Case study methodology and applications

Centralia

Based on your reading of the case, what do you see as the central causes of the tragedy in "The Blast in Centralia No. 5"? Why did these problems develop?

The central cause of the tragedy -- if not the immediate cause -- was probably a form of bureaucratic inertia, combined with a sort of systemic corruption among interacting systems of the state and federal governments, its relevant regulatory agency, and both management and labor hierarchies. The immediate cause was the failure of the chain of command to observe proper precautions after having received warnings from multiple sources. It is worth noting that the safety inspector for the mine, Scanlan, was extremely conscientious. He had also identified the Centralia No. 5 mine as "the worst in his district." And as Martin notes, Scanlan had identified the various malpractices as prevalent in the mine "more than five years before the mine blew up as a result (at least in part) of those very malpractices." (Martin 32). Even though workers had complained repeatedly to both state and management, they found themselves "rebuffed" by the state and to their own union -- but in the matter of the clean-up that would have prevented an explosion, Martin notes that "one cannot discern any labor-management cleavage at all but only what would be called in party politics bi-partisan deals" (Martin 35). However, due to the unusual circumstances relating to a labor strike and government nationalization of the industry, the safety of the mine had suddenly been brought under direct federal jurisdiction: but the new regulatory enforcement agency failed to take any action, and the unusual circumstances prevented any possibility of a labor strike to refuse to work under the persistently unsafe conditions. But in some sense, it is the larger bureaucratic system that Martin indicts -- he notes that "the miners at Centralia, seeking somebody who would heed their conviction that their lives were in danger, found themselves confronted with officialdom, a huge organism" (Martin 43). The shifting bureaucratic systems which handled regulation and enforcement of regulations basically "forever passed from hand to hand a stream of memoranda and letters, decisions and laws and rulings, and they lost their own identities." (Martin 43). Blame cannot be placed on any single aspect of the bureaucracy, but on the interaction of all the separate bureaucratic systems, which permitted it to be possible to put off indefinitely a closure of the mine for safety violations which had been reported repeatedly for years.

What reforms would you recommend to prevent the tragedy from reoccurring elsewhere? How could such reforms be implemented?

The principal reform that would have saved lives in the case of the Centralia disaster would be some kind of rule necessitating automatic closure of a facility in the wake of such repeated violation of safety rules. Martin notes that the initial safety inspector, Scanlan, had the power to close the mine but did not do so -- in the wake of the disaster, he writes, "Scanlan felt that had he closed the Centralia mine" that his supervisors "simply would have fired him and appointed a more tractable inspector" (Martin 43). In a system where regulatory oversight is largely provided by large overlapping bureaucratic systems, which are themselves supported by existing vested interests that have an investment in keeping the mine open, it is clear that one single inspector -- even if empowered to make an executive decision -- cannot go against the large-scale bureaucratic machinery for the sake of law that "expressly provided that an inspector could close a mine which persisted in violating the law" (Martin 43). In giving this kind of executive authority to a mere regulatory inspector, the inspector can be assumed not to wish to exercise the authority unless the circumstances are truly extraordinary. The issue at Centralia is that no individual violation was extraordinary, it was the build-up of effects over time which caused the situation to become so dire -- this is perhaps why the Mining Board, despite Scanlan's reports, claimed that they "didn't think the mine was dangerous enough to close" (Martin 43).