The Cincinnati Zoo: Part of a Dangerous Pattern

I wish that what happened recently at the Cincinnati Zoo was the rare exception. Unfortunately, in my over 30 years of experience as a crisis consultant and university researcher, it's not.
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I wish that what happened recently at the Cincinnati Zoo was the rare exception. Unfortunately, in my over 30 years of experience as a crisis consultant and university researcher, it's not.

As we know, a young child somehow slipped behind a barrier and fell into a gorilla enclosure. In order to save the child from harm, the gorilla was shot. Howls of protest over whether the animal had to be killed and calls for the parents to be charged with child endangerment were immediate.

What rankled me most of all was that in defending their actions, the spokesman for the zoo said that they've never had such an incident in over 38 years. Somehow, we were supposed to be comforted by this statistic. This completely overlooks the fact that a crisis is the worst time to spout statistics. Despite one's good intentions and preparations, nothing prevented the unthinkable from occurring.

The sad fact (statistic!) is that most organizations merely react to major safety failures and crises. Immediately after they occur, organizations become more concerned about safety and reliability. As a result, they invest more time and money in safety, reliability, and crisis prevention and response. But vigilance is temporary. When things get back to normal, and as a result of increases in allocated resources and heightened attention, the safety and reliability of operations do improve. Organizations then begin to mistake the absence of failure for the presence of safety. They become complacent. Eventually, resources drift away from safety and reliability and towards productivity, efficiency, and profitability. The drift toward failure accelerates when there are time and cost-cutting pressures, and when organizations make tradeoffs between safety and efficiency/productivity/profitability. When the next crisis hits, the cycle begins again.

The challenge is to break the cycle and question the fundamental assumption on which it is based: That there are acceptable tradeoffs between safety, efficiency, and normal operations. There aren't, period! But, this is easier said than done.

There is no doubt that after the Gulf oil spill, both BP, Transocean, and other companies in the deep-water drilling industry began to (or were forced to) review their safety procedures, test their equipment, renew their commitment to safety, etc. The corrupt branch of the government (Material Management Service) that was supposed to regulate the industry was also restructured. Unfortunately, the attention paid to safety wanes over time.

Consider the following: In February 2001, a colleague and I mailed a questionnaire on Crisis Management to the top executives of the 1000 largest companies (measured in revenues) in the United States. In one section of the questionnaire, the executives were given a generic list of various types of crises (fires, explosions, product tampering, environmental disasters, major lawsuits, etc.), and they were asked to indicate how many of each their organization had experienced in the last 3 years. They were also asked to indicate the capabilities of their organization in responding to or handling the various types of crises.

We intentionally included "terrorist attacks." We listed this particular type because we wanted to see if U.S. companies were prepared for crises that are extremely infrequent if not improbable. Not surprisingly, the majority of the companies indicated that they had experienced no terrorist attacks and that they had very little capability to handle them. Then, 9/11 happened. In response, we mailed the same questionnaire to the same executives three more times: January 2002, August 2002, and August 2003.

Analyses of the data collected over more than 2 years showed strong support for the notion of the constant drift toward failure and unacceptable tradeoffs between safety and productivity. A significant number of executives who responded to the two questionnaires mailed out in 2002 reported significantly higher levels of capabilities in handling or responding to terrorist attacks. Executives who responded to the questionnaire mailed in 2003, however, reported lower levels. In fact, the average level of capabilities reported before 9/11, and the average level reported two years after 9/11 were about the same. In other words, companies reacted to the 9/11 terrorist attack, increased their preparation level for terrorist attacks, and when it didn't occur again, their levels of preparation went down dramatically.

We also found that the best crisis prepared organizations--no more than 10-15%-were constantly expanding and testing their preparations. As a result, they were not only constantly improving their preparations for those crises that they had already considered, but they were preparing for new types of crises that they had not previously thought about. They also went about new ways of preparing for them.

For example, I've worked as a crisis consultant in a few hospitals. Based on my recommendations, realistic-looking dolls have been placed in maternity wards. The test is to see how far someone can get out of the ward holding the fake child in his or her hands. In some cases, they've gotten completely out of the hospital with no one questioning and thereby stopping them. Needless to say, the test is repeated again and again until procedures are tightened up such that one can't make it by the first nurse's station.

All zoos ought to be practicing something similar. Why weren't dolls used to test how easily young children could slip through the barriers to animal enclosures? Why weren't tests conducted frequently and such that they were increasingly more difficult to pass? Constantly thinking and testing for the unthinkable is the only protection we have against calamities.

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