Systems Analysis

Top-Down Failure, and the Alternative

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Wretchard discusses recent notorious Type II system failures. The Colorado theater killer’s shrink warned the authorities to no avail. The underwear bomber’s father warned the authorities to no avail. The Texas army-base jihadist was under surveillance by the authorities, who failed to stop him. Administrators of the Atlanta public schools rigged the academic testing system for their personal gain at the expense of students and got away with it for years. Wretchard is right to conclude that these failures were caused by hubris, poor institutional design and the natural limitations of bureaucracies. The question is what to do about it.

The general answer is to encourage the decentralization of important services. If government institutions won’t reform themselves individuals should develop alternatives outside of those institutions. The underwear bomber’s fellow passengers survived because they didn’t depend on the system, they took the initiative. That’s the right approach in areas as diverse as personal security and education. It’s also the approach most consistent with American cultural and political values. It is not the approach of our political class, whose interests are not aligned with those of most members of the public.

The Internet is said to route itself around censorship. In the coming years we are going to find out if American culture can route itself around the top-down power grabs of our political class and return to its individualistic roots. Here’s hoping.

Quote of the Day

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The low rate of overt accidents in reliable systems may encourage changes, especially the use of new technology, to decrease the number of low consequence but high frequency failures. These changes maybe actually create opportunities for new, low frequency but high consequence failures. When new technologies are used to eliminate well understood system failures or to gain high precision performance they often introduce new pathways to large scale, catastrophic failures. Not uncommonly, these new, rare catastrophes have even greater impact than those eliminated by the new technology. These new forms of failure are difficult to see before the fact; attention is paid mostly to the putative beneficial characteristics of the changes. Because these new, high consequence accidents occur at a low rate, multiple system changes may occur before an accident, making it hard to see the contribution of technology to the failure.

From:

How Complex Systems Fail (pdf)
(Being a Short Treatise on the Nature of Failure; How Failure is Evaluated; How Failure is Attributed to Proximate Cause; and the Resulting New Understanding of Patient Safety)
Richard I. Cook, MD
Cognitive technologies Laboratory University of Chicago

“Gawande’s Kitchen”

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An insightful critique:

But there is a much more important question being ignored by Gawande — How well does The Cheesecake Factory analogy really apply to health care? We can see how similar the kitchen is to an operating room — lots of busy people rushing about in a sterile environment, each concentrated on a task. But what about the rest of the “system?”
 
At The Cheesecake Factory, the customer is the diner. That’s who orders the service, pays the bill, and comes back again if he is happy. That is who all of the efficient, standardized food preparation is designed to please.
 
In Gawande’s ideal health care model, however, the customer isn’t the patient, but the third-party payer, be it an insurer or government. Let’s call that entity the TPP. The TPP never enters the kitchen. The TTP has no idea what happens in there, and doesn’t really care as long as the steak is cooked to his satisfaction and the tab is affordable.
 
In this model, the patient is actually the steak. It is the steak who is processed in the kitchen. It is the steak that is cut and cooked and placed on a platter. The steak doesn’t get a vote. Nobody cares if the steak is happy. The steak doesn’t pay the bill. The steak isn’t coming back again.
 
So here we are in Dr. Gawande’s kitchen, where you and I are slabs of meat and Chef Gawande will cook us to the specifications of his TPP customers — satisfaction guaranteed.

Worth reading in full.

(Via The Right Coast.)

TSA fail: the end of the road is now visible

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There was an attack in Saudi Arabia using internally placed explosives up the lower GI tract. These explosives cannot be detected by pat downs, metal detectors, or millimeter wave machines. Much more powerful scanning machines would be required or a cavity search. But no follow up bombs have happened using this method. I’d always wondered why. Now things are becoming clear. Apparently there’s been something of a theological problem. It appears that butt bombs are not permitted due to Islam’s prohibition of sodomy. But that prohibition seems to be loosening.

It will take years for the theologians to digest this new complication but once it has been let loose, it is clearly foreseeable that some portion of islamic scholars will hold this position. The consequences for our travel security regime are rather scary. We’re going to have reached the end of the line because routine x-rays at each flight segment are just not going to happen. The accumulated radiation would cause too many cancers. And cavity searches are simply unreasonable. So where does that leave TSA’s current security strategy?

Like most of their terror innovations, I expect that this will take some time for them to organize. It looks like they’ve already put 4 years into it. It may take them another 4 before they’ve worked the theological problems out sufficient to recruit bombers. But then what?

(A) Quote of the Day

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Wretchard:

But though they may hate the Pax Americana, the Greens probably can’t live without it. Can’t live without the Ipods, the connectivity, the store-bought food, the cafe-bought lattes — all the ugly things made by private industry. And by paring down the redundancies in the system as wasteful and unsightly; by reducing the energy reserves of the system in favor of such fairy schemes as windmills and carbon trading the Greens have made the system far less robust than it could have been. Because they are never going to need the Design Margin. Ever. Until they do.