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. 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. 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. 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.