Hey Reader,
After tragedy strikes, we are left with difficult and uncomfortable questions.
Families standing in the rubble of their once loved homes wondering what is left for them. How do they rebuild?
So many of us bewildered as how a mid-air collision with a military helicopter could occur over a major American city.
Was there something we could have done differently? How much agency do we really have ?
The recent LA Wildfires and the DC plane collision raise the failure of complex interdependent systems to protect us. The subsequent investigations and discussion highlight the similarities and differences in approaches to performance, safety and resilience.
Error proofing our future depends on learning the exacting and painful lessons of these recent tragedies to design systems in environments that are rapidly evolving , stochastic and hard to control.
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ERROR
It is well known in operations and safety engineering not to have a single point of failure.
But these tragedies emphasize cascading failures across multiple points of weakness that exploited interrelated but distinct systems.
There are two models of error and risk management: precision and resilience.
Fires in Southern California are unavoidable but prior methods to prevent conflagrations – total suppression – backfired. The current focus towards disaster management is on resilience and adaptability. Failure, in other words, is inevitable but we need to institute methods to minimize damage. Fires cannot be prevented, but they can be managed. This prompted the paradigm shift to controlled burns, fireproof materials, redirecting active fires to other less concerning area.
But as we recently saw in Los Angeles, all resilient systems have their breaking point, no matter how strong they are. This is why redundancy in safety measures matters as much as escape options through mandatory evacuations.
In aviation, nearly all problems are never events. Errors are systemic in nature. Here, precision is needed because failure is catastrophic. Merely mitigating damages associated with a crash is not viable way to sustain commercial flying. Therefore, aviation prompted the use of checklists (which medicine belatedly adopted decades later), autopilot software, and more.
Any crash is over seen the NSTB, which has complete jurisdiction over the investigation. They conduct a complete root cause analysis that can take months from assessing pilots, to engineering assessments of planes, and flight path reconstruction in simulations.
If errors are systemic in nature, then investigations and reforms must be systemic as well. It is why aviation has had the highest safety record of any major industry, especially in comparison to other forms of transportation.
However, in medicine, quality is still seen as a function of individual performance. The thinking goes, providers have trained for so long, they should be fully prepared and need no additional support once they are in their attending era. This despite the fact that medicine has the most complex supply chain of any industry in the planet and requires extensive administrative and logistical support.
Medicine is also characterized by trade-offs. We have incomplete knowledge with incomplete resources and yet are asked as doctors and nurses to treat often critically ill people.
Triaging and competing resources means we have a higher error tolerance. This is a model that cannot be used in aviation and wildfires because (theoretically) all lives and houses are equally worthwhile.
In that regard, medicine exists in the breach between precise and resilient systems and why providers are uniquely susceptible to not only burn out but moral injury. We operate in a grey zone where we often lack the science, tools and resources to achieve our goals. In that manner, we are always coming up short for our patients.
We also make distinctions between errors and adverse events. Many adverse events are unavoidable or the price of doing business. Treating cardiovascular patients with blood thinners is critically important but risks GI bleeding. It is why nearly every medical encounter involves a some discussion of risks and benefits.
The error of the COVID pandemic response was to adopt a precision based (aviation) model of disaster response when a resilience (wildfire) was more appropriate. The public ended up expecting a cure (safe landing) as opposed to a management plan (monitoring fire related climate conditions).So when the first lockdown of the summer of 2020 ended and we still were in the early innings of a global pandemic, anger ensued.
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HUMAN AGENCY
We like to believe we have more control than we do, but human factors are critical to assess in any crisis management response.In fact, we could create a 2x 2 Matrix of Knowledge v Action.
- Safety – We know what to do and we follow through on this. These are high performing systems at their best.
- Catastrophe – This is the nightmare scenario we fear. Unknown unknowns. Not knowing what is happening nor how to respond. This is a failure of ignorance. Classic medical scenario is doctors seeing patients in the 1970’s with systemic failures of their immune system, not recognizing it was the emergence of HIV/AIDs.
- Disaster – This is failure of incompetence – of having to act without sufficient knowledge. Any time you push the boundaries of any area of endeavor, especially when people’s health is at stake, we court disaster.
- Tragedy – Knowing what to do but still not acting appropriately. This is a failure of implementation. Medicine is rife with these problems.
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PROPHESY
Prophesy presumes prevention – to head off problems before they begin. We all want a strategy based on anticipation.
The fires and the collision were not Black Swan events – unexpected and unpredictable events with profound impact. At least not entirely.
The anger over the wildfires is precisely because they were so predictable. Granted the “Big One” that residents have feared has historically always been an earthquake.
Having said that, fires have been endemic to the terrain here for decades, as has been our state’s tenuous supply of water and penchant for building more and more houses in unhospitable areas.
Still, what was unexpected is with unprecedented wind speeds, surges in power lines and possible arson, LA would be surrounded in a ring of fire. Airline crashes have always been feared, but not by our military craft a few miles from the White House.
As much as human knowledge has increased, we are still fooled by randomness.
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STORIES OF LOSS & HOPE
Part of the reason the Ancient Greeks developed Stoicism was because catastrophe was inevitable and to be expected. Whether by Fate, human error (the famed Greek Tragedy) or caprice of the Gods, mankind’s position was always precarious.
America, with its adolescent invulnerability shell, has always been characterized by bravado and visceral denial of abrupt calamity. It is why we can take bold risks but are often caught blind by our own unique form of hubris.
We have discussed two models of safety in complex systems. The future of disaster preparedness is knowing when to be precise and when to be resilient.
Our lives are more disconnected and atomized than ever. But the forces that provide the infrastructure for our lives – how we eat (bird flu); how we travel (failure of Boeing); how we marry (declining marriage and birth rates); how we obtain healthcare (CEO assassination), housing (homelessness), and employment (work from home debate) – are now global, fractured and political in nature.
And it has left us both angered, broken and overwhelmed. What is novel in the current climate is the immediacy of the in-fighting, even as the crisis is unfolding. We get caught in Gordian knots of blame, fault, and shame.
It’s as if we skip the grieving and go straight to attack mode because at least outrage is empowering and mourning hurts too much.
We must avoid the most dangerous lessons of disasters – learned helplessness.
All relationships involve rupture and repair. It seems we have lost the second half of that message.
But if we are to be prepared for the disasters to come, we must broker a peace with ourselves and then get to the work of improving systems that can care for us all – of becoming both precise and resilient.
Black and blue, now, we wake up tomorrow bruised but wiser and looking to a new morning.
Tomorrow can’t wait,
