The mugging anecdote helps illustrate the work of Tinsley and Robin DillonMerrill, also an associate professor. Combining their expertise in decision theory and risk analysis, respectively, they study exactly how and why people make decisions that involve risk. Specifically, Tinsley and Dillon-Merrill have explored and refined the idea of a “near-miss” event. Researchers have varying definitions of near-misses, but for the purposes of their studies, Tinsley defines them as follows: “A near-miss is an event that could have been a failure but for an element of luck or chance.” Near-misses are everywhere. They happen on the highway every day. They happen in the manufacturing industry. They happen in risky ventures such as space flight, and they happen in areas prone to natural disasters such as hurricanes. Tinsley and Dillon-Merrill say the goal of their research is to help managers and others respond to near-misses not by saying, “That was a close call, but we made it,” but instead, “That was a close call. What did we learn?”
The 2003 space shuttle Columbia tragedy spurred Dillon-Merrill and Tinsley to assess why people do not learn from near-misses.
Dillon-Merrill started down the road toward this research when she heard a presentation by Elisabeth Paté-Cornell, a Stanford University researcher who later became her mentor. In the late 1980s and early 1990s, Paté-Cornell performed an extensive risk analysis for NASA about the heat-resistant tiles that protect space shuttles during reentry into Earth’s atmosphere. The report identified the risk that those crucial tiles could be damaged by debris that sheds from the shuttles’ insulating foam. When the space shuttle Columbia disintegrated on Feb. 1, 2003, that foam was the culprit. In the wake of this tragedy and the death of all seven astronauts on board, NASA managers, investigators, and the public were left asking why nothing had been done to deal with a known risk. “When we lost the space shuttle Columbia for a reason that was clearly identified in the risk analysis, it showed me something,” Dillon-Merrill says. “There’s nothing wrong with the risk analysis tools. The issue was everything that had happened from when [Paté-Cornell] turned in her report to when we lost the Columbia — the many different launches when the foam fell off and didn’t cause any problems.” 30
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Tragic Origins
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