Recipe for Miscue and Disasters

By Susan Conniry December 6, 1999

In response to last week's article I received the following email:

Les writes:

"I just read your article on the post office SNAFU. I would also like to note that most of the Y2K remediation going on in large businesses and government addresses only MISSION CRITICAL systems and not the rest of the systems that keep the operations going smoothly in all other areas. Combine this with not addressing interrelatedness issues and your recipe for miscues/disasters increases."

Joe added his own thoughts:

"As a practicing system engineer, I have not previously heard of Dorner's book (The Logic of Failure) but will look for it. However, what you picked as illustration from the book matches experiences I have had. At one level, systems are composed of a set of interdependent components, which taken together perform some useful function. Note that these are interdependent -- hence the correlation with Dorner's observation because in a technical sense these are not necessarily linearly dependent relationships. Linear systems means that I can treat each function independently and when I integrate or add these functions together I achieve the functionality of the whole."

And the beat goes on.

While we tear our hair out worrying about whether or not the computers will work next year, we may have forgotten that we deal with human system failures too. Case in point:

The Pelican Bay State Prison thought they were way ahead of the curve. According to Tom Hopper, Public Information Officer for the prison, their emergency systems and procedures have been tried and tested multiple times throughout the ten years of operation during power outages caused by natural disasters. Back-up generators throughout the facility have never failed until they ran the Y2K test. No, it wasn't a computer glitch that brought things screeching to a halt rather it was human error.

Realizing that Y2K might bring about similar circumstances as a natural disaster, officials determined that a special Y2K drill should be conducted -- a complete test of the emergency facilities in case the disruptions are widespread. For 2 days, the prison functioned without a problem using their back-up system. They announced that they were ready for whatever Y2K might bring. The test completed, the back-up systems were shut down and the facility went back to using traditional electrical power and communications systems.

Then a couple of weeks ago a storm passed through the area. A redwood tree crashed down on power lines and the electricity to the town and the prison went out. The prison immediately rolled over to its back up systems and the generators kicked in and functioned accordingly. For a while. Half way through the night, the generators coughed, spluttered and died. The generators checked out OK. But, there was no fuel. The fuel tanks had not been refilled after the Y2K test.

Human error. It happens. Remember the Peter Principle. Dr. Laurence Peter wrote about reaching our level of incompetence in his world renowned, 1969. His phenomenal bestseller explained why things always go wrong. Regardless of whether it is an educational facility, a government bureaucracy, a military agency or a corporate office, there is a strong tendency to promote people to more responsible tasks until they reach their level of incompetence. Unable to function at this new level of promotion, mistakes are made and things go wrong. Whereas an individual was highly competent making "widgets" he is out of his realm when he is promoted to overseer of "widget" makers.

The fact that in a hierarchy, every employee tends to rise to his level of incompetence certainly explains why human errors [Image]may happen but Dr. Peter also has some sobering words for us in regards to the computer, and bear in mind that his text was first published in 1969. In our desire to improve, speed up and perhaps eliminate human error or mismanagement we substituted the computer. However, as he points out "a computer balks at any unclear instruction, simply blinks its lights and waits for clarification." Further, a computer has no tact. "It will not flatter and it will not use judgment. It will not say 'Yes sir, at once sir!' to wrong instructions, then go away and do the job right. It will simply follow the wrong orders, so long as they are clearly given."

Unfortunately, says Dr. Peter, the "computer may be incompetent in itself" or more frighteningly "even when competent itself, the computer vastly magnifies the results of incompetence in its owners or operators."

A far more somber aspect of the Peter Principle is our continued race towards "total life incompetence." Dr. Peter reflects:

"Conceivably we are all doomed by our own cleverness and devotion to escalation. Our land a few decades ago was dotted with crystal clear lakes and laced with streams of cool clear water. The soil produced wholesome food. Now lakes and streams are cesspools. Air is noxious with smoke, soot and smog. Land and water are poisoned with pesticides, so that the birds, bees, fish and cattle are dying. We have blighted the promise of this century and converted the miracles of science into a chamber of horrors where a nuclear holocaust could become a death trap for the entire human race. If we continue feverishly planning and inventing and building and rebuilding for more of this progress, we will achieve the level of total life incompetence."

Tip of the Week

For emergency systems that rely on back-up generators for power, please make sure that the fuel tanks have been refilled since the last time the system was in use. It is only one part of the entire system but, as the Pelican Bay State Prison found out, it was the most critical.

If we have learned anything at all in these past two years when most Y2K remediation has been active, it is that we are fallible. We have all made errors. We are all responsible in some way for the way the world is today. We are all ingredients in this recipe of miscues and disasters. We sold our souls to the computer in search of progress, fulfilling a desire for more, better and faster. If Y2K teaches us anything it will be that we must slow down, be humble. We can benefit greatly by the failures of the computer in the coming months, if we realize that all we need are shelter, water, fire and food. When we cut back on the wants, the comforts, when we shift from a complacent stupor to one of caring for our fellow man and more importantly, realize that the Earth is indeed a sacred place, perhaps next time we'll get it right. With the computer systems about to turn our world upside down, I would like to believe it is happening so that we use this as a chance not to find our level of "total life incompetence."

Shelter, water, fire and food are your needs. All the rest are wants.

Please review the survival series.

Shelter, water, fire and food are your needs. All the rest are wants.

Read Susan Conniry's Bio

) Westergaard.com, Inc., 1999 www.y2ktimebomb.com

-- Sheri (wncy2k@nccn.net), December 06, 1999

Answers

Good Post Sheri!

Thanks much, I learned something new here...and will adapt my thinking accordingly.

-- (Kurt.Borzel@gems8.gov.bc.ca), December 06, 1999.

In the rare, stratified air of high technology lurks this danger...Our very best and smartest people push their intelligence to the limit. Complex designs become interwined in such complex ways that after the original designers/engineers/programers/installers go their separate ways, we are left with systems that are simply too complicated for the next guys who come along. We build a layered civilization supported by millions of bits and pieces of vastly complicated technology. All held together by very bright technicians inputing their own ideas and workarounds that adds another complex layer to the whole. y2k or no y2k, we have backed ourselves into a byzantine maze with no road map out and no backup when the system fails.

-- citizen (lost@sea.com), December 06, 1999.

The Peter Principle, for those of you who may not have heard of it before, is that within any organization, people who are competent at their jobs will be promoted to a higher position. The process will repeat, until they reach their "level of incompetence". They will then *stay* in that position for the rest of the term of their employment.

So the next time you encounter someone who is clearly incompetent to do the his job, remember that he got promoted over and over until he landed in a position he couldn't handle.

Then contemplate the millions of others just like him in positions of power and authority.

Sorry, no happy moral to that tale. [g]

-- Ron Schwarz (rs@clubvb.com.delete.this), December 06, 1999.

Isn't America great? While back in the days when the Peter Principle was written primarily white males were promoted to their level of incompetence while today you can find incompetent managers of every race, creed, sex, sexual orientation.....

It is called progress! ;-)

-- cgbg jr (cgbgjr@webtv.net), December 06, 1999.

Isn't America great? While back in the days when the Peter Principle was written primarily white males were promoted to their level of incompetence today you can find incompetent managers of every race, creed, sex, sexual orientation.....

It is called progress! ;-)

-- cgbg jr (cgbgjr@webtv.net), December 06, 1999.

And ALL who have tested their generators periodicly, perhaps you might learn from a REd Cross Blood Instalation which shall remain un- located. MAKE SURE that the pump that moves diesel from the underground storage tanks to the operating tank on the Genny is on the RED plug (Generator supplied) circuit.

They test-ran genny for 30 minutes every week. Worked like a champ. Power went out. fired up perfectly. Ran for 2 hours and died. NO blood was damaged but the NEXT DAY the electricians were in, and found and fixed the problem. The pump was re-wired to get it's juice from the generator supplied circuit.

C

-- Chuck, a night driver (rienzoo@en.com), December 06, 1999.

Ron,are you an aikidoka?Onagaeshi-masu!!

-- zoobie (zoobiezoob@yahoo.com), December 06, 1999.