Disaster by Management: Risk Assessment, Communication, and Response in Bureaucracies

Christine M. Rodrigue *

Eugenie Rovai

Department of Geography and

Department of Geography and Planning and

Environmental Science and Policy Program

Social Science Program

California State University, Long Beach

California State University, Chico

[email protected]

[email protected]

(562) 985-4895 or -8432

(530) 898-6091

(562) 985-8993 (fax) * corresponding author Biographical sketches Christine M. Rodrigue is a professor of

Eugenie Rovai is a professor of geography

geography and affiliated faculty in

and planning at California State University,

environmental science and policy and

Chico, and directs the Social Science

emergency services administration at California

Program there. Her interests lie in hazards,

State University, Long Beach. Her research

water resource policy, political redistricting,

publications and presentations are in natural and and cartography. sociogenic hazards and geoscience education.

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Disaster by Management: Risk Assessment, Communication, and Response in Bureaucracies Abstract This paper analyzes the structure of human error in three disaster case studies: September 11th, the Columbia crash, and the marijuana production by international drug cartels in American wilderness areas. The focus is on the systematic erosion of risk assessment communications as they move within complex bureaucracies toward risk managers with the power possibly to mitigate or prevent disaster. Risk assessment is politically subordinate to risk management and often spatially dispersed, while risk management is politically superior to risk assessment and typically spatially concentrated. Risk communications are attenuated during their ascent by the friction of social and spatial distance, diluted by the increasing number and seeming urgency of other managerialist concerns at each hub in the hierarchy, and often divided by competing stovepipes to the top. The outcome can truly be “disaster by management.”

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Disaster by Management: Risk Assessment, Communication, and Response in Bureaucracies

Introduction This paper analyzes the interaction of risk assessment and risk management in complex public organizations. It compares the structure of human error in three case studies, two of which eventuated in catastrophic failures and one of which may yet do so: the September 11th terrorist attacks in the United States, the loss of the Columbia Space Shuttle, and, now, the expansion of marijuana cultivation by Mexican drug trafficking organizations in U.S. National Forest and National Park lands. Analysis of the first two focuses on single Federal agencies: the Federal Bureau of Investigation (FBI) and the National Aeronautics and Space Administration (NASA). The third, still evolving case entails interactions among local and state agencies and the U.S. Forest Service (USFS) and the National Park Service (NPS). In such bureaucracies, risk assessment communication moves along the spokes of an organizational hierarchy toward socially and spatially concentrated hubs of decision-making, each of which makes risk management decisions in politicized contexts peculiar to its own scale and level. These contexts affect the outcome of a given risk assessment communication: Is the risk managed by an effective decision-maker at that level? Is the communication passed along another spoke in search of an effective decision-maker at a more influential hub? Or is the risk assessment suppressed with either no decision taken to alter risk or with sanctions applied to the messengers of risk? In each of the cases, technical information suggesting disaster was, or is, weakly transmitted within an elaborate bureaucracy and high-level decision-makers failed or are failing to authorize action to prevent tragedy. The result is "disaster by management."

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The Theoretical Background The disaster by management framework for these case studies integrates seven elements. These are public sector managerialism, organizational theory, accumulation and legitimization functions of government, accident theory, risk perception, the tension between risk assessment and risk management, and geographies. Managerialism Managerialism represents a search for and application of "scientific" principles of sound management modeled on corporations trying to manage multiple plants, offices, markets, and product-lines (Gordon 1978; Boje 2002). The idealized efficiency of the private sector corporation is contrasted with the public sector, which is assumed shielded from market forces through dependence on tax revenues and, therefore, necessarily, inefficient (O'Connor 1973; Peters and Pierre 1998). Taxes, moreover, are believed to drain the efficiency of the model private corporation. Managerialism exerts pressure to apply managerial techniques from the private sector to optimize the efficiency of a public sector agency or institution, so as to reduce tax burdens on the private sector. This pressure for managerial efficiency can be seen from the very beginnings of the discipline of public administration (e.g., Wilson 1887; Taylor 1911) and has only accelerated with the advent of the New Public Management movement since the 1980s. The specific goals of private companies, public agencies, and the military may differ, but the managerial function is viewed as transferable from one to another. The industry-specific technical knowledge of a manager, then, is less important than the more generic training and background in management. Managerialist themes include hierarchy and management

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expertise, application of technology and expertise to streamline processes, outcome or output assessment, and cost-effectiveness (Peters and Pierre 1998; Boje 2002; Taptiklis 2005). In the public sector, managerialism emphasizes hierarchy and technology and defines the rôle of the manager as balancing the socially- and politically-set goals of the agency with resource constraints, maximizing output for the minimum social investment. There is little empirical work on whether this model is even appropriate for government activity, given that business has a narrow obligation to make a profit and government agencies have multiple “consumers” and sometimes contradictory purposes (Peters and Pierre 1998; Daniels and ClarkDaniels 2006: 7). NASA, NPS, and USFS show greater impact of public sector managerialism than the FBI in the three case studies. Organizational Theory Organizational theory explores the structuring of individuals in organizational settings. One of its classical theories categorizes organizations into mechanistic and organic structures (Burns and Stalker 1961). In a departure from the “one best way” outlook of managerialism, Burns and Stalker argued that the continuum between mechanistic and organic organization is related to the degree of uncertainty in the external environment of the institution. Neither of these end points is intrinsically better than the other: It depends on the environmental context. Mechanistic structures are hierarchical and authoritarian, with finely differentiated and often repetitive tasks, centralization of decision-making and knowledge, and communication channeled along vertical chains of command. In industry, these correspond with Fordist production practices and their massive production of similar or identical pieces for a stable mass market. Mechanistic organizations are suited to external environments with a high degree of 3

predictability, enabling planning, elaboration of the division of labor and hierarchy, and control of the flow of information from the top. Organic organizations, on the other hand, are associated with external environments of high uncertainty. Planning is challenging and information cannot readily be centralized and redistributed. The emphasis is on flexibility and teamwork among people (even outside the organization) with very different skills, lateral communication, and a reduced dependence on hierarchy. Production tends to focus on small batches or one-of-a-kind products and services. All Federal agencies examined here tend towards the mechanistic end of the continuum. For NASA and the FBI, this is possibly a legacy of their military or policing origins. The NPS and USFS grew out of the Progressive Era, when public administration idealized apolitical technocratic expertise in service of the public good, which led to managerialism. Each of them with its mechanistic legacy now finds itself operating in external milieux and performing tasks suited to organic organization. Accumulation and Legitimization Functions of Government Of relevance to understanding the political and economic uncertainties in the extragovernmental environment is James O'Connor's notion of "accumulation functions" and "legitimization functions" of governmental agencies. He presented this dichotomy in a 1973 book, The Fiscal Crisis of the State. Accumulation activities are those facilitating profitable operation of private companies by providing social functions and infrastructure that cannot normally be met by the private sector. Examples include airport and port operation, construction and maintenance of transportation

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systems, operation of State or municipal utilities, maintenance of law and order, and, in some contexts, education and workforce development. These functions enjoy relatively stable funding, often from independent revenue sources, making them less vulnerable to the political process. Legitimization functions, on the other hand, are those taking care of the welfare of those negatively impacted by the free flow of investment and those serving symbolic loyalty-building purposes to promote social harmony even in challenging times. These include public assistance, Social Security, public housing, environmental protection, the needs of smaller businesses, and, to a certain extent, education and public safety functions. Legitimization functions and agencies dominated by them endure more variable funding, depending on the ebb and flow of the political election cycle and general funding. No agency is completely dominated by accumulation or legitimization functions, though it tends to be closer to one end or the other of this continuum. The FBI, with its law and order function, for example, seems to fall more on the accumulation side, dealing with the criminal problems produced by those trying extralegal solutions to economic problems. NASA carries a symbolic freight, which seems optional to many involved in the political battles of a given time. This pushes NASA more toward the legitimization side of the continuum. The USFS, tasked as it is with the management of the “Land of Many Uses,” has a strong accumulation function (e.g., lumber and grazing permits) but a significant legitimization function as well (managing the public commons for future generations). The NPS more unambiguously falls on the legitimization side of the see-saw, conserving wilderness areas from economic exploitation other than tourist uses. NASA and NPS will show more of the economic frailty of legitimization agencies, while the FBI will normally be more stably funded, due to its closeness to the conservative vision of the minimal rôle of 5

government. USFS will fall somewhere in between, its funding stability depending on the political dominance of Republicans and Democrats at any one time. Accident Theory Normal accident theory argues that accidents are "normal" in large, complex systems, because of unexpected interactions among components as much as failure of single components. If these components are tightly coupled in a reaction or in a sequence, then unexpected failure can happen far faster than human beings can grasp and respond and, thus, continue cascading across multiple pathways in unexpected ways, triggering more failures (Perrow 1984). Countering normal accident theory is high reliability theory, which dissects case studies of organizations that have long histories safely operating high consequence technologies (LaPorte and Consolini 1991). High reliability theory argues that these case studies share characteristics, such as the formation and maintenance of an intense "culture of safety." This culture of safety typically features delegation of responsibility to the levels closest to the technical operation of components posing risk, openness to learning from accidents and near misses (rather than blame-seeking), redundancy in personnel handling especially intense and critical tasks, and multiply redundant fail-safes. These characteristics may be latent, emerging visibly and in stages from a traditional hierarchy only during high activity periods or outright emergencies (LaPorte and Consolini 1991; Roberts and Bea 2001). Until the crash of the Challenger, NASA might have been offered as an example of a high reliability organization. Could analysis of its technical and organizational characteristics have detected the departure from the tight safety culture of a high reliability organization in time to avert the first of the Shuttle disasters? 6

Risk Perception Risk perception has garnered a large literature, particularly in geography, psychology, and sociology. A common theme is the discrepancy between perception and analytically derived measures of probabilities and consequences (e.g., Douglas and Wildavsky 1982; Kasperson et al. 1987; Rovai and Rodrigue 1998; Shrader-Frechette 1990; Slovic, Fischhoff, and Lichtenstein 1982). Fairly consistently, people tend to overestimate the frequency of low probability but dramatic hazards (e.g., nuclear power plant accidents or airplane crashes) as compared with expert estimates. Similarly, they tend to underestimate high probability hazards that are less dramatically memorable, such as certain lifestyle-mediated diseases or automobile accidents. Sometimes this reflects faulty heuristics, with a bias toward fear of simultaneous deaths over even higher probability deaths in ones or twos and toward suddenness over long term and incremental hazards (Tversky and Kahneman 1974). While lay audiences may over- or under-estimate risks in comparison with risk assessment scientists, the opposite seems to be true of managers in complex organizations responsible for risky technology: There is a tendency to normalize anomaly and an unwillingness to focus on dire consequences that may be glaringly obvious in investigational hindsight (Feynman 1986; Vaughn 1997). This is one of the mechanisms cited in normal accident theory. A related finding is that people, including managers in complex technological organizations, often make up their minds about an issue before being exposed to an adequate array of facts and arguments, often taking the position of a reference group they trust (Johnson 1993). New facts and arguments are fit into the framework in a way that further solidifies it, to

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avoid cognitive dissonance. Contrary facts are either not perceived or are dismissed (Slovic, Fischhoff, and Lichtenstein 1982). The normalization of anomaly recurs in all three case studies. The Tension between Risk Assessment and Risk Management Complicating the resistance to dissonant information is the tension between risk assessment and risk management. Risk assessment specifies hazards to humans, generally in terms of the expected probabilities of given types and magnitudes of damage. Originally more of a physical science, bioscience, or engineering function, it has increasingly drawn on social science as well, partly to understand how ergonomic factors might contribute to risk and partly to estimate economic and social impact as part of a potential disaster. Risk management is the development and implementation of policy to minimize hazard and draws more on the social sciences to calculate risks and benefits in policy positions and to explore the political, economic, social, and cultural milieu in which policy is decided and implemented (Freudenberg 1988). The distinction, while clear in concept, can be contentious in application, since each depends on the other. Assessors need to understand managers' needs and policy preferences for the proper balance between human safety and other goals, whether de minimis (minimizing false positives and the opportunity costs they impose) or the precautionary principle (minimizing false negatives and their potential for catastrophe). Managers need to understand the results and limitations of assessment, their inherent uncertainties, and their relevance to management decision-making and policy formulation (Lindell 2000). Further complicating this communication is the different status each function occupies in an organization: Risk assessors, as technicians and scientists, answer to managers (Burns and Stalker 1961). If the results of risk assessment do not validate the mental frameworks that have 8

gelled around managers, they may well not really hear the assessment message or may actively suppress its dissemination (Slovic, Fischhoff, and Lichtenstein 1982). Geographies Geography is a latent agent in organizational disaster. Highly complex organizations managing complex issues and technologies may be spatially diffuse, organized in some kind of hub and spoke hierarchy (Pred 1975). NASA has 15 centers of a few different types and a maze of associated aerospace contractors. The FBI has three field offices (Washington, DC; New York; and Los Angeles) overseen by Assistant Directors in Charge, 53 field offices overseen by Special Agents in Charge in major American cities, about 400 resident agencies in smaller cities, and 75 Legal Attaché offices abroad. NPS manages 391 sites, including 58 national parks, 73 national monuments, 23 national memorials, 120 historic sites, 24 battlefields, 18 national recreation areas, and more than half a dozen other types of special units of varying sizes and functions. The USFS operates 155 national forests and 20 national grasslands. This spatial complexity creates a friction of distance within such organizations. This friction of distance may well be only psychological in an era of instantaneous communication via e-mail, texting, and cell telephones. While Giddens (1991) argued that the “time-space distanciation” of modern society essentially disembeds social interaction from the physical and spatial confinement of pre-modern society, the lack of everyday face-to-face contact nevertheless can raise the psychological inertia to be overcome in initiating contact with someone removed in space. Space exerts not only an actual and a psychological friction of distance, but spatial positionality in an organization symbolizes political positionality. This effect has only lightly 9

been touched on in studies of organization (e.g., Sydow 2002). Regional centers are subsumed under and answer to headquarters. Information from regional centers may be thus discounted. Too, regional centers themselves may compete with varying success, creating spatial weighting of information based on which regional center originated it. The spatiality of NASA, the FBI, and the many interacting agencies in the marijuana case study create political and psychological distancing. This distancing itself becomes an agent in the breakdowns of communication that enable these disasters. While there is time-space compression in communications technologies, the friction of spatial and social distance exerts its influence through the symbolic and political time-space distancing of hierarchies in space.

Data and Methods Information on these case studies came from archival analysis of government documents, real-time monitoring of media, and, in the third case study, open-ended qualitative interviews. Information on the Shuttle disaster came from the Columbia Accident Investigation Board Report, while information on the FBI treatment of field office communications came from testimony to the Congressional Joint Investigation into September 11th. The public lands marijuana case integrates media analysis with interviews of USFS and NPS personnel in the Whiskeytown National Recreation Area in northern California.

The Case Studies In the three sections that follow, background on each case study is outlined and disaster by management themes are noted. Recurrent themes are then integrated in the discussion that follows the case studies. 10

Loss of Columbia and NASA's Response to Concerns about the Wing Foam Strike The Space Shuttle Columbia was launched from Canaveral on January 16th, 2003. A large piece of foam insulation from the External Tank detached during launch and hit the left wing's leading edge at a relative speed difference of some 686-922 km/hr (Gehman et al. 2003: 60-62). The foam piece was substantial, weighing about 0.76 kg (Gehman et al. 2003: 34, 62). This impact penetrated one of the dark Reinforced Carbon-Carbon panels or RCCs that protect the internal structure of the wings from the superheated air created by the Orbiter's entry into the atmosphere (Gehman et al. 2003: 65-83). On February 1st, Columbia re-entered the atmosphere and broke up over Texas, killing all aboard (NASA 2008a). The Columbia Accident Investigation Board, however, found that this tragedy was rooted more in NASA's internal organizational structure, history, and Congressional and White House pressures than in this sequence of mechanical failures (Gehman et al. 2003: Part 2). The Columbia was the first Shuttle put into service, after several delays, in April, 1981. The Shuttle has remained throughout its life an experimental vehicle. It took longer to get a returned Shuttle ready for its next mission than anticipated because of safety-compromising developments revealed after each flight. Congress and the White House became increasingly impatient with the constant schedule delays and cost overruns, exerting pressure for NASA to manage its resources in a more businesslike manner, essentially a call for managerialism (Gehman et al. 2003, 21-26; Rogers et al. 1986a, 164-177). These schedule, budgetary, and political pressures led to the decision to launch Challenger in January, 1986, over concerns of engineers at contractors and NASA centers, with lethal results. The Rogers Commission Report on the accident (Rogers et al. 1986a), the Vaughn 11

report (1997), and the Feynman minority report to the Rogers Commission Report (1986a) on the launch decision forcefully exposed the managerialist logic that led to this disaster and the tendency of NASA managers to normalize anomaly on the basis that no Shuttle had crashed yet. The Shuttle Program returned to flight 32 months later, in September 1988 (NASA 2008b). NASA implemented many reforms listed in the Rogers report (ASEB 1988; Rogers et al. 1986b, 1987), but the Shuttle was now organizationally housed with the International Space Station (ISS), the two programs constituting the Human Space Flight Initiative. The Shuttle budget was constrained even more by a 1994 edict from the Office of Management and Budget requiring ISS cost overruns be taken from the other side of the Human Space Flight Initiative, i.e., the Shuttle. From 1993 to 2003, while the overall NASA budget fell 13%, the Shuttle's budget fell 40% in inflation-corrected dollars. The Shuttle workforce was reduced from 30,091 in 1993 to just 17,462 in 2002, a loss of 42% of the labor force (Gehman et al. 2003, 106). Meanwhile, schedule pressure had resumed in the Shuttle Program, due to its coupling with the ISS. By the Bush-Cheney administration, the ISS program was $4 billion over projected budget, leading to a sense that NASA was “on probation” (Gehman et al 2003, 117) from the White House and Congress. The incoming NASA administrator, thus, decided to scale back NASA's ISS contributions, to the installation of US Node 2, to allow Europe and Japan to connect their modules to the ISS. An arbitrary deadline of February 19th, 2004, set up pressure to sequence Shuttle missions very tightly: Any delay would add to the cost of the ISS, and that was unacceptable in the managerialist ethos that pervaded NASA's external political milieu and, thus, Shuttle management (Gehman et al. 2003, 131-139).

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Budgetary, political, and scheduling forces combined to destroy Columbia and its crew. The day after the launch, routine examination of launch videos by the Intercenter Photo Working Group showed the foam strike. They requested that Kennedy Shuttle Program management obtain higher resolution imagery from the Department of Defense, which the Launch Integration manager at Kennedy attempted to do (Gehman et al. 2003, 140). Engineers from NASA and contractors formed a Debris Assessment Team or DAT (Gehman et al., 142). Boeing engineers on the Team arranged for their Houston operation to run a model called "Crater," which is designed to predict depth of penetration through tiles or RCC by falling foam or ice pieces. This was the first application of Crater since its move to Houston from Boeing's Huntington Beach, California, operation where it had been developed. The move resulted in the loss of senior engineering expertise, as not everyone at Huntington Beach wanted to move to Houston (Gehman et al. 2003, 190). The Crater model was designed for popcorn-sized cylindrical-shaped pieces, mostly ice, and had never been used on something so large as the Columbia foam piece (Gehman et al. 2003, 143). When it was run with the data from the foam strike, it predicted penetration clear through to the wing interior (Gehman et al. 145). The team that ran it did not consult with the experts at Huntington Beach despite not trusting the results (Gehman et al. 2003, 145, 190, 192). This uncertainty and knowledge that Crater was designed to err on the side of caution (Gehman et al 2003, 143), would play into NASA Shuttle management's existing preferences to see foam strikes as ordinary action items that trigger maintenance hassles, rather than a safety-of-flight emergency that would trigger crew rescue actions Gehman et al. 2003, 121-176).

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The Debris Assessment Team was so concerned that, like the Photo Group, it filed requests for Department of Defense imagery through the Shuttle Mission Management Team at Kennedy Space Center and through the Johnson Space Flight Center Engineering Management Directorate. They thought the engineering chain of command request would be faster than going through the elaborate Space Shuttle Program management hierarchy. The Johnson manager complied and also notified the Chair of the Mission Management Team. The Mission Management Team Chair knew that a particularly bad strike had happened on the previous mission three months earlier but that Shuttle Program management had not grounded the fleet pending investigation. The Shuttle had, after all, come down safely, and the Shuttle Program was under very tight schedule pressure to meet the February 19, 2004, ISS deadline. She, thus, felt that foam strikes were not all that serious a problem. She had normalized anomaly and was dominated by managerialist concerns for flight scheduling and budget. She was dismayed that the Photo Working Group had gone directly to the DoD without going through the Shuttle management channels, not knowing the Debris Assessment Team had, too. So, she contacted DoD and told them to stop working on the request. The DoD assumed this meant all requests. The Debris Assessment Team took that cancellation as a final order, not a point of negotiation, given the mechanistic and hierarchical organization of NASA management. The Chair, however, expressed concerns to others in Shuttle Management, apparently looking for reassurance that the foam-strike was not really a safety-of-flight issue. She also commented that imagery was no longer being pursued, "since even if we saw something, we couldn't do anything about it. The Program didn't want to spend the resources" (Gehman et al. 2003, 154). This statement expresses the dilemma faced by risk managers making decisions in 14

conditions of uncertainty, caught between the Type II error of dismissing a very serious problem or the Type I error of taking a problem too seriously and squandering resources. There were, however, at least two scenarios for crew rescue, had NASA scrambled into emergency mode. With only the results of Crater to go on and without the high resolution data they needed from DoD, the Debris Assessment Team's presentation on the ninth day after launch was riddled with large uncertainties. Management found nothing compelling to bend their concerns toward Type II error from their natural inclination to worry more about the opportunity costs of making a Type I error (Gehman et al. 2003, 121-176). 9/11 and FBI Headquarters' Response to Field Office Concerns The second analysis focuses on FBI Headquarters' response to field officer reports about the sudden interest in aviation among certain Middle Easterners in the US. The organizational context of this failure lies in the FBI's history. The FBI has alternated between centralized, mechanistic organization and decentralized, organic organization, with highly publicized abuses of investigatory power in both organizational modes. The FBI has had trouble weighting the autonomy of field offices against the authority of Headquarters and balancing its perception of its mandates with the legitimate Constitutional liberties of the American people (Powers 2004). Four incidents in the 9/11 context show this dilemma in action. They took place in summer 2001 at a time of extreme concern at the highest echelons of the Federal government about impending al-Qaeda attacks. On July 5th, Richard Clarke, then the National Coördinator of Security, Infrastructure Protection, and Counter-terrorism, briefed a White House gathering of senior officials from the FBI and other Federal agencies about indications that al-Qaeda was planning what he called a "really spectacular" attack on Americans in the very near future 15

(Breitweiser 2002, 8; Clarke 2004, 236). That urgent concern was not communicated down the hierarchy at FBI Headquarters, much less diffused out to the field offices around the country (Breitweiser 2002). In light of the failure to push this information down the hierarchy, FBI Headquarters analysts and operations specialists acted as they normally would, lacking context to do anything differently. On July 10th, 2001, a Special Agent with the Phoenix field office sent an "electronic communication" (EC) detailing his suspicions about the number of Middle Eastern men taking lessons at flight schools (Hill 2002a). He requested that Headquarters open investigations on certain individuals because of their possible links to terrorist organizations. This message was eventually relayed to Intelligence Operations Specialists (IOSs) in the Usama Bin Ladin Unit or UBLU. The request to investigate the visa status of individuals named in the EC was denied due to concerns about the legality of racial profiling and the seemingly speculative nature of the aviation issue (Hill 2002c). Obviously, these IOSs had not heard about the high-level concern about an impending "really spectacular" al-Qaeda attack. On August 6th, the Central Intelligence Agency gave President Bush the CIA President's Daily Brief entitled, “Bin Ladin Determined to Strike in US.” As with the July 5th meeting, this urgent message went nowhere, the president dismissing the “panicked” CIA briefer with “All right. You've covered your ass now” (anecdote reported in Suskind 2006: 2). Its content was not shared with the agency responsible for internal security, the FBI, neither from the president via the Attorney General to the Department of Justice in which the FBI is housed, nor through interagency links between the authoring agency, the CIA, and the FBI. The August 7th IOS decision to close the Phoenix Memo aviation issue with no further action was thereby isolated 16

both from intraintelligence “chatter” and from the concerns of the highest levels of the FBI. Without that contextualization, the decision was, therefore, reasonable. Internal communication problems come through in a third incident. An agent from the New York Field Office was conducting a criminal investigation of the USS Cole bombing of October 12th , 2000, in Aden, Yemen. On August 29th, 2001, he asked FBI Headquarters to allow New York to use all its criminal investigative resources to find one Khalid al-Midhar, who had apparently recently met with a suspect connected to the Cole attack in Kuala Lumpur and had then entered the United States in July 2001. The agent was told that the FBI National Security Unit had declared that this could not be done: There is a "Wall" barring sharing of information between criminal and intelligence investigations, because use of intelligence information in a criminal case can compromise intelligence sources. The agent was furious, stating "someday someone will die," but Headquarters would not relent (Hill 2002b). Information flow within the FBI organization, thus, involves not only impediments between Headquarters and field offices but also within two parallel, vertical stovepipes: Criminal investigations and intelligence investigations. The Wall made conceptual sense, given that communication between these two functions might possibly disrupt them. The fourth incident entails another failure of communication between Headquarters and a field office. On August 15th, 2001, Pan Am employees at a Minneapolis flight school called the local FBI field office to report concerns that a student, Zacarias Moussaoui, was acting very oddly and might pose a national security threat (Hill 2002c). The Minnesota Field Office contacted the FBI's legal attaché's offices in Paris and London, which then approached French and British intelligence. The Minneapolis case agent also reached out to an FBI detailee and a 17

CIA desk officer at the Counterterrorism Center. The CIA officer, too, contacted counterparts in London and Paris.

These inquiries provided information that Moussaoui indeed had ties with

extremist Islamist groups, including one of the Chechen rebel groups. The field office personnel arrested him the next day on immigration violations and asked Headquarters for a Foreign Intelligence Surveillance Act or FISA search warrant. They were turned down, because an agent in the Radical Fundamentalist Unit at headquarters felt that the Minneapolis Field Office had not demonstrated sufficient cause for a FISA search warrant, in light of an investigation of possible abuses of the FISA search warrant process initiated by Attorney General John Ashcroft half a year earlier and the new “Woods Procedures” sent down the hierarchy as a result. The RFU agent was acting to prevent abuse of the FISA search process by a Field Office supervisor he felt had a flimsy ad hoc case as well as a prior habit of too quickly resorting to FISA. The RFU agent was balancing the Type II error of letting a terrorist go on to commit a crime with the Type I error of authorizing a request for a FISA search without sufficient cause. The earlier investigation of FISA search abuses may have sensitized him more to the latter possibility than the former. Sadly, a search of Moussaoui's possessions would have revealed the 9/11 plan in detail and possibly allowed its prevention (Kean et al. 2004: 273-276; Leahy et al. 2003; Breitweiser 2002). In all four cases, hindsight reveals failures of communication between the CIA and the FBI and within the FBI. Within the FBI, these failures are mediated through tensions between Headquarters and field offices and over the Wall dividing intelligence and criminal investigations. A FBI Special Agent, Coleen M. Rowley, working in the Minneapolis Field Office during the Moussaoui case, bluntly testified to Congress about the managerialism in the 18

FBI that contributes to these tensions, noting she had been told there are “between seven and nine management levels at FBIHQ” (Rowley 2002, 2), which create an almost insuperable obstacle to risk messages and decision-making. In all four of these cases, the tensions between field offices/specialized offices and lowerlevel Headquarters staff created a serious friction of social and spatial distance for risk messages rising from lower assessment levels to higher management levels, with the lower level at Headquarters being the critical junction at which dimming messages from below met failed messages from above: The decisions of lower level Headquarters personnel seem oddly reasonable in light of what they knew at the time and their legitimate concerns about due process and proper investigation. Particularly disturbing is the failure to communicate on the part of the highest levels in the FBI, the people who were privy to the meeting in the White House on July 5th. Given the intense concern expressed at that meeting, why was the situation not communicated down to all Headquarters staff, if not all the way out to the field offices? Had this information been conveyed to them as forcefully as Clarke, the National Coördinator of Security, Infrastructure Protection, and Counter-terrorism, had conveyed it to the White House meeting, the lower-level personnel at Headquarters might have been much more receptive to the Type II risk of failing to stop an imminent terrorist attack rather than to the Type I risk of abusing FISA search powers or the Wall between intelligence and criminal investigation. Marijuana Plantations in National Parks and Forests For at least two decades, National Forest and National Park lands have been used for growing marijuana. California leads the nation in terms of numbers and acreage of illegal marijuana plantations on public lands, but they are increasingly found everywhere in the US, 19

including Florida, North Carolina, Virginia, and Kentucky (CAMP 2009; NDIC 2009a, 2009b). At first, in California, it was simply American working class people displaced by the structural unemployment in the “Emerald Triangle's” lumbering, fishing, and farming economy (Humboldt, Mendocino, and Trinity counties) as well as countercultural migrants trying to avoid forfeiture of their personal real-estate during a drug bust (Leeper 1990; Ritter 2005). As the new millenium dawned, however, the scale of operations has exploded (CAMP 2009). Joining the High Times demographic since the late 1990s have been Mexican drug cartels (Gaffrey 2003), accelerating after the post-9/11 border securitization (CAMP 2009; Peters 2003; Sanchez 2009; Simon 2009). Cartels now dominate public lands dope growing (Sanchez 2009). According to the National Drug Information Center, the eastward shift in public lands cultivation sites can be attributed to ramping up of detection and eradication efforts in California and the cartels' efforts to seek out areas unprepared for effective enforcement (NDIC 2009b). Mexican nationals, usually from Michoacán, are smuggled into the US and placed on site as early as April (Sanchez 2009). Each is paid a small amount, as little as $200 a month, and given food and growing supplies, such as pesticides and fertilizers, irrigation supplies, shovels, axes, and a .22 caliber rifle (Roosevelt 2003). These gardeners (two or three earlier in the season to 20 or more later in the season on each site) stay until fall when heavily armed cartel operatives join them for harvest. If the gardeners can make it through the whole cycle, they are promised large payoffs, making them anxious to protect their crop from rival cartels, thieves, land management and law enforcement personnel, and ordinary users of the public lands (Sanchez 2009). Additionally, their employers are violent outfits, sending their heavily armed enforcers to join the gardeners toward harvest. The stage is set for confrontations between these 20

armed crews and the unwitting user of the public lands and employees of public agencies, which have taken place sporadically (e.g., Gaffrey 2003; Sanchez 2009; Wood 2003). These illegal marijuana plantations negatively impact local environments, with trash, human feces, fertilizers, pesticides, PVC piping, and lead in and around the hidden dwellings. Impacts on wildlife include poaching of bears and deer and poisoning of rodent populations. Native trees and shrubs are cleared, trimmed, poisoned, or girdled and killed in order to allow more sunshine through the canopy into the gardens (Gaffrey 2003). There are inadvertent impacts, too, notably the importation of invasive exotic species other than marijuana (Wood 2003), such as Ailanthus altissima (tree of heaven). Among inadvertent effects was the 89,500 acre La Brea fire in the Los Padres National Forest Fire in Southern California in August 2009, caused by a growers' camp fire (InciWeb 2009). Particularly impressive are the hydrologic and geomorphic impacts of hidden marijuana cultivation. There are large scale water diversions that entail the construction of small dams and plastic-tarp lined reservoirs for mixing of fertilizers and pesticides, laying and burying of miles of PVC piping to distribute water from these dams and from streams and springs, and chemical pollution downslope and downstream: Aquatic life kills in Northern California have been traced to these operations (Peters 2003) and there are claims of damage to marine organisms in Southern California as well (Lee 2006). The water diversions are significant enough to impact drought-stricken water supplies in some California localities (O'Carroll 2009) and the water needs of animal species (Wood 2003). The living and growing areas are often terraced, because of the steep terrain, and terraces are often unstable (Wood 2003). Commuting between the camps and the fields and out to get supplies has created soil compaction, which along with water 21

diversions has accelerated erosion as well (USFS 2008). Stream ecology has been degraded, and fish kills have been implicated, not just by chemicals (Wood 2003), but by increased turbidity and deposition of these eroded materials (Lee 2006). Plants are not only grown on wilderness lands, but they are processed there, too, often being dried in hidden shelters (e.g, Sanchez 2009) just before the cartels come by to move the harvest and pay the workers. The camps and processing facilities are often elaborately camouflaged from ærial detection efforts (Sanchez 2009). Without better detection methods, pot busts are serendipitous and rare enough that the cost to benefit ratio of growing pot in the public lands favors the illegal growers. Particularly troubling with the “whack and stack” approach to law enforcement is that law enforcement’s priority has to be arrest, not remediation of the environmental damage done by these operations. It is conservatively estimated to cost at least $10,000 per acre to clean up and do basic restoration (Sanchez 2009; NPS 2009). Park and Forest Service agencies do not have funds to meet this new cleanup and restoration demand. Forest Service personnel interviewed by Eugenie Rovai (2006-09) report frustration with the situation, given that the Forest Service budget has been a low priority over the last couple decades (classic accumulation agency dilemma). They are understaffed and find that pot enterprises in their jurisdiction are forcing them to take on a law enforcement rôle for which they have little training or desire. Because of the danger to wilderness users, they diligently report every garden they find, but the Federal and county law enforcement cut the Forest Service out of the communications loop while they are conducting operations. These operations often require the cessation of Forest Service activities, including trail repair, public education, habitat restoration, and prescribed burns. These Forest Service activities, many of them costly and with 22

difficult logistics, are thrown into abeyance until law enforcement takes on a problem area, which they may or may not inform the Forest Service people about. Forest Service staff have voiced concerns that the lack of communication from law enforcement is actively endangering the public by not taking advantage of the public communication functions of rangers. This marijuana situation has the earmarks of “disaster by management”: There are competing chains of command, often working at cross-purpose. Law enforcement is secretive about information-sharing outside its own stovepipe, which cuts it off from people who can help improve their effectiveness through better GIS-based modeling. This secretiveness ironically puts more people at risk, because the Forest Service and the Park Service cannot warn the public about situations they are not privy to. Information flow is diluted. There is some media reportage, and Federal agencies have knowledge of the situation, but there is little public outcry, because, while incidents occur, they do not involve large numbers of simultaneous victims. Reduced public pressure reïnforces the normalization of anomaly by public agency management. The public is in danger. So are the natural resources and environmental quality of its public lands. There is potential for the levels of violence currently seen in parts of Mexico due to drug cartels’ activities. Environmental damage is pervasive and significant. And the problem is rapidly increasing across the country. A failure of effective managerial response, at the Federal level, may have already allowed the problem to scale up beyond any hope of control.

Discussion Commonalities in the case studies can now be integrated. These are organizational geographies, stovepiping within and between organizations, the Catch-22 of legitimization

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agencies dealing with risk under managerialist pressures, risk perception biases, tension between risk assessment science and risk management policy, and normal accident theory. Geography Geography is a camouflaged player in all three “disaster by management” case studies. In all three, geographically complex hierarchies underscored the junior status of risk assessment science. Not only were the risk assessors who first realized the importance of the hazards junior in rank to their management supervisors, but their lower status was amplified by their housing in spatially peripheral offices. The first concerned FBI agents were in the field offices; the first concerned NASA engineers were at Canaveral, and the first concerned Boeing engineers in Texas felt some inhibition against contacting Boeing software developers in California. The first concerned USFS and NPS personnel are often rangers and staff at individual Parks and Forests. Hierarchy is constituted and expressed at least in part by the spatiality of an organization, and the friction of distance adds to the friction of social distance that risk messages must traverse. Stovepiping Stovepiping of information running along parallel but often not touching chains of command is another theme seen in these case studies. The FBI separated intelligence work from criminal investigation work to prevent the compromising of sources. The firewall between these two functions and chains of command was not breached by the risk messages coming in from the field offices about Khalid al-Midhar and Zaccharias Moussaoui. The CIA and the FBI field offices were working on similar signals of terrorist intent in the United States, but there was apparently no means for each to know what the other was doing. The Columbia crash shows this same confused flow of information: The NASA Debris Assessment Team was unsure which 24

chain of command would be the right one to lift their urgent risk messages: the Johnson Space Flight Center Engineering Management Directorate or the Shuttle Mission Management Team chain at Canaveral. When they used the engineering chain and management in the other chain was notified as a routine courtesy, a political issue was created in the Shuttle Mission Management Team. This shut down further movement of the risk communication and data gathering. In the public lands, the secretiveness of law enforcement and the disruptiveness of their responses to marijuana plantation sighting reports could conceivably discourage USFS and NPS personnel from reporting them. They also cut law enforcement off from natural allies in the effort to protect the public from violent confrontations with drug growers. This stovepiping issue suggests that mechanistic organizations may be peculiarly vulnerable to miscommunication of vital risk messages in an uncertain and changing risk environment, a cost of hierarchicalization. Incorporation of some features of organic organizations might improve flexibility and teamwork among those assessing often new risks and trying to manage their outbreaks. Catch-22: Legitimization, Risk, and Managerialism The Catch-22 of legitimization agencies in the face of managerialist pressures comes across in two of the case studies: Columbia and wilderness marijuana gardens. The agencies involved are political footballs, with their funding rising and falling relative to the rest of the Federal government with the ideology of the party in control of the White House and Congress, the state of the economy, and the political pressures that result. The buildup of budgetary and schedule pressures is probably the critical element in the loss of the Space Shuttle Columbia. Looking to the potential future disaster emerging in the Federal public and wilderness lands, the 25

NPS and USFS, too, have been caught in the managerialist demands for doing more with less. Like many legitimization oriented agencies, they are expected to handle their politically marginalized mandates with reduced funding, efficiently. As they have been reduced to virtual skeleton crews, a costly new risk has been building in the lands they manage, a risk they are not trained to handle and a risk that disrupts their ability to carry out their normal tasks. Risk Perception Biases Risk perception biases were produced or intensified by managerialist pressures, mechanistic organization, and stovepiping of risk communication in various combinations. Normalization of anomaly is seen in all three case studies. The Shuttle Mission Management Team manager who actively blocked a request for DoD imagery sent by the Debris Assessment Team and the Intercenter Photo Working Group clearly exhibited this kind of Type II Error thinking: Earlier foam strikes on previous Shuttle flights had not ended in disaster. The manager refused to face a safety-of-flight risk that would drastically add to the costs and delays in the Shuttle launch schedule and, so, chose to frame the circuitous request for imagery as an end run around her authority and shut it down, rationalizing that nothing could be done anyway. The response to the increasing terrorist “chatter” about a huge impending strike in the US fell on ears at all levels deafened by the normalization of anomaly. The downward communication of extreme risk failed in FBI Headquarters, so that the ISOs there had no context to sensitize them to anomalous communications coming in from several field offices. In the wilderness lands of California and, increasingly, the rest of the country, no-one seems to be integrating the big picture of violent international drug cartels setting up marijuana plantations where hikers, hunters, campers, and Scouts could blunder into extreme harm's way. After all, “hippies and 26

hillbillies” (Burke 2005) have been growing a few plants up there all along and, yes, a few of them are known to set booby traps. So, in this dismissive fashion, the anomaly of massive pot farms in the public commons and the potential disaster they represent are normalized away. Tension between Risk Assessment and Risk Management The contentious relationship of risk assessment and risk management interacts with the normalization of anomaly to raise the potential for disaster through faulty risk communication within a bureaucratic hierarchy. Risk assessment in all these case studies is done, informally or formally, by scientists, analysts, and practitioners, who stand below those who make decisions about the management of risk. Risk communications originate from people in a position to assess risk but possibly confused about the proper channels to use, possibly spatially remote and affected by the friction of distances both physical and social, or intimidated by their perceptions of a manager's receptiveness to such communications. Such a message may, then, start out weakened and then flow through tortuous spokes toward managerial hubs, looking for someone with the authority and inclination to do something about the risk involved. Every spoke it traverses, however, lands it at a hub in which a given risk message is competing with multiplying concerns. These other concerns are increasingly managerialist in nature, so risk messages are not just diluted but biased by budgetary limits, opportunity costs, and scheduling pressures, which facilitates a tendency to normalize anomaly in service of these competing concerns. As these risk messages rise and weaken, the scientist's fear that managers will make a Type II Error drifts into the manager's fear of a scientist's having made a Type I Error. Increasingly attenuated the higher a risk communication climbs, it may eventually be too weak for anyone to hear.

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The costs of the Debris Assessment Team's finding that the foam strike could have done safety-of-flight level damage to Columbia's wing and the implication that subsequent Shuttle flights would be thrown off schedule were too awful for a manager to face and dulled contemplation of the consequences of trying to land a catastrophically damaged Columbia. The socially and geographically circuitous route take by the DAT's request for DoT imagery weakened the risk message and fed the appearance of some kind of political end run, which led the manager to erect bureaucratic dams against the acquisition of further data that could have had life-saving but costly and disruptive implications. Thus, the DAT was in no position to argue that the possibility of a wing breach should be considered despite the Crater program's known bias toward false positives and the precautionary principle. In the case of the FBI, several field offices tried to pass on urgent risk messages about anomalous patterns that actually presaged the 9/11 attacks. In each case, Headquarters personnel dismissed their concerns. The IOS staff had, for some reason, not been informed by their chains of command about Richard Clarke's very pointed warnings in July and there had been no transmission of the contents of the CIA President's Daily Brief of August from the CIA to the FBI. Furthermore, they had been made aware of the Attorney General's and the Acting FBI Director's risk management preferences for reining in excessive use of FISA and the appearance of racial profiling. The IOS personnel had no context to situate the content of those messages. In the wilderness marijuana situation, risk messages originate from spatially isolated rangers and then bifurcate into notification of USFS or NPS supervisors and local law enforcement. USFS and NPS defer to the law enforcement need for containment of information flow and then worry about the risk to the public they cannot warn because of this requirement. 28

Isolated, they are marginalized by law enforcement and by their own geographically diffuse locations. On the law enforcement side in California, there is better coördination between local agencies, state, and Federal agencies, as seen in CAMP teams (Campaign Against Marijuana Planting), but the rangers and their responsibilities remain peripheralized. Normal Accident Theory The case studies validate normal accident theory over high reliability organization theory. More than that, they exemplify specific structures and mechanisms that can amplify the probability of accident and disaster. Normal accident theory holds that complexity of organizations and processes creates the preconditions for accident because of the unforeseeable interactions possible among different components and links. Repeated patterns in these case studies, however, suggest that these conditions may be foreseeable, if not necessarily remediable. Mechanistic organizations produce tall hierarchies between risk assessors who first identify a risk and risk managers with enough authority to do something about it. With multiple managerial nodes and links between these levels, dilution is inevitable for a risk assessment communication moving upward or even a risk management policy communication moving downward. At some point, it may simply become too diluted to make a strong enough impression on anyone able to stop the process and address the risk. This is an effect that even the best of organizations, those most committed to high reliability and learning from past mistakes, must struggle to offset. Most organizations are not quite so ideal, however. Over the years, ad hoc adjustments to their structures may have generated unclear or multiple chains of command, placing confusion in the path of personnel first registering a hazard and wanting to communicate it to the proper level in the organization. This confusion may be especially likely 29

in geographically ornate organizations, adding the friction of spatial distance to that of the social distance between different levels in a hierarchy. Organizations may be embedded in budgetary and scheduling situations that make the consequences of opportunity costs vividly frightening to a manager. A larger political-economic ideology of managerialism transmitted from the top down a hierarchy is nearly guaranteed to skew the balance of terrors from the precautionary principle to de minimis concerns about the opportunity costs of overreacting to safety concerns. Managers are human beings subject to perceptual biases and faulty heuristics. Their professional situations may make them particularly susceptible to the normalization of anomaly, which attenuates perception of the consequences of false negatives and amplifies those of false positives.

Conclusions Risk cannot be completely erased from human enterprises: Spacecraft fail; terrorists pull off disasters; criminals invent solutions to legal obstacles; and natural disasters are part of the human experience. Risk can be minimized to a greater or lesser extent, depending at least partly on the political will and economic capacity to accept the trade-off between exponentially increasing marginal costs of mitigation, preparation, response, and recovery with marginal gains in safety. This trade-off is fundamentally ideological. These case studies suggest structural and perceptual paths leading to accident-prone and accident-resistant organizations. Assessment of a very serious and imminent risk at any level in an organization should have an emergency internal route to the highest or most relevant levels in the hierarchy, bypassing or end-running the normal channels and the way they ablate the urgency of a message

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through physical and social friction of distance. It should also protect emergency attempts to acquire relevant information from a parallel “stovepipe” without normal permissions, as the FBI Minneapolis office attempted through direct contacts with legal attachés in Paris and London and the FBI New York field intelligence officer tried through requests of FBI criminal investigation contacts. This alternative route may be able to graft some of the advantages of organic organization onto traditional mechanistic organizations grappling with uncertain environments. The higher reliability organizations do seem to have ways of temporarily suppressing hierarchy and creating informal, horizontal networks during crises or times of high demand, so thinking through a “short circuit” may be an attainable improvement. Whistleblower-like protections need to be part of this alternative route to protect anyone using it from the resentments of managers interpreting this as disrespect for their position, as happened in the Columbia tragedy and in the interactions between one FBI Headquarters staffer and the Minneapolis field office director concerning Zacarias Moussaoui. It should also be designed to recognize that the use of this route is without prejudice to the immediate supervisor of the party using it: This is an emergency alternative only, recognizing that there may not be time enough to use the “proper channels” and that the established route may be clogged with the more ordinary managerialist traffic. The question is how high is high enough and how to compensate for the fact that the highest levels in a bureaucracy may, in fact, be the source or transmitter of the managerial pressures on the lower level managers that lead to the de minimis and normalization of anomaly biases in the first place and that even a very good manager may have other urgent, if ultimately less important issues at hand that would dim anyone's ability to understand and prioritize a grave risk communication. Recognizing that the alternative route is

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not the solution to every disaster by management scenario, it yet retains value in the sense that it could work as a circuit relay around structural obstacles and biases in at least a few situations. Having a system in place that might save even a few critical risk messages from enfeeblement in bureaucracy would be a worthwhile and life-affirming endeavor.

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