Daniel Little
Electronic Health Record systems (EHRs) have been broadly implemented by hospitals and health systems around the country as a way of increasing the accuracy, availability, and timeliness of patient health status and treatment information. (These systems are also sometimes called "Digital Medical Records" (DMRs).) They are generally regarded as an important forward step in improving …
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Allan McDonald's Truth, Lies, and O-Rings: Inside the Space Shuttle Challenger Disaster (2009) has given me a somewhat different understanding of the Challenger launch disaster than I've gained from other sources, including Diane Vaughan's excellent book The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. McDonald is a Morton Thiokol (MTI) insider who was present through …
It is of both intellectual and practical interest to understand how organizations function and how the actors within them choose the actions that they pursue. A common answer to these questions is to refer to the rules and incentives of the organization, and then to attempt to understand the actor's choices through the lens of …
The Federal agency responsible for investigating chemical and petrochemical accidents in the United States is the Chemical Safety Board (link). The mission of the Board is described in these terms: The CSB is an independent federal agency charged with investigating industrial chemical accidents. Headquartered in Washington, DC, the agency’s board members are appointed by the …
Serious nuclear accidents are rare but potentially devastating to people, land, and agriculture. (It appears that minor to moderate nuclear accidents are not nearly so rare, as James Mahaffey shows in Atomic Accidents: A History of Nuclear Meltdowns and Disasters: From the Ozark Mountains to Fukushima.) Three Mile Island, Chernobyl, and Fukushima are disasters that …
It is intriguing to observe how pervasive organizational and regulatory failures are in our collective lives. Once you are sensitized to these factors, you see them everywhere. A good example is in the business section of today's print version of the New York Times, August 1, 2019. There are at least five stories in this …
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The 1986 meltdown of reactor number 4 at the Chernobyl Nuclear Power Plant was the greatest nuclear disaster the world has yet seen. Less well known is the Kyshtym disaster in 1957, which resulted in a massive release of radioactive material in the Eastern Ural region of the Soviet Union. This was a catastrophic underground …
Andrew Hopkins has written a number of fascinating case studies of industrial accidents, usually in the field of petrochemicals. These books are crucial reading for anyone interested in arriving at a better understanding of technological safety in the context of complex systems involving high-energy and tightly-coupled processes. Especially interesting is his Lessons from Longford: The …
Herbert Simon made paradigm-changing contributions to the theory of rational behavior, including particularly his treatment of "satisficing" as an alternative to "maximizing" economic rationality (link). It is therefore worthwhile examining his views of organizations and organizational decision-making and action -- especially given how relevant those theories are to my current research interest in organizational dysfunction. …
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The topic of the organizational causes of technology failure comes up frequently in Understanding Society. The tragic crashes of two Boeing 737 MAX aircraft in the past year present an important case to study. Is this an instance of pilot error (as has occasionally been suggested)? Is it a case of engineering and design failures? …
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