Any Lessons for Nuclear Safety Culture from VW’s Initiative to Improve Its Compliance Culture?

VW Logo (Source: Wikipedia)

The Wall Street Journal (WSJ) recently published an interview* with the head of the new compliance department in Volkswagen’s U.S. subsidiary.  The new executive outlined the department’s goals and immediate actions related to improving VW’s compliance culture.  They will all look familiar to you, including a new organization (headed by a former consultant) reporting directly to the CEO and with independent access to the board; mandatory compliance training; a new code of conduct; and developing a questioning attitude among employees.  One additional attribute deserves a brief expansion.  VW aims to improve employees’ decision making skills.  We’re not exactly sure what that means but if it includes providing more information about corporate policies and legal, social and regulatory expectations (in other words, the context of decisions) then we approve.

Our Perspective 

These interventions could be from a first generation nuclear safety culture (NSC) handbook on efforts to demonstrate management interest and action when a weak culture is recognized.  Such activities are necessary but definitely not sufficient to strengthen culture.  Some specific shortcomings follow.

First, the lack of reflection.  When asked about the causes of VW’s compliance failures, the executive said “I can’t speculate on the failures . . .”  Well, she should have had something to say on the matter, even party line bromides.  We’re left with the impression she doesn’t know, or care, about the specific and systemic causes of VW’s “Dieselgate” problems that are costing the company tens of billions of dollars.  After all, this interview was in the WSJ, available to millions of critical readers, not some trade rag.

Second, the trust issue.  VW wants employees who can be trusted by the organization, presumably to do “the right thing” as they go about their business.  That’s OK but it’s even more important to have senior managers who can be trusted to do the right thing.  This is especially relevant for VW because it’s pretty clear the cheating problems were tolerated, if not explicitly promoted, by senior management; in other words, there was a top-down issue in addition to lower-level employee malfeasance.

Next, the local nature of the announced interventions.  The new compliance department is for VW-USA only.  The Volkswagen Group of America includes one assembly plant, sales and maintenance support functions, test centers and VW’s consumer finance entity.  It’s probably safe to say that VW’s most important decisions regarding corporate practices and product engineering are made in Wolfsburg, Lower Saxony and not Herndon, Virginia.

Finally, the elephant in the room.  There is no mention of VW’s employee reward and recognition system or the senior management compensation program.  We have long argued that employees focus on actions that will secure their jobs (and perhaps lead to promotions) while senior managers focus on what they’re being paid to accomplish.  For the latter group in the nuclear industry, that’s usually production with safety as a should-do but with little, if any, money attached.  We don’t believe VW is significantly different.

Bottom line: If this WSJ interview is representative of the auto industry’s understanding of culture, then once again nuclear industry thought leaders have a more sophisticated and complete grasp of cultural dynamics and nuances.

We have commented before on the VW imbroglio.  See our Dec. 20, 2015 and May 31, 2016 posts or click on the VW label.


*B. DiPietro, “Working to Change Compliance Culture at Volkswagen,” Wall Street Journal (Nov. 16, 2017).

The Criminalization of Safety (Part 2)

Risky Business 

As we illustrated in Part 1 of this post a new aspect of safety management risk is possible criminal liability for actions, or inactions, associated with events that did, or could have, safety consequences.  While there has always been the potential for criminal liability it has generally been directed at the corporate level versus individual employees.  Heretofore, “few executives have been on the hook, partly because it is tough for prosecutors to prove an individual had criminal intent in a corporate setting where decision-making is spread among many.” ^1,2

The Justice Department has been making a new push to target individuals more frequently to hold them accountable for corporate malfeasance. Much of the criminal liability in recent years has been cropping up in industries other than nuclear, as illustrated in the summary table in Part 1.  The Deepwater Horizon drill rig explosion and the Massey Coal explosion at the Upper Big Branch mine have been leading examples.  More recently the series of scandals involving automobile manufacturers are adding to the record.  And the Flint water contamination situation is also evolving rapidly.  We’ll discuss the significance of these cases and how it could impact the conduct of individuals responsible for safe nuclear operations and the role of regulation.  In particular, under what circumstances criminal liability may attach and whether the potential to be held criminally liable is an effective force in assuring compliant behaviors and ultimately safety. 

Who’s a Criminal?

The various cases are a mix of corporate and individual liability.  All three corporations involved in Deepwater pleaded guilty to various charges and paid very large fines.  In BP’s case, it pleaded guilty to felony manslaughter.  Manslaughter charges against individuals employed by BP were dropped prior to trial.  Individual liability was limited to violations of the Clean Water Act and obstruction of justice (misdemeanors).³

David Uhlmann, a professor at the University of Michigan Law School and former environmental-crimes prosecutor stated, “The Justice Department always seeks to hold individuals accountable for corporate crime, but doing so in the Gulf oil spill meant charging individuals who had no control over the corporate culture that caused the spill.” ⁴

Other cases followed a similar pattern until Upper Big Branch.  Mostly lower level individuals were being targeted; higher ups were insulated from knowledge or direct involvement in the specific event.  With Massey prosecutors worked their way up the management chain all the way to the CEO.⁵  However even where there were significant indications of the CEO driving a “production first” culture, the felonies he faced were based on securities fraud and making false statements.  Ultimately he was convicted of violating safety standards and will serve jail time.⁶  Fukushima will be another attempt to hold senior management accountable (for something termed, “professional negligence”) but, as previously noted, the case is thought to be difficult.  The Attorney General in the Flint water cases promises more indictments and implies higher ups will be charged.  It remains to be seen whether this targeting of individuals will prove to be a truer preventive measure than other remedies.

Proof of Criminal Behavior is Difficult

Ultimately the prospect of criminal prosecution is fraught with legal and practical obstacles.⁷  Current law does not provide a realistic platform for prosecution or sentencing.  Statutory provisions are often limited to misdemeanors.  Making applicable statutes “tougher”, as already proposed by a presidential candidate, is also problematic as it risks over-criminalizing management actions which occur in a complex environment and involve many individuals.  Simple negligence is a problematic ground for criminal liability which generally requires a showing of intent or recklessness.⁸  As noted in regard to the VW scandal, “…investigations are ongoing. Whether criminal prosecutions result may be a matter of balancing suspicion of criminal wrongdoing against the standards of proof required - and the track record of recent prosecutions.⁹

All of the recent experience involving corporations were guilty pleas - the cases did not go to trial and so the standard of proof was not tested. In the BP cases, the DOJ made quite a splash with its indictments of individuals but clearly overreached in charging as the courts and juries quickly dismissed most cases and all felony charges.

Fukushima may be a bit of an oddity as the charges have been mandated by a citizen’s panel.   The charge is “professional negligence” which probably does not have a direct analog in U.S. law.  It does suggest that there will be scrutiny of the actual decisions made by executives which resulted in safety consequences.  In the Flint cases, there will another attempt to review an actual safety decision.  An engineer of the Michigan Department of Water Quality is charged with “misconduct” in authorizing use of the Flint water plant “knowing” it was deficient.  Bears watching.

Competing Priorities and Culture Are Being Cited More Frequently 

Personnel are already in a difficult position when it comes to assuring safety. Corporations inherently, and often quite intentionally, place significant emphasis on achieving operational and business goals.  These goals at certain junctures may conflict with assuring safety.  The de facto reality is that it is up to the operating personnel to constantly rationalize those conflicts in a way that achieves acceptable safely.  Those decisions are rarely obvious, may imply significant benefits or costs, and are subject to ex post critical review with all the benefits of time, hindsight, and no direct decision making responsibility.  Thus the focus may shift from decisions to the culture that may have produced or rationalized those decisions.

The Mine Safety and Health Administration report concluded that the [Upper Big Branch] disaster was "entirely preventable," and was caused in part by a pattern of major safety problems and Massey's efforts to conceal hazards from government inspectors, all of which "reflected a pervasive culture that valued production over safety.”  The Governor of West Virginia’s independent review also found that Massey had “made life difficult” for miners who tried to address safety and built “a culture in which wrongdoing became acceptable.”

As noted in the media, “the automotive industry is caught up in an emissions rigging scandal that exposes systematic cheating and an apparent culture of corrupt ethics."  At VW nine executives so far have been suspended but blame has been focused on a small group of engineers for the misconduct, and VW contends that members of its management board did not know of the decade-long deception.  The idea that a few engineers are responsible “just doesn’t pass the laugh test,’ said John German, a former official at the Environmental Protection Agency…its management culture — confident, cutthroat and insular — is coming under scrutiny as potentially enabling the lawbreaking behavior.¹⁰  Mitsubishi Motors is also implicated and investigations are being launched into their peers – including Daimler and Peugeot – to assess the extent of the problem around the world.

Ineffective Regulation is Becoming a Focus 

Last but perhaps the most intriguing evolution in these cases is a new emphasis on the responsibility of the regulator when safety is compromised. There was an extensive and ongoing history of violations at Big Branch Mine, many unresolved, but which did not lead to more stringent enforcement measures by the Mine Safety and Health Administration (MSHA) - such as a shutdown of mine operations.  State of West Virginia investigators claimed that the U.S Department of Labor and its MSHA were equally at fault for failing to act decisively after Massey was issued 515 citations for safety violations at the UBBM in 2009.  “…officials with the MSHA repeatedly defended their agency’s performance. They were quick to point to the fact that the Mine Safety Act places the duty for providing a safe workplace squarely on the shoulders of the employer, insisting that the operator is ultimately responsible for operating a safe mine.” ¹¹

Similar concerns have arisen with regard to Fukushima where safety regulators have been perceived to lack independence from nuclear plant operators. And thinking back to Davis Besse, it seems that the NRC’s actions could have been more intrusive and proactive in determining the condition of the RPV head prior to allowing the inspections to be delayed.

With regard to Flint we noted above that criminal (felony) charges have been brought against a state engineer for “misconduct in office” for authorizing use of the Flint plant.  In addition, he and a supervisor are also charged with misconduct in office for “willfully and knowingly misleading the federal Environmental Protection Agency…”   An expert in environmental crimes notes ”It’s extremely unusual and maybe unprecedented for state and local officials to be charged with criminal drinking water violations, . . .” ¹²

Whether these pending actions lead to a robust effort to hold regulators and their staff accountable is hard to know.  It bears watching, particularly the contention by MSHA and other regulatory agencies including the NRC, that operators are primarily and ultimately responsible. In Part 3 we’ll share some thoughts on what might other approaches might be effective.

¹ P. Loftus, "Criminal Trials of Former Health-Care Executives Set to Begin," The Wall Street Journal (May 22, 2016).

² The Davis Besse case is prototypical of the way cases were handled in the past.  The corporation pleaded guilty to making false statements and paid a big fine.  Lower level individuals were found guilty of similar charges.  In the Siemaszko trial the court was quite ready to attribute to the defendant knowledge of the content of NRC communications, whether directly prepared by him or not, or acquiescence in materials drafted by others that misrepresented conditions for the RPV.  They also dismissed his contention that he lacked proper expertise.  The court found that he knew and had a motive - keeping the plant running.  There was testimony that higher management was the source of the operational pressure but culpability did not extend beyond the individuals making the actual statements and submittals to the NRC.

³ Transocean Deepwater Inc. also admitted that members of its crew onboard the Deepwater Horizon, acting at the direction of BP’s Well Site Leaders were negligent in failing fully to investigate clear indications that the well was not secure and that oil and gas were flowing into the well.  Halliburton was the supplier of drilling cement to seal the outside of the drilling pipe.  Its guilty plea admitted destroying evidence of instructions to employees to “get rid of” simulation analyses of the event that failed to show that Halliburton’s recommendations to BP would have lowered the risk of a blowout.  [S. Mufson, "Halliburton to Plead Guilty to Destroying Evidence in BP Spill," The Washington Post (July 25, 2013).]  This was an attempt to show that a decision by BP to use fewer pipe centralizers was a serious error contributing to the accident.

⁴ A. Viswanatha, "U.S. Bid to Prosecute BP Staff in Gulf Oil Spill Falls Flat," The Wall Street Journal (Feb. 27, 2016).

⁵ Notably the lower level managers pleaded to charges and did not go to trial.  The acquittal of the CEO on felony level charges illustrates the challenges of proving these cases.

⁶ “Large punitive or compensating settlements, so the argument goes, act as an effective deterrent for mining companies, forcing them to improve their safety systems or face potentially debilitating fines. However, given the revelations about Massey and the several major US mining disasters that have taken place in the last ten years, it's impossible to argue that financial punishment has been a wholly effective scarecrow, especially when companies feel they can game the MSHA system.”  [C. Lo, "Upper Big Branch: the search for justice," Mining-technology.com (June 20, 2013).]

⁷ "To this point, research on corporate crime has been, for the most part, overlooked by mainstream criminology. In particular, corporate violations of safety regulations in the coal mining industry have yet to be studied within the field of criminology.”  [C. N. Stickeler,  "A Deadly Way of Doing Business: A Case Study of Corporate Crime in the Coal Mining Industry," University of South Florida (Jan. 2012).]

⁸ “carelessness which is in reckless disregard for the safety or lives of others, and is so great it appears to be a conscious violation of other people's rights to safety. It is more than simple inadvertence, but it is just shy of being intentionally evil.”  Read more: http://dictionary.law.com/Default.aspx?selected=838#ixzz41W5CGRf0.

⁹ J. Ewing and G. Bowley, "The Engineering of Volkswagen’s Aggressive Ambition," The New York Times (Dec. 13, 2015).

¹⁰ Ibid.

¹¹ The quote is from the case study and references the Governor’s investigation - McAteer, J. D., Beall, K., Beck, J. A., Jr., McGinley, P. C., Monforton, C., Roberts, D. C., Spence, B., & Weise, S. (2011). Upper Big Branch: The April 5, 2010, explosion: A Failure of Basic Coal Mine Safety Practices (Report to the Governor).

¹² M. Davey and R. Perez-Pena "Flint Water Crisis Yields First Criminal Charges," New York Times (April 20, 2016). 

The Criminalization of Safety (Part 1)

US DOJ logo

Nuclear safety management and culture relies on nuclear personnel conducting themselves in accordance with espoused values and making safety the highest priority.  When failures occur individual workers may be (and often are) blamed but broader implications are generally portrayed as an organizational culture deficiency and addressed in that context.  

Only rarely does the specter of criminality enter the picture, requiring a level of malfeasance - intentional conduct or recklessness - that is beyond the boundaries of conventional safety culture. 

The potential for criminal liability raises several issues.  What is the nexus between safety culture and criminal behavior?  What is the significance of the increased frequency of criminal prosecutions following major accidents or scandals in nuclear and other industries?  And where does culpability really lie - with individuals? culture? the corporation? or the complex socio-technical systems within which individuals act?

If one has been paying close attention to the news fairly numerous examples of criminal prosecutions involving safety management issues across a variety of industries and regulatory bodies is occurring.  It is becoming quite a list of late.  We thought this would be an appropriate time to take stock of these trends and their implications for nuclear safety management.

Recent Experience

We have prepared a table* summarizing relevant experience from the nuclear and other high risk industries.  (The link is to a pdf file as it is impractical to display the complete table within this blog post.)  Below is a table snippet showing a key event: the criminal prosecutions associated with the Davis Besse reactor vessel head corrosion in 2001/2002. First Energy, the owner/operator, pleaded guilty to criminal charges and two lower level employees were found guilty at trial.  A third individual, a contractor working for First Energy, was acquitted at trial.

More currently high level executives of TEPCO, the owner/operator of the Fukushima plant in Japan, were charged, though the circumstances are a bit odd.  Prosecutors had twice declined to bring criminal charges but were ultimately overruled by a citizens panel.  The case is expected to be difficult to prove.  Nonetheless this is an attempt to hold the former TEPCO Chairman and heads of the nuclear division criminally accountable.

The only other recent examples in the U.S. nuclear industry that we could identify involved falsification of documents, in one instance by a chemistry manager at Indian Point and the other a security officer at River Bend.**  One has pleaded guilty and sentenced to probation; the other case has been referred to the U.S. Department of Justice (DOJ).

Looking beyond nuclear, the picture is dominated by several major operational accidents - the Deepwater Horizon drill rig explosion and the explosion of the Upper Big Branch coal mine owned by Massey Energy.  Deepwater resulted in guilty pleas by the three corporations involved in the drilling operation - BP, Transocean and Halliburton - with massive criminal and civil fines.  BP’s plea included felony manslaughter.  Several employees also faced criminal charges.  Two faced involuntary manslaughter charges in addition to violations of the Clean Water Act.  The manslaughter charges were later dropped by prosecutors.  One employee pleaded guilty to the Clean Water Act violations and was sentenced to probation, the other went to trial and was acquitted.

The Massey case is noteworthy in that criminal charges ultimately climbed the corporate ladder all the way to the CEO.  Ultimately he was acquitted of felony charges of securities fraud and making false statements, but he “was convicted of a single count of conspiring to violate federal safety standards; he was not convicted of any count holding him responsible for the 2010 accident at the Upper Big Branch mine.”***  It “is widely believed to be the first CEO of a major U.S. corporation to be convicted of workplace safety related charges following an industrial accident.”****  Three other individuals also pleaded or were found guilty of misdemeanor charges.

Next up are the auto companies, GM, Volkswagen and Mitsubishi.  The GM scandal involved the installation of faulty ignition switches in cars that subsequently resulted in a number of deaths.  GM entered into a plea agreement with DOJ admitting criminal wrongdoing and paid large monetary fines.  As of this time no criminal charges have been brought against GM employees.  VW and Mitsubishi have both admitted to manipulating fuel economy and emissions testing and there is speculation that other auto manufacturers could be in the same boat.  The investigations are ongoing at this time but criminal pleas at the corporate level are all but certain.

Last in this pantheon is the city of Flint water quality scandal.  The Attorney General of Michigan recently filed criminal charges against three individuals and promised “more charges soon”.  The interesting aspect here is that the three charged are all government workers - one for the city and two for the Michigan Department of Environmental Quality.  And the two state officials have been charged with misconduct in office, a felony.  Essentially regulators are being held accountable for their oversight.  As David Ullmann, a former chief of DOJ’s environmental crimes section, stated, “It’s extremely unusual and maybe unprecedented for state and local officials to be charged with criminal drinking water violations.”  This bears watching.

In Part 2 we will analyze the trends in these cases and draw some insights into the possible significance of efforts to criminalize safety performance.  In Part 3 we will offer our observations regarding implications for nuclear safety management and some thoughts on approaches to mitigate the need for criminalization.


*  Criminal Prosecutions of Safety Related Events (May 22, 2016).

**  We posted on the Indian Point incident on May 12, 2014 and the River Bend case on Feb. 20, 2015.

***  A. Blinder, "Mixed Verdict for Donald Blankenship, Ex-Chief of Massey Energy, After Coal Mine Blast," New York Times (Dec. 3, 2015 corrected Dec. 5, 2015).

****  K. Maher, "Former Massey Energy CEO Sentenced to 12 Months in Prison," Wall Street Journal (April 6, 2016).  The full article may only be accessible to WSJ subscribers.

How Top Management Decisions Shape Culture

A brief article* in the December 2015 The Atlantic magazine asks “What was VW thinking?” then reviews a few classic business cases to show how top management, often CEO, decisions can percolate down through an organization, sometimes with appalling results.  The author also describes a couple of mechanisms by which bad decision making can be institutionalized.  We’ll start with the cases.

Johnson & Johnson had a long-standing credo that outlined its responsibilities to those who used its products.  In 1979, the CEO reinforced the credo’s relevance to J&J’s operations.  When poisoned Tylenol showed up in stores, J&J did not hesitate to recall product, warn people against taking Tylenol and absorb a $100 million hit.  This is often cited as an example of a corporation doing the right thing. 

B. F. Goodrich promised an Air Force contractor an aircraft brake that was ultralight and ultracheap.  The only problem was it didn’t work, in fact it melted.  Only by massively finagling the test procedures and falsifying test results did they get the brake qualified.  The Air Force discovered the truth when they reviewed the raw test data.  A Goodrich whistleblower announced his resignation over the incident but was quickly fired by the company.  

Ford President Lee Iacocca wanted the Pinto to be light, inexpensive and available in 25 months.  The gas tank’s position made the vehicle susceptible to fire when the car was rear-ended but repositioning the gas tank would have delayed the roll-out schedule.  Ford delayed addressing the problem, resulting in at least one costly lawsuit and bad publicity for the company.

With respect to institutional mechanisms, the author reviews Diane Vaughan’s normalization of deviance and how it led to the space shuttle Challenger disaster.  To promote efficiency, organizations adopt scripts that tell members how to handle various situations.  Scripts provide a rationale for decisions, which can sometimes be the wrong decisions.  In Vaughan’s view, scripts can “expand like an elastic waistband” to accommodate more and more deviation from standards or norms.  Scripts are important organizational culture artifacts.  We have often referred to Vaughan’s work on Safetymatters.

The author closes with a quote: “Culture starts at the top, . . . Employees will see through empty rhetoric and will emulate the nature of top-management decision making . . . ”  The speaker?  Andrew Fastow, Enron’s former CFO and former federal prison inmate.

Our Perspective

I used to use these cases when I was teaching ethics to business majors at a local university.  Students would say they would never do any of the bad stuff.  I said they probably would, especially once they had mortgages (today it’s student debt), families and career aspirations.  It’s hard to put up a fight when the organization has so accepted the script they actually believe they are doing the right thing.  And don’t even think about being a whistleblower unless you’ve got money set aside and a good lawyer lined up.

Bottom line: This is worth a quick read.  It illustrates the importance of senior management’s decisions as opposed to its sloganeering or other empty leadership behavior.


*  J. Useem, “What Was Volkswagen Thinking?  On the origins of corporate evil—and idiocy,”  The Atlantic (Dec. 2015), pp.26-28.

Fukushima and Volkswagen: Systemic Similarities and Observations for the U.S. Nuclear Industry

Fukushima

VW Logo (Source: Wikipedia)

Recent New York Times articles* have described the activities, culture and context of Volkswagen, currently mired in scandal.  The series inspired a Yogi Berra moment: “It’s deja vu all over again.”  Let’s look at some of the circumstances that affected Fukushima and Volkswagen and see if they give us any additional insights into the risk profile of the U.S. commercial nuclear industry.

An Accommodating Regulator

The Japanese nuclear regulator did not provide effective oversight of Tokyo Electric Power Co.  One aspect of this was TEPCO’s relative power over the regulator because of TEPCO’s political influence at the national level.  This was a case of complete regulatory capture.

The German auto regulator doesn’t provide effective oversight either.  “[T]he regulatory agency for motor vehicles in Germany is deliberately starved for resources by political leaders eager to protect the country’s powerful automakers, . . .” (NYT 12-9-15)  This looks more like regulatory impotence than capture but the outcome is the same.

In the U.S., critics have accused the NRC of being captured by industry.  We disagree but have noted that the regulator and licensees working together over long periods of time, even across the table, can lead to familiarity, common language and indiscernible mutual adjustments. 

Deference to Senior Managers

Traditionally in Japan, people in senior positions are treated as if they have the right answers, no matter what the facts facing a lower-ranking employee might suggest.  Members of society go along to get along.  As we said in an Aug. 7, 2014 post, “harmony was so valued that no one complained that Fukushima site protection was clearly inadequate and essential emergency equipment was exposed to grave hazards.” 

The Volkswagen culture was a different but had the same effect.  The CEO managed through fear.  At VW, “subordinates were fearful of contradicting their superiors and were afraid to admit failure.”  A former CEO “was known for publicly dressing down subordinates . . .”  (NYT 12-13-15)

In the U.S., INPO’s singled-minded focus on the unrivaled importance of leadership can, if practiced by the wrong kind of people, lead to a suppression of dissent, facts that contradict the party line and the questioning attitude that is vital to maintain safe facilities.

Companies Not Responsible to All Legitimate Stakeholders

In the Fukushima plant design, TEPCO gave short shrift to local communities, their citizens, governments and first responders, ultimately exposing them to profound hazards.  TEPCO’s behavior also impacted the international nuclear power community, where any significant incident at one operator is a problem for them all.

Volkswagen’s isolation from public responsibilities is facilitated by its structure.  Only 12% of the company is held by independent shareholders.  Like other large German companies, the labor unions hold half the seats on VW’s board.  Two more seats are held by the regional government (a minority owner) which in practice cannot vote against labor. So the union effectively controls the board. (NYT 12-13-15)

We have long complained about the obsessive secrecy practiced by the U.S. nuclear industry, particularly in its relations with its self-regulator, INPO.  It is not a recipe for building trust and confidence with the public, an affected and legitimate stakeholder.

Our Perspective

The TEPCO safety culture (SC) was unacceptably weak.  And its management culture simply ignored inconvenient facts.

Volkswagen’s culture has valued technical competence and ambition, and apparently has lower regard for regulations (esp. foreign, i.e., U.S. ones) and other rules of the game.

We are not saying the gross problems of either company infect the U.S. nuclear industry.  But the potential is there.  The industry has experienced events that suggest the presence of human, technical and systemic shortcomings.  For a general illustration of inadequate management effectiveness, look at Entergy’s series of SC problems.  For a specific case, remember Davis-Besse, where favoring production over safety took the plant to the brink of a significant failure.  Caveat nuclear.


*  See, for example: J. Ewing and G. Bowley, “The Engineering of Volkswagen’s Aggressive Ambition,” New York Times (Dec. 13, 2015).  J. Ewing, “Volkswagen Terms One Emissions Problem Smaller Than Expected,” New York Times (Dec. 9, 2015).