Catastrophic system failure

Cameron Blow Out Preventer
A Cameron Blow Out Preventer (BOP) is installed at the base of the BP leased, Transocean owned Deepwater Horizon rig. An unmanageable surge of oil led to the fire that sunk the rig and ended 11 lives.

The BOP is not preventing up to 200,000 gallons/day of oil from gushing into Gulf of Mexico. At this point, no one appears to understand why.

The Blow Out Preventer is only a very visible part of an intricate human and technological system under enormous economic pressure to deliver crude oil.

If interactive complexity and tight coupling — system characteristics — inevitably will produce an accident, I believe we are justified in calling it a normal accident, or a system accident. The odd term normal accident is meant to signal that, given the system characteristics, multiple and unexpected interactions of failures are inevitable. This is an expression of an integral characteristic of the system. System accidents are uncommon, even rare; yet this is not all that reassuring if they produce catastrophes. — Normal Accidents: Living with High-Risk Technologies

Laminated ethics

From the Washington Post, Days Before Scandal, Interior Got Ethics Award:

The inspector general said Wednesday that federal officials in the Mineral Management Service’s royalty-in-kind program allegedly were plied with alcohol and expensive gifts from industry representatives, and in some cases had sex and did drugs with them. The Denver-area office takes in roughly $4 billion each year in oil and natural gas reserves from companies drilling on federal and Indian land and offshore.

But, on Monday, the Interior Department was praised for “developing a dynamic laminated Ethics Guide for employees” that was a “polished, professional guide” with “colorful pictures and prints which demand employees’ attention.” The guide, the award noted, was small enough for employees to carry. Interior also was lauded for having held a four-day seminar for its ethics advisors nationwide.

Written policy, mandatory training and a whistle blowing mechanism simply insulate organizations from legal liability. They are the surface show of reform not reform itself.

What did the management of the Interior Department think it was accomplishing with a formal ethics guide and why did it matter to them that it was laminated and “small enough for employees to carry.”

I keep the best part of myself on small pages sheathed in plastic in my back pocket, like a condom, in the event I have cause to use it.