Beyond Blame

Chapter 9. Reliable Errors (or Reliably Error-Prone)

“You ought to get it framed,” said Ollie, examining the jaywalking ticket that Bill put on his desk. “It’s like a two-dollar bill—lucky and rare.”

“Coffee?” Bill asked, smiling. “Downstairs?”

“And talk about trade-offs again?” Ollie replied, getting up from his seat. “I thought you’d never ask! After you, Sir!”

As they walked toward the elevators, Ollie said, “E.T.T.O. is efficiency-thoroughness trade-off. You know, Professor Erik Hollnagel’s idea.”

“Right. I was just thinking about that,” Bill said. “Hollnagel noticed that you can’t have both efficiency and thoroughness, and that we have to continually balance between the two. For instance, you can say that in some sense before 9/11, the transportation safety folks favored efficiency. You could whisk through baggage check in 5 minutes, without having to take your shoes off!”

Ollie cut in. “But after 9/11, we swing deeply into thoroughness territory, maybe too much. So now we might be moving in the direction of efficiency again.”

“I was thinking about Mike,” Bill said. “And how he was making these trade-offs during the outage.”

“Definitely,” Ollie said. “We’ve all been there: there’s a fire—literal or figurative—and we have to make a split-second decision about whether to put it out the fast way, or”—Ollie made air quotes—“‘the right way.’ The dirty little secret here is that we make decisions in real time, but evaluate them with the benefit of hindsight. Whether a decision ...