Tuesday, April 13, 2010

Death by Bureaucratic Rules

Here is a bit from the Pulitzer Prize winning article by Gene Weingarten in the Washington Post about a peculiarly modern way of death: fatal distraction. I've put in bold what I consider to be key:
An otherwise loving and attentive parent one day gets busy, or distracted, or upset, or confused by a change in his or her daily routine, and just... forgets a child is in the car. It happens that way somewhere in the United States 15 to 25 times a year, parceled out through the spring, summer and early fall. The season is almost upon us.

Two decades ago, this was relatively rare. But in the early 1990s, car-safety experts declared that passenger-side front airbags could kill children, and they recommended that child seats be moved to the back of the car; then, for even more safety for the very young, that the baby seats be pivoted to face the rear. If few foresaw the tragic consequence of the lessened visibility of the child . . . well, who can blame them? What kind of person forgets a baby?

The wealthy do, it turns out. And the poor, and the middle class. Parents of all ages and ethnicities do it. Mothers are just as likely to do it as fathers. It happens to the chronically absent-minded and to the fanatically organized, to the college-educated and to the marginally literate. In the last 10 years, it has happened to a dentist. A postal clerk. A social worker. A police officer. An accountant. A soldier. A paralegal. An electrician. A Protestant clergyman. A rabbinical student. A nurse. A construction worker. An assistant principal. It happened to a mental health counselor, a college professor and a pizza chef. It happened to a pediatrician. It happened to a rocket scientist.
The article focuses on the issue of manslaughter or excusable mistake and the vagaries of the justice system. These are worthy of analysis by an article like this. But I find something different to focus my attention on.

To me this is a classic problem of a "technological fix" that ignore the complexity of situations and personalities and distractions. The fix puts a kid in a back seat where somebody who is distracted can forget them and thereby cause their death. The joke is that this move was done bureaucratically to "save lives" but instead directly leads to a predictable number of deaths.

When you do a proper safety analysis you look at all failure modes to understand how your design might fail. These "safety experts" who mandated car seats in the back obviously never investigated failure modes. They saw a quick fix for a safety problem and mandated the "obvious" answer. But that is exactly how you get "unintended consequences" from your technology, from your designs, from your regulations. Sad.

Go to the end of the article, read the last section where the author interviews Janette Fennell who runs a nonprofit organization called Kids and Cars. You get a taste of the bad safety design and "unintentional consequences" of our technology.
The answer to the problem, Fennell believes, lies in improved car safety features and in increased public awareness that this can happen, that the results of a momentary lapse of memory can be horrifying.
What I don't understand is how the legal system can hold parents liable for deaths when manufacturers are not held liable for their design decisions or lack of action:
The 2008 Cameron Gulbransen Kids' Transportation Safety Act -- which requires safety improvements in power windows and in rear visibility, and protections against a child accidentally setting a car in motion -- originally had a rear seat-sensor requirement, too. It never made the final bill; sponsors withdrew it, fearing they couldn't get it past a powerful auto manufacturers' lobby.

There are a few aftermarket products that alert a parent if a child remains in a car that has been turned off. These products are not huge sellers. They have likely run up against the same marketing problem that confronted three NASA engineers a few years ago.

In 2000, Chris Edwards, Terry Mack and Edward Modlin began to work on just such a product after one of their colleagues, Kevin Shelton, accidentally left his 9-month-old son to die in the parking lot of NASA Langley Research Center in Hampton, Va. The inventors patented a device with weight sensors and a keychain alarm. Based on aerospace technology, it was easy to use; it was relatively cheap, and it worked.

Janette Fennell had high hopes for this product: The dramatic narrative behind it, she felt, and the fact that it came from NASA, created a likelihood of widespread publicity and public acceptance.

That was five years ago. The device still isn't on the shelves. The inventors could not find a commercial partner willing to manufacture it. One big problem was liability. If you made it, you could face enormous lawsuits if it malfunctioned and a child died. But another big problem was psychological: Marketing studies suggested it wouldn't sell well.
What I don't understand is a legal system that can hold a parent responsible for a failure to act, but doesn't fix a failing in the legal system that creates deaths because manufacturers are terrified of selling a product that might fail and leaves them open to liability lawsuits. It is not OK for a parent to fail to act, but it is OK for the legal system (or a manufacturer) to fail to act. This is a strange notion of "justice" that makes no sense to me.


Unknown said...

When I was a young child my mom and dad only had a pickup and all three of us rode standing up in the seat. My mom would put her arm out to hold us when she braked. I know this sounds crazy by todays standards. We often rode in the back of the pickup in summer because there would be no room up front and we liked riding there. The world has become become a lot less safe and the more people try to make it safer the less safe it is. I am not saying that we should not try to make things safer, but there should be adjustments so that we can be safe in our circumstances.

I have never come close to leaving a child in a car, but one night our old dog went for a ride in the van we had and upon returning to the house my wife forgot he was there and we looked for many hours for him and even went back out and drove the van around looking and calling. Then I happened to remember that he had gone with her earlier and sure enough he was still in the van... We laughed a lot, but if it had been day time in the summer...

I feel for the people who lose children this way and other unfortunate and awful ways. It has to be almost unbearable for them. I don't see how one safety devise is used without worry and another that would save children and families is not because it could fail. If so, then for the sake of all parents of small children do something to fix the problem that has been created by trying to make it so safe for everyone. I would not own a vehicle with airbags when my boys were little and I did my best to keep them out of cars that had them.

RYviewpoint said...

Thomas: Your experiences remind me of mine and stories of my father. My father rode the running board and fender of cars back in the late 1920 and early 1930s. That was crazy and dangerous. I was a kid in the era of bank seats with no seat belts so kids roamed the car at will. Today that is considered crazy and dangerous. The line constantly changes.

There is a paradox of "safety". As you make cars safer, people push them to extremes to make them less safe. You add seat belts, people feel safer so they drive faster. You put in anti-skid brakes and nobody bothers to learn braking skills or properly attends to road dangers as much as before.

People forget that there is no such thing as absolute safety. It is always a trade-off. You can put in more design features to provide safety but then you increase the cost of driving.

People say "any safety feature is worth it if it will save only one life". But they don't mean it. If we did, we would all drive 5 mph while continually tooting the horn. (Actually when the car was first introduced some towns required somebody to run alongside the car shouting to warn people of this dangerous contraption!)

If we really valued safely so highly, then antibiotics would be under lock-and-key and only used in an emergency after a committee decided they were called for. The current system of compliant doctors giving prescriptions for viral infections for which they do nothing and feeding antibiotics to domestic livestock principally to get them to grow faster means that we are creating superbugs that will come back and bite us. We know this danger, but we do nothing about it. That shows that we may claim a high regard for safety, but we refuse to do simple, low-cost actions to achieve it.

Government regulations and laws are our attempt to protect people from themselves. Most laws are meant to hem in the foolish and young to keep them safe. That's a trade-off a society must call and it should be reviewed periodically.

We shouldn't get caught up in the illusion that we can buy or build absolute safety. We can't.

As for the article... I have great sympathy for those who make the tragic mistake and their child dies in a car. This shouldn't be prosecuted. But as the article points out, there is a fine line. And here's where the state and regulations and laws get involved. Some people are criminally negligent. We need to hold them accountable when they callously or cruelly kill their own kids. But drawing the line between innocent and criminal will always be difficult because we can never know the whole story. The legal system is put on a pedestal and we tell ourselves stories about dedication to "truth and justice" but in real life, the justice system is a bureaucracy filled with overpaid lawyers and judges who are concerned more with money and social position than with justice and truth.

Unknown said...

Another aspect to the safety issue is it became a political issue often supported by insurance companies at the expense of the taxpayers while insurance gets the benefits at no cost to them. When safety becomes a political tool to gain votes the losers are the consumers. As you say nothing is 100% safe. If the speed limit were reduced it would make the highways safer, but no one will go for that, so there is no real goal to make things safer.

Education and practice make driving safer than seat belts or airbags because a driver learns, more than driving skills, his own limitations and what he is capable of. If a driver knows that he or she can not physically drive 75 MPH than they are safer for everyone around them than if they think they are safe since they have airbags and seat belts and antilock brakes.

RYviewpoint said...

You are right Thomas. Education, practice, experience are ultimately the best safety devices. Laws & rules generally don't take that into account because it is hard to measure. Instead you get a "one size fits all" approach.

I find that I'm having to slow down while driving. My reactions are slower. My night vision is degrading. Worse, I notice that my ability to size up a situation has slowed. I'm compensating through my knowledge, using defensive driving skills, and not getting out on the road when the crazies are out there.

The first line of defense in safety is taking personal responsibility. The next line is to rely on informal social restraints (this is where you would hope that manufacturers would spend the right dollars to design in safety). The last line of defense is to pass regulations and laws. You get your worst bang for the buck at this last line of defense. You get manufacturers who formally comply with regulations but don't really put in the design effort to get solid safety.