The Culpability Trap
Cloherty, Jack
The Culpability Trap by Jack Cloherty We are all familiar with the cliche that nobody ever corrects a problem until it is too late. King Lear didn't recognize the virtue of his only...
...Later that day I interviewed District Fire Chief Theodore Coleman...
...besides, most of the city's fire trucks were already equipped with mansaver bars...
...Our allies in...
...Dixon's sin lay in his responding to an order by Assistant Fire Chief Harry Shaffer to install the bars, a violation of the official chain of command, since Assistant Chief Maurice Kilby, not Shaffer, is Dixon's boss...
...In addition to referring to Steve repeatedly as "Stevens:' he insisted that the chains were "just as safe as the bars!' "Why, then:' I asked, "has the chain been taken off and the bar put on...
...At first I thought, rather naively, that he was being disciplined because he hadn't had the bars installed when they first arrived...
...Insiders at Labor saw CETA as a "disaster waiting to be discovered:' a former official recalls...
...A man who is trying to save lives in the future has been disciplined...
...Instead, the NRC crossed its bureaucratic fingers and hoped disaster wouldn't strike...
...Later I found out the real reason...
...In some cases, the human response to a mistake once its repercussions are felt is not to correct the mistake, but to desperately avoid correcting it...
...In the case of Engine 12, the fire department's investigation after the accident found, the chain had become too tangled to reach across the stairwell and clip into place...
...But the chain has a major drawback: the firefighter has to remember to attach it across the stairwell, and in a hurry, he might forget...
...The Culpability Trap dictates that the worst time to correct a problem is after disaster has struck, because remedial action would show that the disaster could have been averted had you thought to correct the problem beforehand...
...A bureaucracy that seems to bear some responsibility for a fireman's death has decided to stonewall it...
...That in itself is probably stronger evidence of negligence than Dixon's installation of the mansaver bars after Steve's death...
...Of course, the District of Columbia government probably will have a lawsuit on its hands anyway because the mansaver bars had been available for months prior to the accident and no one had bothered to install them...
...He died of head injuries on November 23, leaving a wife and three children under the age of three...
...For months before the accident, the captain of his engine company had been after the fire department to install "mansaver bars" on the truck from which Steve fell...
...it then snaps down and serves as a passive restraint...
...Yet Coleman, aside from his embarrassment at being caught flatfooted in a television interview, reportedly was very concerned (along with the fire department's legal counsel) that the installation of the bars after the accident would seem a tacit admission of negligence...
...To acknowledge a problem so conspicuously is to suggest negligence, and thus to open the possibility of bad publicity, or a lawsuit, or both...
...Several high-ranking officials in the department say it would have been unusual for Dixon to consult anyone higher up before making such a routine equipment change...
...Coleman seemed stunned...
...Malign neglect...
...Take Labor Secretary Ray Marshall's response to the possible exposure of problems in the CETA program in the 1970s...
...But when the story finally broke, Labor focused its energies on a giant public relations blitz of brochures and films designed to demonstrate what a great job CETA was doing...
...Of course, keeping mum isn't always the response of somebody caught in the act of malfeasance...
...But in the world as ruled by The Culpability Trap, Dixon was punished not for neglecting to place the safety device on the truck, but for installing the safety device after the accident—to protect others from injury...
...But just because something is a cliche doesn't mean it's always true...
...Instead, it argued that the two inspectors who okayed the Mianus Bridge six months before could not have been expected to observe that anything was amiss...
...In a world without lawyers, such an action would indicate only that somebody was being punished for doing his job badly...
...Congress then responded by raising military pay 25 percent across-the-board, in the name of attracting "higher quality'.' In general, however, the more serious the negligence, the stronger the bureaucratic urge to avoid any action that risks acknowledging it...
...Not all examples involve matters of life and death...
...Then came Three Mile Island...
...The new pumper arrived last spring without any restraining device across the stairwell, so Deputy Chief Dixon installed a chain as a stopgap measure until the mansaver bars arrived...
...The day after Steve's death, I received calls from a couple of firemen I know...
...came clean...
...His friends at the firehouse say he might have lived if a standard safety device had been in place on the truck...
...Secretary Marshall had hired the guy responsible, and to criticize would be to say Marshall had screwed up:' recalls the former official...
...Soon after Steve's death, Howard Dixon, the deputy chief responsible for the safety of fire "apparatus:' was placed on administrative leave...
...That would have tacitly acknowledged the NRC's negligence when it approved the designs in the first place...
...If the public is whipped into a frenzy about something, a bureaucrat may have no choice but to resign himself to solving the problem, or risk a public hanging...
...There is no shortage of examples...
...I've been thinking about The Culpability Trap ever since I reported a story for WRC-TV, a Washington, D.C., station, about Calvin Steve, a 24-year-old fireman for the District of Columbia who died last November after he was thrown from a moving fire truck...
...He sputtered for a moment, and then said, "That has not been told to me...
...But the difficulty of recalling very many examples where this has happened in real life makes me suspect that this limit is largely theoretical, even in a democracy...
...Several days later I learned that Dixon had been placed on administrative leave...
...So we just decided to ride it out and hope the problems would go away!' Obviously, there can be an upper limit to the magnitude of the unsolved problem in cases like this...
...When I visited the engine house where Steve had been stationed with a camera crew, I noticed that mansaver bars had been hastily installed on the truck, apparently in reaction to Steve's death...
...In the late 1970s, for example, the military discovered it had miscalculated the scores on its intelligence tests...
...Sometimes all that's at stake is a reputation...
...When the company learned that its new drug, Oraflex, was probably the cause of a number of deaths overseas, it did not withdraw it from the market...
...It is clear from the evidence that a little foresight might very well have saved Calvin Steve's life...
...But never underestimate a bureaucrat's terror of The Culpability Trap...
...The mansaver is a padded bar on a hinge that is mounted across the lower entry to the stairwell...
...After a huge chunk of Interstate 95 fell into the Mianus River in Connecticut, taking three drivers with it, the Connecticut Department of Transportation did not, as you might expect, call for a drastic alteration of its highway inspection procedures...
...Sometimes a little confession can bring instant absolution...
...Instead, it withheld the information from the Food and Drug Administration and continued to press ahead with efforts to introduce it into the American market...
...King Lear didn't recognize the virtue of his only loving daughter, Cordelia, until after his false daughters, Goneril and Regan, tricked him into giving them his kingdom...
...They had been delivered soon after the pumper had arrived...
...And, to illustrate the principle on a less grandiose scale, every mother knows that a child won't really learn to keep his hand away from the flame until he's felt the burn...
...For the benefit of future anthropologists studying America's litigious .late 20th century, we'll call this phenomenon The Culpability Trap...
...Then there's the case of Eli Lilly...
...Coleman assured me that wasn't the case, and claimed the action "had nothing at all to do with Steve's death:' Dixon's leave was an "internal personnel matter;' nothing more...
...when the real scores emerged, it turned out the new recruits were even dumber than originally assumed...
...Europe didn't recognize the threat posed by the Nazis until after Neville Chamberlain made peace with Hitler at Munich...
...The Pentagon went to Congress and Jack Cloherty is a reporter for WRC-TV in Washington, D.C...
...When Steve fell on November 12, the chain wasn't in use...
...When Nuclear Regulatory Commission engineers discovered in the 1970s that many of the reactors the commission had approved had serious design flaws, the NRC did not instruct utilities to make the necessary repairs...
...A fireman must lift the bar to get to the stairs...
...I do not have that information:' Deputy Chief Dixon apparently had ordered the bars installed without telling Chief Coleman...
...They told me that the mansaver bars that might have saved Steve's life were sitting in a firehouse storeroom...
...And a very clear message has been communicated to everyone else in the District of Columbia fire department: It's better to insist you did nothing wrong than to learn from your mistakes...
Vol. 16 • February 1984 • No. 1
