Institutional Failure

 "Small-minded people blame others.  Average people blame themselves.  The wise see all blame as foolishness."

 I'm on "vacation" right now, taking a much-needed week off to catch up on spring chores, and to sort through a bunch of belongings that we ended up with after an elderly relative had to be placed in a care facility.  The tractor is coming together, too.  Finally.  I got it to kick yesterday while cranking it over.

Yesterday I experienced one of the more interesting days of my working life.  I got called in to work by a desperate night shift control room operator - to cover my own shift.  Apparently the guy who was supposed to cover my shift wasn't aware of the fact, and wasn't answering his phone.  The night shift guy needed to get home and sleep, so I covered the day shift until someone else - who wasn't on vacation - finally answered their phone and showed up.

Which brings me to the subject of "Institutional Failure" - the inability of organizations to function at an optimum level.  This is an interesting subject, and I'll be investigating root causes and trying to identify them, rather than assigning blame - like our stoic today says we should.

I'll list a few examples of what appear to be institutional failures.  The list will be somewhat US-centric because of my familiarity with the subject matter.  These institutional failures will be events of obvious poor decisions leading to bad outcomes, without attempting to assign blame.  Then we will see how these came to happen and why - without wading into the specifics of each event.

Lastly it would be beneficial to discuss what could be done better *right now* so that such things don't continue to happen in the future.  Given human nature, I don't have great hopes here :)

• Flint, Michigan:  Municipal water poisoning
• California Energy Crisis of 2000-2001
  
• Oroville Dam Spillway
• The classic case of institutional failure: The Space Shuttle Challenger Disaster
•  Legendary failure:  Sinking of the RMS Titanic
• World War 1
• Covid-19 Pandemic Response
• Exxon Valdez Oil Spill
• St. Francis Dam failure
• Banqio Dam Disaster
• Chernobyl Unit 4 Disaster
• Bhopal, India Pesticide Plant Disaster
• 737 MAX 
• Ponte Morandi Bridge Collapse
• Vioxx for Arthritis
•  Thalidomide for Morning Sickness
•  Vajont Dam Disaster
• Infant Formula Contamination, Recall, and shortages 
• Church Rock, NM Uranium Spill 
• VW Emissions Scandal
  

 I'd encourage readers to follow each link to Wikipedia and familiarize (or re-familiarize) themselves with a quick synopsis of these events.  

What do they have in common?  Well, for one thing, they were all bad - that's how they made it onto my list.  Most of these were bad enough that they had plenty of attention once they happened, although the horrific Banqio Dam Disaster is nearly unknown in the western world.  

What they also have in common is that they *didn't have to happen* - these were not natural disasters.  People within institutions - often government, but not always - made decisions that caused each of these events.  And with that thought, it's time to introduce "The Peter Principle".  I'll turn it over to Wikipedia now to explain The Peter Principle:

"The Peter principle states that a person who is competent at their job will earn a promotion to a position that requires different skills. If the promoted person lacks the skills required for the new role, they will be incompetent at the new level, and will not be promoted again.^[1] If the person is competent in the new role, they will be promoted again and will continue to be promoted until reaching a level at which they are incompetent. Being incompetent, the individual will not qualify for promotion again, and so will remain stuck at this final placement or Peter's plateau.

This outcome is inevitable, given enough time and enough positions in the hierarchy to which competent employees may be promoted. The Peter principle is therefore expressed as: "In a hierarchy, every employee tends to rise to his level of incompetence." This leads to Peter's corollary: "In time, every post tends to be occupied by an employee who is incompetent to carry out its duties.""

The Peter Principle doesn't explain each of these events though...  Some are caused by greed, some by political pressure, some by corruption, and some by "go along to get along".  There is a term for accepting degraded conditions, and that term was coined after the Space Shuttle Challenger Disaster.  The term is "Normalization of Deviance".  At its most basic, the thought process is that "OK we got away with it this time.  We can probably continue to do so."

One thing institutions excel at is blaming the individual who happens to be working when a long-standing problem finally causes a disaster, which is why Root Cause Analysis is useful - and often disliked. 

Root Cause Analysis: A means of determining the source of an event chain by determining the "how", "why", and "what", without falling into the trap of focusing on "who". 

 The reason that Root Cause Analysis is frequently disliked - by authorities and by management - is that it often points the finger right back at authorities and management.  After all, they are the ones responsible for implementing hiring, employee training, safety systems, inspections, or deferring maintenance which lead to nearly all of these events.  It's so much easier to point the finger at the guy operating the machine when it finally self-destructed than to really investigate why it self-destructed.

Which brings us back to The Peter Principle.  In a hierarchy, most of the people are incompetent at their job.  I would be remiss if I didn't take the opportunity to throw the mainstream media under the bus right now.  They refuse to conduct basic journalism.  Instead they shape public opinion and distract from real issues, by focusing on outrage.  Right now the mainstream media is distracting us with the Johnny Depp/Amber Heard civil trial, rather than spending time probing what happened at the baby formula plant that is depriving infants across the country of basic nutrition.

As members of society, an economy, organizations, we need to be better.  So what could we be doing better?  I have a thought on that, one that moves away from a core principle of Root Cause Analysis - a focus on "Who".  One thing I've noticed is that, at least in the western world, we are no longer hold the wealthy and powerful to account.  There is a point at which wealth/class/status makes a person immune from the rules that apply to the rest of us. 

If a person holds up a convenience store for $20, punishment will be harsh and inevitable.  But if a wealthy and connected individual is up to no good, the authorities seem unable to make the necessary punishment harsh and inevitable, unless victims finally force their hand.  And this too is an Institutional Failure!  It's endemic at this point, and I struggle to see how things improve from here.

One final thought:  Institutional Failure leads to an erosion of trust in institutions - those that we count on to protect us and our loved ones.  Regulatory Institutions, specifically, are there to protect the public from exploitation, from poisoning, from disasters.  They frequently defer to those whom they are legally required to regulate, allowing those other institutions to "self-regulate".  There is no such thing as corporate self-regulation, as all companies are deeply conflicted by their own profit/loss cultures.  When government institutions fail to perform their function, it destroys trust, and this appears to cause harm society well beyond the disaster.