Institutional Knowledge

Harold Wilensky coined the term "organizational intelligence" to describe the institutional ability to process and utilize information.^[5] The concept seems particularly relevant to standards-setting, since the activity is so information-intensive. Three kinds of information contribute to "organizational intelligence" in setting safety standards: technical know-how, information on real-world experience, and applied research and development. The comparative strengths and weaknesses of the two standards-setting systems are striking. Private institutions are most intelligent in the first respect, public institutions in the second and third.

Technical Know-How

The most basic information utilized in standards-setting is know-how; that is, elementary knowledge about how a product or process works. The private sector is not only, as attorney David Swankin points out, "where the bodies are" (tens of thousands of people participate in private standards-setting); it is also where practical and technical knowledge often originates. Private standards-setters have a marked advantage in this regard over their public counterparts. They usually have a working knowledge of technical terms and basic engineering considerations, and they understand the practical implications of commercial use. One of the most active participants in revising NFPA 408 supervised Factory Mutual's study of hand-held fire extinguishers (conducted under contract for the FAA). Similarly, engineers for producers of space heaters and component parts participated on the Z21.11.2 subcommittee.

The personnel of public agencies, on the other hand, seldom have technical backgrounds or previous experience with the products or processes they regulate. Few are engineers. Many are lawyers or former compliance officers. In 1985, three of the CPSC commissioners were lawyers; none were engineers. A similar imbalance exists on the staff.

Neither regulators nor rulemaking staff members accumulate much technical experience over time, because public agencies do not specialize to the same extent as private standards-setters. Even at the FAA, which has a narrow mandate compared to most regulatory agencies, a rulemaking staff member might work on fire extinguishers one day, fire-blocking seat cushions the next, and tactile aisle markers thereafter. A staff member at the CPSC might work on woodstoves, gas furnaces, or a host of other "fire and thermal burn" hazards.

The result in all four public cases was ignorance and confusion over basic facts. Limited know-how led to longer and often more adversarial public proceedings. Woodstoves, described by a former CPSC commissioner as a "simple" issue, and airplane smoke detectors, described by Congressman Mineta as "straightforward," both involved issues that exceeded the technical capabilities of the respective regulatory agencies. The CPSC spent two years trying to decide whether to grant the Banner petition.

In the process of acquiring knowledge, government agencies often lose credibility and are put on the defensive. It took the CPSC years to differentiate in its injury statistics between the various types of space heaters; some say that many CPSC investigators still don't understand the difference between vented and unvented equipment.^[6] The CPSC staff also did not understand the special problems posed by fireplace inserts until very late in the proceedings on wood and coal-burning stoves. The commissioners had an even worse understanding of the technical issues. Analysts at the FAA lacked a basic understanding of the different types of Halon extinguishers and the special training needed for their use. OSHA's proposal for smaller grates on grain-loading pits was apparently born of ignorance about the operating effect of grate size on grain throughput and about the availability of other options for removing hazardous debris. Lacking basic knowledge, public standards-setters also tend to gloss over difficult technical questions, concentrating instead on more accessible, but less important, issues. The FAA plowed ahead in ignorance on smoke detectors. "They may be a good idea," noted an engineer at Factory Mutual, "but the feds are jumping in without the technical background to do the right thing. They were too slow to recognize the issue, and now they are moving too fast." They knew there were serious technical questions about smoke detectors and fire extinguishers, but they chose to ignore them. In the woodstove and gas space heater proceedings, the CPSC left the significant decisions to industry, concentrating instead on issues that

could not be resolved through technical knowledge—such as the wording of warning labels and the effective date of regulations—even though technical questions, particularly about creosote, seemed to have greater safety implications.

In short, how standards-setters approach the task appears to be partly a function of their technical knowledge and capabilities. Lacking specific expertise, government agencies try to avoid technical issues, concentrating on issues where the agency is at less of a disadvantage. When technical issues are unavoidable, however, limited technical knowledge tends to reduce the agency's credibility and to result in longer, more contentious proceedings.

Information about Real-World Experience

Obtaining feedback on real-world incidents is the second form of institutional knowledge essential to setting safety standards. Without information about the type and frequency of accidents, it is almost impossible to spot trends or even identify some hazard scenarios. As a UL vice president puts it, "The proof of the pudding is in the field evidence." The case studies suggest, however, that such evidence is rarely generated by the private sector. Government agencies, although far from ideal, have much better information systems than their private counterparts.

Private information sources are largely anecdotal and play only a negligible role in shaping safety standards. UL, for example, has institutionalized contacts with building inspectors in order to learn about problems "in the field." But a UL engineer acknowledges that the information is of limited use. UL also has a clipping service that collects newspaper stories on product-related injuries. The information is always sketchy and often inaccurate. How the injury actually came about is unlikely to be described in any detail; brand names are rarely mentioned, let alone model numbers; and a vented heater with clogged vents might be described as unvented. The AGA also has a national reporting system—dubbed the Gas Appliance Information Network (GAIN)—which relies on voluntary reporting from gas utilities. The system is much less impressive than its name. An earlier version was nicknamed N-FLOP by staff members at AGA.^[7] GAIN is also a flop. Reporting is scattered and, according to an AGA staff member, only one report was forwarded to a standards-writing committee in 1985.

NFPA makes a greater effort to collect injury information, but with only slightly more success. It, too, has a clipping service as a supplement

to reports received from local fire departments. This was the only available data base on grain elevator fires when the NAS began its study. Unfortunately, the information was of questionable reliability. NFPA also sponsors comprehensive investigations of major fire incidents, such as the MGM Grand Hotel fire and the Air Canada incident. These investigations can improve standards-setting by providing better information on specific hazard scenarios, particularly if they are not duplicative of government efforts (as they were with the Air Canada fire). Unfortunately, the investigative function of NFPA is generally limited and plays little role in standards-setting. The 408 committee drafted its requirements before the Air Canada fire, and the NFPA investigation did not result in any changes. Committee minutes do not indicate whether the 61B committee ever evaluated NFPA's survey of grain elevator explosions. Only anecdotal information was discussed during committee deliberations at the July 1985 meetings.

There are two reasons why the private sector collects so little useful injury information: information has the quality of a public good, and it often carries worrisome liability implications. Public goods have value to those beyond the immediate purchaser. National defense is the classic example of a good that benefits all, whether or not they pay for it. A similar phenomenon affects the collection of injury information. Many private organizations would benefit from reliable national information on consumer product injuries, but the cost of any given organization collecting such information is prohibitively high. Since private standards-setting organizations are decentralized, there is also no easy mechanism for spreading the cost to all those who would benefit from a national information system.

Injury information also carries threatening legal implications. Lawsuits are rarely discussed openly in standards-setting committees, although Eads and Reuter report that such discussion might occur off the record.^[8] Most firms keep records of consumer complaints involving allegations of injury, but it is unlikely they would share such information, given the adverse effect it could have in court. Even trade associations—according to staff members at the CPSC, the Outdoor Power Equipment Institute, and the Gas Appliance Manufacturers Association—generally do not receive this kind of information from their own members. NFPA's fire investigators are also inhibited by liability concerns, sometimes stopping short of certain conclusions or recommendations because the organization does not want to become embroiled in the litigation that inevitably follows the kinds of disasters they investigate.

Public information systems, though obviously flawed, are vastly better than private ones. The public sector does much more than clip newspapers. The CPSC has several information systems to provide feedback on consumer product safety. The agency collects injury data daily from hospital emergency rooms around the country and, through its field offices, conducts hundreds of in-depth investigations each year on selected hazards.^[9] The hospital data provide the basis for national injury estimates; the accident investigation reports provide details of specific hazard scenarios. Similarly, the FAA maintains an extensive computerized file of Service Difficulty Reports, and the NTSB investigates all serious airplane accidents. In both the grain elevator and aviation fire safety cases, the government paid particular attention to accident investigations. OSHA deferred drafting its grain elevator standard so that the NAS could collect explosion data and conduct in-depth studies. Many of the recommendations from the NAS study were incorporated into the OSHA proposal.

Applied Research and Development

Applied research is the third type of knowledge essential to a standards-setting system. It is the only method short of actual experience for determining whether new technologies are actually feasible and reasonably effective. Such questions were prominent in all four case studies. The oxygen depletion sensor had a track record in Europe, and the question was whether the device would be as reliable with American fuels.^[10] Similarly, questions were raised about the effectiveness of using household smoke detectors in airplanes. In the grain elevator case, there was significant controversy over whether pneumatic dust control could achieve airbone dust levels below the lower explosive limit. And with woodstoves there were a surprising number of technical questions, including the extent to which catalytic combustors could minimize creosote production.

Some standards-setters in both sectors have the in-house capability to conduct such research. The FAA Technical Center is well respected by industry. So is the National Bureau of Standards, which conducts applied research under statutory agreements with several agencies, including the CPSC. On the private side, UL and AGA conduct applied research both for in-house purposes and under contract. NFPA also supports a limited fire safety research effort.

The case studies suggest, however, that government does a better job of generating the kind of applied research that can inform standards-setting. The NBS conducted numerous helpful studies on wood-burning appliances. Its study on wall pass-through systems, a major source of fires related to woodstoves, filled a gaping hole in the private standard. Experiments conducted at the NBS also convinced the CPSC of the reliability of the oxygen depletion sensor—something that AGA Labs was reluctant to admit. The FAA funds extensive research into aviation safety, including the investigation of hand-held fire extinguishers, prompting the president of a major airline to declare at a recent Flight Safety Foundation conference that "airlines and manufacturers rely on the government to do development and testing."^[11] There were only scattered instances of private research efforts connected with the case studies. Two airlines and a major airframe manufacturer conducted tests on Halon fire extinguishers. The other major research effort, considered a public relations ploy by some, was undertaken by the National Grain and Feed Association. In the woodstove case, however, the lack of private research was notable. Catalytic combustors, a possible method of reducing creosote formation, were not (and have not) been considered by UL because, as a UL engineer said, "Nobody [in the industry] wanted to spend the money."

Research is expensive and private organizations generally do not do it unless someone else pays. Some private groups simply have no resources. "ASTM is just a building with rooms and secretaries," quips a former CPSC commissioner. It relies on its members to bring to the standards-setting process any information about relevant research. NFPA does much the same. Committees do not have budgets; nor does NFPA at large conduct applied research to support its standards-setting activities.

Product certifiers are also reluctant to undertake research aimed at improving standards. This research can have the quality of a public good. If UL improves a standard through applied research, other testing labs might be able to capitalize on the expenditure. Since UL must ultimately pay for such research efforts through its certification fees, the organization is not likely to conduct research in those areas, like woodstoves, where it shares the certification market with other labs. According to a UL spokesman, however, woodstoves are unusual in this respect. "We are often a monopoly for all practical purposes."

The funding of public research depends on the politics of the budgetary process, but there is certainly the potential (realized in several of

the cases) to fund projects not likely to be done privately. Many research budgets have been cut on the public side, particularly at the CPSC, but there are also indications that funding might actually increase for the FAA. The need for more public research and information collection is discussed in the final chapter.