “friction” are to be found within government, as they are within all kinds of large social collectivities.

Moreover, the bureaucratic state has changed greatly in the past century, and plays a much larger role in everyday life than at any earlier point in history. In a sense the subject matter of public administration simply didn’t exist at all in the ancient world of Plato and Aristotle. There was no “public administration” in the polis. (The same cannot be said of the Roman Empire, where there were clear divisions of bureaucratic responsibility and accountability, but I am not aware of any philosophers who studied the functions and dysfunctions of Roman administration.) So the fact of a deeply ramified and bureaucratized state is a fairly modern phenomenon that it makes sense for philosophers to attempt to address.

Another important change that has occurred in the past fifty years is the emergence of a much better-defined area of sociological research aimed at achieving a better understanding the workings of organizations than has been possible in the past. Organizational sociology and organizational studies have progressed rapidly since the 1960s, and these new areas of social-science research provide new theories and questions on the basis of which to try to understand the workings of governments and their agencies.

We might think of this field in analogy with the philosophy of action. Philosophers in the philosophy of action ask questions about the rationality and purposiveness of the individual, the materiality of the acting individual, the connections that exist between mental reasoning and bodily skill and habit, and other intriguing questions about how humans and other organisms can be said to “act”. These questions are similar in form to the questions that can be raised about government: how does an ensemble of separate organizations of government come to function in some limited way as a “collective actor”? How are the individual actors within government brought into some degree of coordination and collaboration in pursuit of common purposes? What is the substrate underlying action in the two realms (neurophysiology and organizational functioning)?

A good start for thinking about the philosophy of public policy is to ask, how does government work? What are the constituent processes of government through which governments “think” and “act”? What kinds of dysfunctions and surprises are embedded in the processes that appear to constitute the workings of government? And what hidden assumptions do we make when we think about the workings of government?

Here is a preliminary list of interesting questions:

  • How is authority conveyed through the multiple levels and organizations of government?
  • How are principal-agent problems solved within governments?
  • How can governments handle problems of conflict of interest in its agents?
  • How can governments address the issues raised by conflicting assumptions and priorities driving the actions of a range of sub-units of government?
  • How are purposes and goals embodied in agencies and departments?
  • Do agencies serve “functions”?
  • How can governments achieve a degree of unity of purpose and action?

And we might add a final question: what makes these topics philosophical rather than sociological?

Philosophy of public administration?

 

Philosophy has well-developed theories about the foundations of government — the moral principles that underlie the legitimacy of government; the nature of rights and duties of citizens; the limits of government authority; and so on for a large number of issues. These debates take place within social and political philosophy, a field whose lineage extends back to the ancient Greek philosophers, through Hobbes, Locke, Rousseau, Kant, Hegel, Marx, and Mill, and into the twentieth century in the writings of people like Rawls, Habermas, van Parijs, and Nozick.

What does not yet exist is a discipline that treats the workings of government itself as a philosophical subject. This field could be called “the philosophy of public administration.” This subject matter invites us to focus on the “social ontology” of government — the mechanisms of governments as concrete human institutions and the logic of interaction that these constituents produce. How do governments, as extended social entities, perform the functions we attribute to them — knowledge gathering, belief formation, policy and priority setting, legislation, regulation, and enforcement? Governments are not unified entities; they are extended networks of agencies, organizations, alliances, interests, and actors, and it is worth careful philosophical investigation to consider how this kind of entity can be purposive, intentional, and calculating. A philosophical reflection on these questions would focus on issues about mechanisms, order, and dysfunction within government, through attention to the actors, institutions, and organizations that constitute it.

The topics of dysfunction and imperfect functionality run throughout these discussions — not because government is an especially defective kind of social organization, but because all extended social collectivities confront the sources of dysfunction mentioned at many points in Understanding Society. Principal-agent problems, conflicts of interest within individuals and between groups of individuals, multiple understandings of the setting of organizational action and the means that are available, conflicting priorities across agencies and groups involved in coordinated activity — all of these features of social “friction” are to be found within government, as they are within all kinds of large social collectivities.

Moreover, the bureaucratic state has changed greatly in the past century, and plays a much larger role in everyday life than at any earlier point in history. In a sense the subject matter of public administration simply didn’t exist at all in the ancient world of Plato and Aristotle. There was no “public administration” in the polis. (The same cannot be said of the Roman Empire, where there were clear divisions of bureaucratic responsibility and accountability, but I am not aware of any philosophers who studied the functions and dysfunctions of Roman administration.) So the fact of a deeply ramified and bureaucratized state is a fairly modern phenomenon that it makes sense for philosophers to attempt to address.

Another important change that has occurred in the past fifty years is the emergence of a much better-defined area of sociological research aimed at achieving a better understanding the workings of organizations than has been possible in the past. Organizational sociology and organizational studies have progressed rapidly since the 1960s, and these new areas of social-science research provide new theories and questions on the basis of which to try to understand the workings of governments and their agencies.

We might think of this field in analogy with the philosophy of action. Philosophers in the philosophy of action ask questions about the rationality and purposiveness of the individual, the materiality of the acting individual, the connections that exist between mental reasoning and bodily skill and habit, and other intriguing questions about how humans and other organisms can be said to “act”. These questions are similar in form to the questions that can be raised about government: how does an ensemble of separate organizations of government come to function in some limited way as a “collective actor”? How are the individual actors within government brought into some degree of coordination and collaboration in pursuit of common purposes? What is the substrate underlying action in the two realms (neurophysiology and organizational functioning)?

A good start for thinking about the philosophy of public policy is to ask, how does government work? What are the constituent processes of government through which governments “think” and “act”? What kinds of dysfunctions and surprises are embedded in the processes that appear to constitute the workings of government? And what hidden assumptions do we make when we think about the workings of government?

Here is a preliminary list of interesting questions:

  • How is authority conveyed through the multiple levels and organizations of government?
  • How are principal-agent problems solved within governments?
  • How can governments handle problems of conflict of interest in its agents?
  • How can governments address the issues raised by conflicting assumptions and priorities driving the actions of a range of sub-units of government?
  • How are purposes and goals embodied in agencies and departments?
  • Do agencies serve “functions”?
  • How can governments achieve a degree of unity of purpose and action?

And we might add a final question: what makes these topics philosophical rather than sociological?

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