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Millions of Americans report being the victim of workplace violence each year in the United States. According to the Occupational Safety and Health Administration (OSHA), incidents of workplace violence have reached epic proportions, reaching nearly two million reported incidents annually (U.S. Department of Labor Occupational Safety and Health Administration [OSHA], 2002). Although the total number of workplace violence incidents that are reported annually is staggering, only a very small percentage of those incidents end up in serious injury or death. The Federal Bureau of Investigation (Rugala & Isaacs, 2002) reports that shocking workplace homicides or multiple homicides actually represent a very small number of reported workplace violence incidents. In fact, the majority of workplace violence incidents that most organizations and employees have to deal with on a daily basis are lesser cases of assaults, domestic violence, stalking, threats, harassment, sexual harassment and physical and/or emotional abuse that never make the headlines (Rugala & Isaacs, 2002).
Workplace violence is one of many crisis situations that police officers respond to that not only have risks inherent for the responding officers and individuals caught in the dynamics of the crisis itself but for the innocent bystanders that are drawn into the scenario through the pure misfortune of being at the wrong place at the wrong time. No matter how diligently police personnel train in coordinating their response and controlling their actions to minimize the risk of harm to innocent individuals, quickly evolving and dynamic situations always seem to attract collateral damage and subsequent media scrutiny. Regardless of the extent of training, planning, and care that a police organization can employ to keep innocent bystanders safe, there are certain unforeseen system accidents, or failures, that make catastrophic events either worse or harder to diagnose (Perrow, 1999).
In his book, Charles Perrow (1999), posits that in any tightly coupled system with high interactive complexity will inevitably have Normal Accidents. Normal accidents are defined as accidents that are extremely rare, but that is, in fact, normal, that are created by certain system failures or failures resulting from specific interactions or transformation processes. These interactions can either be tightly coupled, meaning there is a direct and immediate connection and interaction between components or they can be loosely coupled, meaning there is some sort of slack or buffering between components (Perrow, 1999). Additionally, the interactions and transformation process can be linear or complex. Linear having orderly, easily isolated components and step by step processes that only interact with adjacent steps or complex interactions that have many connections and interrelationships (Perrow, 1999).
Although in Perrow’s theory of Normal Accidents (1999), he focuses largely on technological systems in high-risk industries that are tightly coupled with the complexities of the human-machine, his theory can be applied to societal system and how accidents can be a result of the multiple failures design, equipment, procedures, operators, supplies, and the environment. One such accident is when nine bystanders were wounded after being hit by gunfire from members of the New York City police department on August 24, 2012 (Oh, 2012). An accidental police shooting of bystanders on a crowded city street is an example of how the tightly coupled complexities of the human-machine and multiple failures of procedures, operators and the environment can result in a system failure or Normal Accident.
On August 24, 2012, Steven Ercolino, the vice-president of a New York-based import company was gunned down outside of his business. The suspect, a disgruntled former co-worker named Jeffrey Johnson, was previously a designer of women’s accessories for Ercolino’s company and had been laid off a year earlier as a result of downsizing (FOX News.com, 2012). Immediately after Johnson shot and killed Ercolino on a busy New York sidewalk, he fled the area on foot. The shooting was witnessed by a construction worker, who then followed Johnson until he was able to alert two police officers of what Johnson had done (Prokupecz, Dienst, & Cheng, 2012). As Johnson walked near the entrance to the Empire State Building he was confronted by two New York City police officers. Johnson immediately drew a .45 caliber handgun, and while pointing it at the officers, was shot and killed by officers in response to the threat (Deprez, Goldman, & Varghese, 2012). As a result of the shooting, nine bystanders were inadvertently wounded, six from gunshot wounds and three from fragments caused by ricocheting bullets (Ariosto, 2012).
Police officers routinely train for these types of incidents where an otherwise innocuous-looking individual suddenly presents himself/herself as an immediate threat to either the officers themselves or the general public. However, it is impossible to train for every possible scenario due to the inherent complexities of people and their ability to think, reason and make decisions that are not always predictable. As Perrow (1999) stated, normal accidents arise from an incident or series of incidents or localized failures that then expand to disrupt or damage the larger system. An incident such as an active shooter is interactively complex and tightly coupled with environmental dynamics that in many instances leaves insufficient time and understanding to effectively control the incident and avoid accidents.
In a public setting, random bystanders create interactive complexity through their mere presence and through the fact that their decision-making during a time of crisis may be erratic, unfamiliar or unplanned and can result in an unexpected sequence of events in a system that are either not visible or not immediately comprehensible (Marais, Dulac, & Levenson, 2004). Bystanders may decide to assist in the apprehension of the actor, do nothing but stand there, or flee from their perceived danger, only to run directly into the path of the drama that is unfolding. Public active shooter events are tightly coupled events that are highly interdependent, yet tightly linked to many other parts operating within the environment and therefore a change in one part can rapidly affect the status of other parts. These tightly coupled events respond quickly to perturbations, but not unlike this event, the results may be disastrous (Marais et al., 2004).
The actor himself is another essential part of the equation. Police officers train constantly using ever-changing scenarios to confront a deadly threat and hone their crisis decision-making skills. There rarely are two real-life scenarios that are ever alike. Some may be strikingly similar, but ultimately the differences in human decision-making can cause a cascading effect that can cause what started out as a routine event, to spiral horribly out of control very quickly, before officers are able to assess the situation and take the appropriate corrective action (Marais et al., 2004). The decision of an actor to draw a weapon and take his own life or to turn that weapon on innocent bystanders or responding officers can occur within fractions of a second. In such systems, what begins as an apparently trivial incident can cascade in unpredictable ways and with possibly severe consequences (Marais et al., 2004).
The police officer’s shooting skill is also a contributing factor to system failure. Most law enforcement agencies qualify with their weapons on an annual basis. However, budgetary constraints tend to limit the amount of ammunition allotted to each officer and the training time dedicated to effective firearms training. That leaves officers on their own to hone their skills in one of the highest liability areas in the realm of public safety, the use of deadly force. Perrow (1999) posits that one of the most effective ways to eliminate hazards and reduce failures is to implement redundancy in the system. In this scenario, the most effective redundancy would not be having multiple officers firing at one offender, but to have a well trained and proficient firearms expert placing accurate and effective shots on target. The problem for police administrators boils down to tradeoffs and determining how much risk is acceptable in order to achieve safety and reduce the risk of failure (Marais et al., 2004). However, to the extent that training for these types of incidents can be made safer by the elimination of human error, it will never eliminate the chance for the occurrence of a normal accident simply because of the interactive complexity of this type of tightly coupled scenario.
Workplace violence, active shooter incidents and other rapidly evolving and dynamic events will continue to present themselves within our society. The analogy that safety defenses are like slices of Swiss cheese is exactly how Normal Accident Theory would describe the chances of a system failure occurring in an interactively complex and tightly coupled scenario. No matter how high you stack the slices it is inevitable that organizational movement will cause a set of holes to line up eventually and safety defenses will be compromised (Reason, 1997; Cooke & Rohleder, 2006).
Ariosto, D. (2012). 2 dead, 9 wounded in Empire State Building shootings, police say. Retrieved from http://www.cnn.com/2012/08/24/justice/new-york-empire-state/
Cooke, D. L., & Rohleder, T. R. (2006, Fall). Learning from incidents: from normal accidents to high reliability. System Dynamics Review, 22(3), 213-239.
Deprez, E. E., Goldman, H., & Varghese, R. (2012). Man slain after shooting ex-colleague near Empire State. Retrieved from http://www.bloomberg.com/news/print/2012-08-24/several-people-shot-near-empire-state-building-n-y-police-say.html
Marais, K., Dulac, N., & Levenson, N. (2004). Beyond normal accidents and high reliability organizations: The need for an alternative approach to safety in complex systems [White paper]. MIT: Author.
Oh, I. (2012, August 24,). Mayor Bloomberg addresses Empire State Building shooting, Ray Kelly IDs shooter as Jeffrey Johnson. Huffington Post. Retrieved from http://www.huffingtonpost.com/2012/08/24/mayor-bloomberg-empire-state-building-shooting_n_1827825.html?view=print&comm_ref=false
Oh, I. (2012, August 25,). NYPD gunfire in Empire State Building shooting wounded all nine bystanders, says Ray Kelly. Huffington Post. Retrieved from http://www.huffingtonpost.com/2012/08/25/empire-state-building-shooting-nypd-bullets-shot-all-nine_n_1830007.html#slide=more246660
Perrow, C. (1999). Normal Accidents: Living with high-risk technologies. Princeton, NJ: Princeton University Press.
Prokupecz, S., Dienst, J., & Cheng, P. (2012). Empire State shooting: Bystanders hit by police rounds. Retrieved from http://usnews.nbcnews.com/_news/2012/08/24/13455394-empire-state-shooting-bystanders-hit-by-police-rounds?lite
Reason, J. (1997). Managing the risks of organizational accidents. Aldershot, UK: Ashgate Publishing.
Rugala, E. A., & Isaacs, A. R. (Eds.). (2002). Workplace violence: Issues in response. Federal Bureau of Investigation Critical Incident Response Group. Quantico, VA: National Center for the Analysis of Violent Crime.
The National Center for Victims of Crime. (n.d.). http://www.victimsofcrime.org/library/crime-information-and-statistics/workplace-violence
U.S. Department of Labor Occupational Safety and Health Administration. (2002). OSHA fact sheet. Retrieved from http://www.osha.gov/OshDoc/data_General_Facts/factsheet-workplace-violence.pdf
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