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 loving daughter, Cordelia, until after his false daughters, Goneril and Regan, tricked him into giving them his kingdom. Our allies in Europe didn’t recognize the threat posed by the Nazis until after Neville Chamberlain made peace with Hitler at Munich. 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.
But just because something is a cliche doesn’t mean it’s always true. 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. For the benefit of future anthropologists studying America’s litigious late 20th century, we’ll call this phenomenon The Culpability Trap.
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. To acknowledge a problem so conspicuously is to suggest negligence, and thus to open the possibility of bad publicity, or a lawsuit, or both.
Of course, keeping mum isn’t always the response of somebody caught in the act of malfeasance. Sometimes a little confession can bring instant absolution. In the late 1970s, for example, the military discovered it had miscalculated the scores on its intelligence tests; when the real scores emerged, it turned out the new recruits were even dumber than originally assumed. The Pentagon went to Congress and came clean. 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. There is no shortage of examples. 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. 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.
Then there’s the case of Eli Lilly. 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. 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.
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. That would have tacitly acknowledged the NRC’s negligence when it approved the designs in the first place. Instead, the NRC crossed its bureaucratic fingers and hoped disaster wouldn’t strike. Then came Three Mile Island.
Not all examples involve matters of life and death. Sometimes all that’s at stake is a reputation. Take Labor Secretary Ray Marshall’s response to the possible exposure of problems in the CETA program in the 1970s. Insiders at Labor saw CETA as a “disaster waiting to be discovered,” a former official recalls. 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. “Secretary Marshall had hired the guy responsible, and to criticize would be to say Marshall had screwed up,” recalls the former official. “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. 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. 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.
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. His friends at the firehouse say he might have lived if a standard safety device had been in place on the truck. Soon after Steve’s death, Howard Dixon, the deputy chief responsible for the safety of fire “apparatus,” was placed on administrative leave. In a world without lawyers, such an action would indicate only that somebody was being punished for doing his job badly. 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.
It is clear from the evidence that a little foresight might very well have saved Calvin Steve’s life. 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. The mansaver is a padded bar on a hinge that is mounted across the lower entry to the stairwell. A fireman must lift the bar to get to the stairs; it then snaps down and serves as a passive restraint.
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. 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. 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. When Steve fell on November 12, the chain wasn’t in use. He died of head injuries on November 23, leaving a wife and three children under the age of three.
The day after Steve’s death, I received calls from a couple of firemen I know. They told me that the mansaver bars that might have saved Steve’s life were sitting in a firehouse storeroom. They had been delivered soon after the pumper had arrived. 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. Later that day I interviewed District Fire Chief Theodore Coleman. 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?” Coleman seemed stunned. He sputtered for a moment, and then said, “That has not been told to me. I do not have that information.”
Deputy Chief Dixon apparently had ordered the bars installed without telling Chief Coleman. Several days later I learned that Dixon had been placed on administrative leave. At first I thought, rather naively, that he was being disciplined because he hadn’t had the bars installed when they first arrived. 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.
Later I found out the real reason. 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. 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; besides, most of the city’s fire trucks were already equipped with mansaver bars. 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.
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. That in itself is probably stronger evidence of negligence than Dixon’s installation of the mansaver bars after Steve’s death.
But never underestimate a bureaucrat’s terror of The Culpability Trap. A man who is trying to save lives in the future has been disciplined. A bureaucracy that seems to bear some responsibility for a fireman’s death has decided to stonewall it. 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.