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So just over 10 years ago, I was a brand-new
assistant professor at Duke and I remember
sitting at my dining room table in the morning
drinking coffee and reading The Wall Street
Journal, back when I still read The Wall Street
Journal before Rupert Murdoch took it over.
And, uh, I read this article about Lilly Pharmaceuticals
throwing failure parties to celebrate science
that was well conceived and well executed,
but that for whatever reason, just didn't
result in a pharmaceutical product that could
be brought to market.
And as somebody who studies innovation in
governance and trying to bring evidence-based
policy to governance, I thought this was fascinating.
Although I'm sure to those of you in the room
who live here in San Francisco and Silicon
Valley, you're well aware that risk is inherently
a part of innovation. and that you have to
be willing to fail in order to move forward.
But as you might imagine in Washington, D.C.,
or in Brussels, in the government circles
the failure is often about fault and it's
to be avoided at, basically, all costs.
So you could imagine the headlines if instead
of Lilly Pharmaceuticals EPA, U.S. EPA wastes
millions of taxpayer dollars on unproven [ph]
experiments.
I thought this was interesting and probably
didn't have any future and I went back to
my research, which is what all good junior
faculty members do, designing randomized control
trials and-and survey instruments and evaluations
of-of government policies.
And just as the haze of the pre-tenure life
was lifting, the real world brought me back
to these important questions about how do
we design institutions and government that
can actually learn from failure.
And what were those major events?
Of course, in 2010 we had the Deepwater Horizon
oil spill in the Gulf of Mexico.
We had the Fukushima nuclear accident after
the tsunami in Japan.
We had the 2008 financial crisis that affected
the entire global economy.
So during that time period sort of brought
about by those major events, I was fortunate
enough to start working with the research
team at Duke, consisting of two law professors,
Jonathan Wiener and Kim Krawiec, and a history
professor, Ed Balleisen, as part of this rethinking
regulation working group.
And we started a book project that was going
to look at under what circumstances are government
responses to disasters productive and result
in positive change and less likely occurrence
of those disasters in the future.
And under what circumstances are they basically
kneejerk reactions or symbolic reactions that
may actually make things worse, and what can
we learn and generalize from government responses
to disasters.
And as we were focused on this book project,
we recognized that there, in fact, was an
institution in government that was widely
regarded as enormously successful at learning
from failures, and whose reputation was positive
amongst the public, amongst Congress, amongst
the executive.
Right, an organization that could show up
at the seat of a disaster and say, "We're
from the government and we're here to help,"
and it's not a bad joke.
And that organization is the National Transportation
Safety Board, or the NTSB.
And if you've heard of it before, it's probably,
uh, because they investigate all airline crashes
in the United States or that involve U.S.-made
equipment.
And so, when a Delta Airline plane skids off
the runway at La Guardia in a snowstorm, it's
the NTSB that shows up to figure out what
went wrong and how we can prevent that from
going wrong in the future.
But what you may not know is they actually
investigate a wide range of transportation
accidents.
So when a train goes off the rails, carrying
crude oil from the Bakken region in North
Dakota and explodes, the NTSB is on the scene.
If a pipeline leaks, the NTSB is on the scene.
All of that is in their jurisdiction.
And regardless of which area of transportation
they work on, they are widely regarded as
being successful at identifying problems,
making recommendations that are recommendations
both to the government for improvements and
to industry for improvements, and seeing those
recommendations through.
So this sounds great, right?
This is our solution.
We'll just have everything be NTSB-like.
In fact, during the-the 2010/2011 period it
wasn't uncommon at academic conferences to
hear everybody say, "We just need an NTSB-like
agency for healthcare.
We need an NTSB-like agency for finance."
We need an NTSB-like agency for-you name it.
But there's a problem with that, and that
is that it turns out there's another agency
in the U.S. government that was designed in
a similar way as the NTSB, actually used a
very similar charter modeled after the NTSB,
but does not share the NTSB's, um, reputation
as being highly successful.
And that agency is the Chemical Safety Board,
or the CSB.
And the Chemical Safety Board's mission is
to go in after any accident at a chemical
manufacturing plant, but much more broadly,
in any industrial manufacturing plant, and
determine again what went wrong and what they
could-what recommendations they could make
to ensure worker and industrial safety in
the future.
Right, so when the West Texas fertilizer plant
blew up, it was the Chemical Safety Board's
job to go in and figure out what went wrong.
But unfortunately, unlike the NTSB, the-the
entire history of the CSB has been mired in
controversy that has really prevented it from
being able to be successful, and they have
been called to the Hill multiple times to
testify before Congress on issues of mismanagement,
whistleblower retaliation.
They have lost many of their senior investigators.
Their reports take four or five years from
the time of the accident to come out, so nobody
thinks they're that useful anymore.
Um, and just two weeks ago, Chairman Dr. Moure-Eraso,
who is the former chairman of the CSB, was
asked to resign by the Obama administration
three months before the end of his term.
So how can this be, right?
How can you have an organization that was
modeled after the NTSB, was designed to-exactly
replicate the successful agency that figures
out what's wrong and makes things better,
and then have it just completely not work?
So our research suggests that there are several
critical features of success for the NTSB
that we need to keep in mind as we move forward.
The first, of course, is that independence
is necessary but it's not sufficient.
Both the CSB and the NTSB are independent,
but they have vastly different, um, levels
of success that depend on some of these other
features, including the nature of the industry.
So when a Delta Airline plane skids off the
runway at La Guardia, it doesn't just make
people fearful of flying Delta.
Right.
It makes people fearful of flying.
And so that common sense of fate that the
airline industry has is something that has
been cultivated over time and that really
impacts the way in which NTSB relates with
the industry and the way in which NTSB has
an impact, both on the industry and on the
regulators of that industry.
Because now everybody sort of feels like we're
in it together.
And if we can learn something from what happened
to Delta, it can make all of us safer and
improve all of our bottom lines, right?
The same, unfortunately, is not true in chemical
and industrial manufacturing.
So when the fertilizer plant blows up in West
Texas, a sugar plant may not think that they
have anything to learn from that, even though
they actually do.
The third thing has to do with leadership.
And this is something that I found really
fascinating as someone who has spent her entire
career studying public policy and economics
and governance, is that one of the reasons
that the NTSB is so widely successful is that
it's actually led by engineers, not people
with degrees in public policy, uh, but people
with degrees in engineering.
And the ethos of engineering is really about
what went wrong and how do we fix it, right?
And so, the NTSB has gone out of its way,
they make recommendations, but they don't
make specific policy recommendations, and
they-they don't get into the business of making
policy.
They leave that to the Department of Transportation
or the, um, FAA or other places that, that
actually regulate the industry.
And the CSB, unfortunately, has not been able
to do that.
They've largely drawn their leaders from areas
of public health, um, or worker's safety,
often associated pretty heavily with unions.
And so, they haven't been able to establish,
even though they're technically independent,
they haven't been able to establish that sense
of independence from either the regulators
or from the industry, to allow them to really
be these objective third-party, uh, evaluators.
One of the things that it affects is their
ability to follow through on their recommendations.
So because the CSB has been trying to promote
specific policies as opposed to broad recommendations,
they have a very difficult time then working
with the regulators to follow through, and
that's something that the NTSB hasn't suffered
from, largely, again, because of this problem
focused ethos.
So what I think we should take away from all
of this is when we're investigating disasters
or we're thinking about learning from failure,
if the focus is on blame, then nobody wins.
The focus has to be on assessing what went
wrong and how we can make the world better,
all of us in it together.
And only then can we actually move the world
forward.
Look I, I grew up in a time, like probably
many of you, where I actually believed that
the government could make a real difference
in people's lives.
And today, the most loathed profession in
America is not tax auditor for the IRS, but
U.S. congressperson.
And I think that only through bringing these
kinds of evidence-based approaches to government
and thinking carefully about how we can learn
from failure and make government better, can
we actually return to a time where government
can make a real positive difference in people's
lives.
Thank you.
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