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Thursday, August 28, 2003


Check out this post from Confined Space which deconstructs the NASA report and the NY Times analysis:
The footnote accompanying this paragraph states:

Changing personnel is a typical response after an organization has some kind of harmful outcome. It has great symbolic value. A change in personnel points to individuals as the cause and removing them gives the false impression that the problems have been solved, leaving unresolved organizational system problems.

Which makes the following headline from the New York Times "interesting":

Human Error Likely Cause of Blackout, Timeline Says

So, let me get this straight. Does this mean that a simple human booboo resulted in the gigantic blackout that swept parts of eight states and eastern Canada, cost billions of dollars and darkened the homes of millions of people? And does this imply that a slap on the hand (or maybe even jail time) will fix the electrical grid problem?

The only "substance" behind that headline is a quote from an unnamed investigator:
"Had all of the existing policies been followed, this would not have developed into a cascading event," the investigator said. "What we see are institutional breakdowns, not a breakdown of the system itself."
Those who do incident investigations realize, however, that the fact that procedures were not followed are rarely due to human failure. It is far more likely that the procedures were confusing or didn't anticipate the situation that the operators found themselves in.
Don't you worry your pretty little heads about it. After all, the compassionate conservatives are in charge.

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