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Meltdown

Meltdown

Why Our Systems Fail and What We Can Do About It
edition:Paperback
also available: Hardcover
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I.

    It was a warm Monday in late June, just before rush hour. Ann and David Wherley boarded the first car of Metro Train 112, bound for Washington, DC, on their way home from an orientation for hospital volunteers. A young woman gave up her seat near the front of the car, and the Wherleys sat together, inseparable as they had been since high school. David, sixty-two, had retired recently, and the couple was looking forward to their fortieth wedding anniversary and a trip to Europe.
    David had been a decorated fighter pilot and Air Force officer. In fact, during the 9/ 11 attacks, he was the general who scrambled fighter jets over Washington and ordered pilots to use their discretion to shoot down any passenger plane that threatened the city. But even as a commanding general, he refused to be chauffeured around. He loved taking the Metro.
    At 4:58 p.m., a screech interrupted the rhythmic click-clack of the wheels as the driver slammed on the emergency brake. Then came a cacophony of broken glass, bending metal, and screams as Train 112 slammed into something: a train inexplicably stopped on the tracks. The impact drove a thirteen-foot-thick wall of debris—a mass of crushed seats, ceiling panels, and metal posts—into Train 112 and killed David, Ann, and seven others.
    Such a collision should have been impossible. The entire Washington Metro system, made up of over one hundred miles of track, was wired to detect and control trains. When trains got too close to each other, they would automatically slow down. But that day, as Train 112 rounded a curve, another train sat stopped on the tracks ahead—present in the real world, but somehow invisible to the track sensors. Train 112 automatically accelerated; after all, the sensors showed that the track was clear. By the time the driver saw the stopped train and hit the emergency brake, the collision was inevitable.
     As rescue workers pulled injured riders from the wreckage, Metro engineers got to work. They needed to make sure that other passengers weren’t at risk. And to do that, they had to solve a mystery: How does a train twice the length of a football field just disappear?
 
II.

Alarming failures like the crash of Train 112 happen all the time.
Take a look at this list of headlines, all from a single week:
 
CATASTROPHIC MINING DISASTER IN BRAZIL
 
ANOTHER DAY, ANOTHER HACK: CREDIT CARD
STEALING MALWARE HITS HOTEL CHAIN
 
HYUNDAI CARS ARE RECALLED OVER
FAULTY BRAKE SWITCH
 
STORY OF FLINT WATER CRISIS, “FAILURE OF
GOVERNMENT,” UNFOLDS IN WASHINGTON
 
“MASSIVE INTELLIGENCE FAILURE” LED
TO THE PARIS TERROR ATTACKS
 
VANCOUVER SETTLES LAWSUIT WITH
MAN WRONGFULLY IMPRISONED
FOR NEARLY THREE DECADES
 
EBOLA RESPONSE: SCIENTISTS BLAST
“DANGEROUSLY FRAGILE GLOBAL SYSTEM”
 
INQUEST INTO MURDER OF SEVEN-
YEAR-OLD HAS BECOME SAGA OF THE SYSTEM’S FAILURE
TO PROTECT HER
 
FIRES TO CLEAR LAND SPARK VAST WILDFIRES AND
CAUSE ECOLOGICAL DISASTER IN INDONESIA
 
FDA INVESTIGATES E. COLI OUTBREAK AT
CHIPOTLE RESTAURANTS IN WASHINGTON
AND OREGON
 
It might sound like an exceptionally bad week, but there was nothing special about it. Hardly a week goes by without a handful of meltdowns. One week it’s an industrial accident, another it’s a bankruptcy, and another it’s an awful medical error. Even small issues can wreak great havoc. In recent years, for example, several airlines have grounded their entire fleets of planes because of glitches in their technology systems, stranding passengers for days. These problems may make us angry, but they don’t surprise us anymore. To be alive in the twenty-first century is to rely on countless complex systems that profoundly affect our lives—from the electrical grid and water treatment plants to transportation systems and communication networks to healthcare and the law. But sometimes our systems fail us.
    These failures—and even large-scale meltdowns like BP’s oil spill in the Gulf of Mexico, the Fukushima nuclear disaster, and the global financial crisis—seem to stem from very different problems. But their underlying causes turn out to be surprisingly similar. These events have a shared DNA, one that researchers are just beginning to understand. That shared DNA means that failures in one industry can provide lessons for people in other fields: dentists can learn from pilots, and marketing teams from SWAT teams. Understanding the deep causes of failure in high-stakes, exotic domains like deepwater drilling and high-altitude mountaineering can teach us lessons about failure in our more ordinary systems, too. It turns out that everyday meltdowns—failed projects, bad hiring decisions, and even disastrous dinner parties—have a lot in common with oil spills and mountaineering accidents. Fortunately, over the past few decades, researchers around the world have found solutions that can transform how we make decisions, build our teams, design our systems, and prevent the kinds of meltdowns that have become all too common.
    This book has two parts. The first explores why our systems fail. It reveals that the same reasons lie behind what appear to be very different events: a social media disaster at Starbucks, the Three Mile Island nuclear accident, a meltdown on Wall Street, and a strange scandal in small-town post offices in the United Kingdom. Part One also explores the paradox of progress: as our systems have become more capable, they have also become more complex and less forgiving, creating an environment where small mistakes can turn into massive failures. Systems that were once innocuous can now accidentally kill people, bankrupt companies, and jail the innocent. And Part One shows that the changes that made our systems vulnerable to accidental failures also provide fertile ground for intentional wrongdoing, like hacking and fraud.
    The second part—the bulk of the book—looks at solutions that we can all use. It shows how people can learn from small errors to find out where bigger threats are brewing, how a receptionist saved a life by speaking up to her boss, and how a training program that pilots initially dismissed as “charm school” became one of the reasons flying is safer than ever. It examines why diversity helps us avoid big mistakes and what Everest climbers and Boeing engineers can teach us about the power of simplicity. We’ll learn how film crews and ER teams manage surprises—and how their approach could have saved the mismanaged Facebook IPO and Target’s failed Canadian expansion. And we’ll revisit the puzzle of the disappearing Metro train and see how close engineers were to averting that tragedy.

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Dysfunction

Dysfunction

Canada after Keystone XL
edition:eBook
also available: Paperback
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Excerpt

I
The story of Keystone XL began back in the early part of 2007. At that time, my colleagues at TransCanada and I believed that the company would be able to simply apply to the appropriate regulatory entities for necessary permits, and then, within a reasonable time frame, proceed with constructing KXL. Operations would likely begin, we believed, as soon as late 2012.
In our estimation, KXL had no fundamentally special elements differentiating it from comparable pipelines that traversed most of North America. It was merely a logical extension of the base Keystone system, for which the company would soon receive the necessary permits from the same regulatory entities that would next adjudicate KXL. Construction of base Keystone would commence while we prepared and submitted the regulatory applications for KXL. Base Keystone was to connect the Alberta oil sands to the United States mid-continent, and KXL would extend that reach to the U.S. Gulf Coast. That market access and the overall scale of the project were enormously significant for the Alberta oil sands industry’s long-term economic prospects. At TransCanada, we were genuinely excited about the project, as a private economic opportunity and also as essential infrastructure for Canada.7
TransCanada applied for permission to build KXL in September 2008,8 and even in mid-2009, no one seriously imagined that this pipeline project might be rejected. Yet when I retired in mid-2014, the approval still remained unresolved, despite over five years of review. The project needed a presidential permit from Barack Obama to cross the Canadian border into the United States — a permit that was supposed to be predicated on an environmental impact assessment and a National Interest Determination (NID) process led by the U.S. Department of State (DoS). The U.S. government’s vesting of the final decision with the president himself was meant to expedite the approval process, but in this case leaving the decision with the president had had the opposite effect. When I retired in late 2014, I had come to the view that the Obama administration would likely reject the project, despite the DoS’s two separate, extensive environmental assessments, in 2011 and 2014, that consistently found the project environmentally acceptable, albeit with certain special operating conditions, to which TransCanada had agreed.9 Environmentalist resistance to the project and the president’s response to that resistance had, incredibly, proved decisive. It was a triumph of symbolism over substance and reasonable expectation of due process.
So, when the project I had so enthusiastically contributed to conceiving and planning, the project that had once seemed so valuable for the continent, and especially to Canada, my company, and, yes, me personally, was formally rejected, I asked myself the questions I had pondered so many times: How and why did this happen? Why did TransCanada persist so intensely? Why did we meet ultimate failure and unprecedented notoriety? These questions deserve substantial analysis and rationalization. The first part of this book sets out to provide that, directly and fairly.

II
A specific confluence of events precipitated KXL’s demise — Nebraska’s resistance to the company’s route through the state, the breakdown of the Kyoto Treaty and subsequent failure of the 2009 Copenhagen conference to find a viable alternative, U.S. Congress’s 2010 failure to enact an economy-wide cap-and-trade bill to deal with carbon emissions, a few highly publicized oil spills, the basic reality of the higher carbon intensity of oil sands–derived crude oil, a regulatory process vesting ultimately with President Obama, and failure in both countries to find an accommodation to rationalize its approval. Was this pipeline’s rejection an anomalous experience or a harbinger of things to come? Has social acceptance of the oil sands resource been lost?
The Alberta oil sands resource offers Canada a great economic opportunity; more than $200 billion of investment in production and related facilities over the last twenty years is a testament to that.10 In 2016, notwithstanding current low commodity prices, production has continued at over two million bbl/d.11 Without KXL, is Canada prepared to go forward with alternatives such as the Northern Gateway, Energy East, and TransMountain pipeline projects? Although those projects may not represent the same value to Canada as KXL could have, the economic potential of the oil sands resource cannot be realized without them.
Of course, if Canada fully exploits this potential, Canadian carbon emissions will grow; that is an inescapable reality in the short and medium term.12 We need to rationalize that growth to a world committed to dealing with the risk of climate change. Producing and consuming hydrocarbons cause increasing risk of climate change. Yet, those hydrocarbons still provide great economic value. Whether the world can significantly decrease its demand for hydrocarbons, especially crude oil and natural gas, over the remainder of this century is an open question.
As well, it must be conceded that the oils sands resource emits more carbon on a unit basis than most other crudes in its production processes. This carbon intensity is perhaps the fundamental reason for the unique hostility directed at this Canadian resource, culminating, even within Canada, in an implacable resistance to its exploitation.
However, Canadians should be able to support hydrocarbon development, provided the country adopts a credible and proportionate carbon policy. Unfortunately, this is not the case at present. The hydrocarbon industry and several successive governments have failed to show Canadians adequately that resource development not only serves their economic self-interest but can be managed within an acceptable climate-policy framework, comparable and proportionate to those embraced by other relevant countries, especially the United States. Canadians remain largely misinformed about oil sands carbon emissions and the economic consequences of extreme carbon policy. Sadly, much of the animosity over the oil sands is now aimed at obstructing the regulatory processes related to hydrocarbon infrastructure, with opposition to KXL serving as the template for that larger struggle. National, non-partisan regulators adjudicate the costs and benefits of hydrocarbon infrastructure projects, but their authority is increasingly diminished if not entirely undermined by legal obstruction, outright civil disobedience, and a lack of political will. Dysfunction has become the default. How much economic opportunity is Canada prepared to lose?
The demise of KXL should force Canada to come to terms with the difficult issues created by the loss of that project. The second part of this book is dedicated to confronting those issues. What has the pipeline’s demise cost Canada? What can, and must, Canada learn from the experience? Do Canadians agree with the reasons President Obama gave when he rejected KXL? Where do we stand on our other pipeline projects, such as the Northern Gateway pipeline through British Columbia and Energy East to New Brunswick, in the wake KXL’s demise? Even more fundamentally, where does Canada stand on hydrocarbon development at all?

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