Crises as catalysts for change

In the past few weeks, there have been a number of mass shootings in the US. In turn, gun control has again emerged as a central discussion point among politicians vying for the 2016 U.S. presidency. The arguments have been predictable: Many Republicans have been vocal that strict gun control regulations would not have prevented the shootings, while many Democrats have been vocal about wanting more gun control regulations to prevent these tragedies from reoccurring. And then there are those that argue that using tragedies to push policy change is in bad taste.

I’m not here to talk about my stance on gun control. I’m not here to offer a solution, either. I just want to refute the inane argument that, in the wake of a tragedy, we should shrug our shoulders, silently mourn and chalk it up to “shit happening”. Sometimes there are freak occurrences. Sometimes there clear patterns. There have been more than 300 mass shootings [1] in 2015 alone, so mass shootings are certainly not freak occurrences. Regardless of your personal politics, I think we can all agree that the shrugging-our-shoulders strategy is not viable.

We should definitely be talking about how we can mitigate these tragedies in the future, regardless of whether you believe in more or less gun control. And, pushing this dialogue in the wake of a tragedy is the best time if we want that dialogue to result in change. It might feel disrespectful, but what better way to honor the victims than by preventing the same mistake from happening again? Historically, tragedies and crises have been one of the few effective catalysts for policy change in organizations that otherwise have had too much inertia to change.

Three clear examples come to mind:

1) Rhode Island Hospital: In 2007, an eighty-six year old man died while being treated at the Rhode Island Hospital. He had fallen on his head, which caused a “subdural hematoma”. Blood was quickly collecting within the left side of his skull, dangerously increasing the pressure in his cranium. If the pressure wasn’t relieved quickly, he would die. Unfortunately, the surgeon who was treating him initially operated on the wrong side of the man’s head — a mistake that the man’s family would later argue caused his ultimate death.

This tragedy was one in a string of others that warranted a closer investigation into the practices of the hospital. Eventually, it became evident that many of the fatal errors were the result of doctors and surgeons who were dismissive of nurses. For example, a nurse urged the surgeon who was operating on the eighty-six year old man to double-check the films to ensure that he was operating on the correct side of the head. The surgeon bullishly ignored this warning and made a mistake that may have been the difference between life and death.

In the wake of these tragedies, the hospital had to make changes. They shut down operations for a day to mend the broken relationship between doctors and nurses in the hospital, and, in so doing, implemented new safety procedures. Since that time (in 2009), no wrong-site errors have occurred [2].

2) Korean Air [3]: On August 6, 1997 a Korean Air flight carrying tourists from Seoul to Guam crashed into Nimitz Hill, killing 228 of the 254 people on board, making it one of the deadliest aviation disasters. An investigation by the National Transportation Safety Board concluded that the probable cause of the incident was a failure in communication between the captain and his first officer and flight engineer. In fact, it turned out that this was a pattern among many Korean Air flight crews: pilots were often retired air force veterans who ignored their subordinates and discouraged junior pilots from speaking up.

In response to this and many other crashes between 1970 and 1999, Korean Air has made radical changes to its “cockpit culture” that foster a healthier relationship between flight crew. As a result, Korean Air’s safety record has markedly improved.

3) London underground: In 1987, a fire broke out in one of London’s most heavily trafficked tube stops: King’s Cross station. It all started from a simple match that had been dropped onto an escalator. Soon, a combination of physical forces and bad organizational habits would allow the fire to grow into an inferno that killed 31 and injured a hundred more.

In his book, The Power of Habit, Charles Duhigg explains that a big contributor to this tragedy was bureaucracy. There were four separate organizational hierarchies that each held equal power and refused to step on each other’s toes. As a result, the workers who worked for ticketing — who were also the first to hear about this fire — were untrained in fire safety. They were not even allowed to report in fires or use emergency fire extinguishers. Furthermore, to avoid causing a panic, they were discouraged from calling the Fire Brigade.

An immediate public inquiry into the incident resulted in an upending of the existing organizational structure. Staff were better trained to deal with fires. Wood panels on escalators were replaced with metal panels. And smoking was banned in all London underground stations.

Notice a pattern in the three stories above? tragedy -> dialogue -> reflection -> improvement. I’m sure there are many more examples.

The point is: Tragedies, like the recent campus mass shootings, are clearly terrible events that we should aim to mitigate to the best of our ability. The silently mourn strategy is dangerous because it quashes our opportunity to learn and grow. It ensures only that the same tragedy might strike again.

TL;DR: Read this onion article


[1] According to this page, mass shootings are defined as events where four or more people are shot.

[2] I was first introduced to this story by Charles Duhigg’s “The Power of Habit”, and much of what I’m writing here is based on the materials I read in that book and the sources it cites.

[3] I was first introduced to this story in Malcolm Gladwell’s book “Outliers: The Story of Success”. Since then there has been debate about the validity of Gladwell’s framing of the story: i.e., as that of cultural issues in communication leading to the crashes. So, while I’m not endorsing Gladwell’s framing of the issue, the story does still exhibit the trend I am trying to convey about how tragedies are effective catalysts for change.

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