Of Course An Individual Got Blamed

Update (1/7/10): Turns out the TSA agent walked away from his post. I’d certainly hold someone accountable for that, since it was a conscious choice, unless there were VERY extenuating circumstancs.

After seeing the news on CNN last night (video and photos here) about the security breach at Newark International Airport, my first thought was a cynical one: “Who are they going to blame for this one?”

Apparently, a lone male managed to walk into the “secured” zone through what’s supposed to be the exit for arriving passengers. As a frequent flyer, I’ve exited many airports and have seen what’s often an open door “guarded” by a TSA agent who looks ready to fall asleep from the boredom of that assigned task.Sometimes, the airport has a revolving door with alarms that would sound if somebody is going through the wrong way (a better way of detecting the breach, I guess — not perfect mistake proofing of the system, but it might help avoid having to evacuate the entire terminal). Often, it’s just a regular door that might be watched from the inside or the outside. It’s hardly a consistent or error proof system that prevents people from entering via the exit.

The TSA and the airports must know (right?) that this is a systemic problem, but, sure enough, the TSA agent was punished and reassigned to other duty (“TSA: Officer reassigned after Newark security breach“). Maybe that’s not a punishment if guarding that door is such a boring task. Having to watch (or inspect) that door for any period of time must create a situation where one’s mind can wander.   If this is a system that requires superhuman attention spans and not making errors, is that the fault of the individual or the fault of the system designers? I’d say the system designers.

One reader of the CNN article commented, basically, “how hard is it to guard a door?” I think that misses the point. It’s an easy job, sure, but try doing it for any length of time effectively. It seems like a mistake that almost anyone could make, which seems to point to a systemic cause, I’d say.

How about a better system? How would you error proof the exits? The exits from a Boston “T” station are more sophisticated than the exit from many airports. Whose fault is this? Is it a lack of funding, a lack of caring, or an attitude that our TSA agents will “be careful” (a phrase that falls in the “famous last word” category).

A security consultant, in this article, makes this same point:

And besides, should it be so easy that all it takes is for someone to walk past a sign to get into the airport?

It’s a flaw in the system. They should implement a barrier system, kind of like the subways where people coming through, you come through, you have to go through the gate,” said Boehm.

I hope we get beyond just blaming that one TSA agent. With the media’s short attention span, who will follow up on the system so this mistake doesn’t occur again? Put new agents in that same system and I’d guarantee the same thing happens again, it’s a matter of time.

If you’re a regular reader, you know I’m fascinated by the tendency of people to want to blame an individual. We, as people, tend to accept blame, the “bad apple,” as answer. This is often true in other important fields, like aviation and medicine. Dr. Deming always criticized Western management for using blame too often as a default (as this nice article by the Poppendiecks summarizes well). Blame seems to be in our DNA, as it was also exhibited famously by Koko, the gorilla who could speak sign language (famously blaming a pet cat for tearing out a sink from the wall when zookeepers were away, as written about here).

When will we evolve (pun intended) away from using blame as a default “management” strategy? Will more hospitals adopt “no blame” cultures like ThedaCare did, moving away from “blaming and shaming” as the norm? Note: “no blame” doesn’t mean “no accountability” (as Dr. Bob Wachter wrote about).

For more stories, often sad ones, involving the lure of blame, click the “Blame” tag at the bottom of the post.

Update: Paul Levy also blogged about this topic on Monday.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

15 Comments on "Of Course An Individual Got Blamed"

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  1. Mike Sporer says:

    I call it “blameology” and many Americans have a degree in it! People seem to want to ignore systemic problems and go right to blameology.

  2. Bruce Baker says:

    It is easy to blame, especially when everybody else jumps on board with you. It was weird for me coming out of the military – all of a sudden everything had to be somebody’s fault. In the military we would do after action reports whether things when well or bad. If things didn’t go as planned there wasn’t necessarily blame assigned. It might just be agreed that relatively unforeseeable things happened. That isn’t great – unforeseeable abnormalities should be escalated to a problem and countermeasures implemented, etc, but not blaming is better than blaming. When they made me a labor trainer in my department they taught me a philosophy from a guy named Mager (Robert I think). His philosophy said that there were two ways that errors happened: 1) lack of knowledge, 2) unwillingness to perform task. So, the model that I was taught was that if you ‘put a gun to the head’ of the learner and they could do it right once then you didn’t have a training issue, therefore it must be a performance issue and discipline is in order.

    I suggest that there is a third component – diligence. how much diligence can reasonably be expected from a cognitive creative sentient being while performing a mindnumbingly boring task like watching a door (or a machine run)? I think not much. In addition to the boring task aspect – think about the difference between doing something once and doing it 284 times in an 8 hour shift while perfoming other tasks because of muri in loud, noisy, or otherwise poor environment.

    I have read very little of Mager’s work and I am recounting what my train the trainer instructor taught me about his philosoply so I may be unduly casting aspersions on his philosophy (disclaimer). Whatever Mager’s model was – the knowledge / willingness model is what we used and it is a bad model. I think this model, wherever it came from is part of why we blame so much.
    I think that ‘respect for humanity’ includes respecting the natural limitations on human performance. Which leads me to an academic point – poka yoke, although viewed as a “hard” and mechanistic part of the TPS is actually a way of implementing the ‘softest’ part of the toyota way – respect for people, and their inherent limitations.

  3. Mark Welch says:

    Sad how the media likes to sensationalize these occurrences, and blaming, unfortunately heightens the drama and sells…

    Do you suppose it even occurred to the developers of the security system to rotate the people fairly frequently (whatever time interval is best for heightened observation) throughout the areas they are observing? Perhaps the attention spans might be better and the fresh eyes might see things others might miss…

  4. Mark Graban
    Twitter:
    says:

    @Mark W. – I know there is fairly frequent rotation among TSA roles at the security screening point. I wonder how often the “guard the exit” job is rotated?

    @Bruce – I think you’re spot on that the model you cite is wrong. Being able to do a job once is no proof that you can do it effectively on a repeated basis.

  5. Bruce Baker says:

    Great immediate countermeasure Mark W. – rotate people. Let them do really boring stuff for a short time, then let them doing something more interactive and engaging. Trying to tell the difference between my LED flashlight and my electric shaver, and bombs on an xray machine for awhile would be less boring than ‘guarding’ a big door. It is something that uses a brain anyway. Even if your the person by the big metal detector you get to talk to people which is better than having to sit and watch a door.

  6. Elad Sherf says:

    Great post.

    It reminded me of something I wrote a while back. Check out the second part of the post: http://tinyurl.com/yk64frh.

    Too much emphasis on finding who to blame, not enough on asking what is systematically wrong.

    Elad

  7. Connor Shea says:

    Your analogy to the subway is interesting. A critical difference seems to be that for the subway system, the entry points are where the monetary transaction occurs. This must be secured, as once you’re past the gate, there is no “check” on one’s ticket. However, at airports, there is always a check on one’s ticket when you board. Therefore, it seems attaching a monetary implication to either the airport or the airlines collectively, for people entering through the exit, may be an incentive (albeit negative) needed to improve the system and not just blame the guard.

  8. I don’t so much care about the media response, as they usually get it wrong anyway and I have little influence about it. What I really care about is how you would respond were it your organization. For example, what was the response of the person’s supervisor when they found out? They don’t really tell us that because it’s not a very interesting story. His response should have been (a) first focus everyone on solving the immediate problem until it’s solved, (b) hold the person accountable (even in an imperfect system, there are still responsibilities), (c) use this as a coaching opportunity to solve systemic problems at a local level.

    Yes, you could redesign all the exits. But in the U.S. airport system, that’s a lot of them. Capital should be last. Would have been better had the system been different? Yes. Does Kansas City’s layout give plenty of opportunity for this kind of error? Certainly. But there is only so many problems you should solve with $100M. We’re still waiting for puffer systems in security, which solves an even bigger problem. So I would rather the supervisor work with the individual and the team to figure out what they can do at a local level. It could be rotation, radio check ins at random intervals for alertness, “mystery crasher” who spends all day trying to get in the wrong way to keep people on their toes – I have no idea, it’s for them to solve.

    But here’s the question I ask you: do you have a standard and structured response for when one of your people “screws up”? Or do you leave it to chance? I write about a structured response here: http://jamieflinchbaugh.com/2009/11/are-you-stupid-or-something/

  9. Mark Graban
    Twitter:
    says:

    @Jamie – I’d challenge the mantra of “creativity before capital” here. I don’t think that expression should mean “no capital” (which often seems the case with airport exits). Let’s skip the puffers and full body scanners then and relying on behavioral profiling and pat downs… cheaper? You have a good point about other procedure fixes, but I wouldn’t rule out having the “right” capital to get the job done.

    Connor raises an interesting point that the MBTA has a clearer financial incentive to keep people out of the T who haven’t paid than do the airlines (not that a plane blowing up is good for business in the long-term, but most don’t think long-term).

    I’ll assume the TSA agents are trying to do a good job, that they don’t want to let anyone through. So when somebody *does* get through, if there’s not an alarm, what does the employee do? Do they report the problem to their boss? Maybe not, if they’re afraid of punishment that often comes with “being held accountable.” Punishment leads people to cover up mistakes, if possible. I’d be afraid of that here. The agent at the door was “reassigned.” I’m sure they don’t feel good about being involved in that, but was it really their “fault”? They’re accountable for what? Never having a slack moment?

    Now if the agent intentionally walked away and left the door unattended, that’s different than if they were distracted or spaced out. We’re human, that happens.

    We’re all speculating here, but if the “error” was the result of poor system design and distraction (ala this Grey’s Anatomy episode):

    http://www.leanblog.org/2009/10/mcdreamy-fights-blame-game-on-greys/

    then, can you really hold the individual accountable?

    It’s going to sound like I’ve been in Cambridge too long, but aren’t the lowest level employees most likely to be “held accountable?” There’s a fairness issue here, are the managers and TSA leaders being held accountable for the poor system? Often not.

    According to this article, Newark was a comedy of errors:
    http://wcbstv.com/local/newark.airport.continental.2.1407062.html

    The video recording wasn’t working properly.

    They didn’t have procedures for how to call the airline to access their video (and didn’t have the phone number).

    Who is being held accountable for that?

  10. I’m not weighing in as much on Newark, because I wasn’t there, but trying to distinguish between fixing the system at a global and a local level. You make several points here so I’ll come back to that one.

    Let me address the accountability first: my point is that at whatever level you have improved a system or not, there still is a personal responsibility to do the work as design. It’s not to focus ONLY on that, but it’s also not to remove it altogether. If a Toyota worker just let a few cars go by without brakeline clips, that’s wouldn’t be OK. The point is in focusing on the bad system, don’t eliminate all accountability, at all levels. I didn’t say we should concentrate our focus on accountability of the individual. Accountability is just PART of a system.

    On the capital point, of course it doesn’t mean no capital and I think that’s a bit unfair. But we also shouldn’t always jump to capital. I could also improve rotation by hiring 12 more people and giving them 5 minutes on and 55 minutes rest. There are limits to throwing resources at the problem. We can’t solve EVERYTHING with capital. My point is consider the local level. If you were the manager, should you also say “there’s nothing I can do because they won’t give me the money to closet the exists.” The local supervisor has to be able to act responsibly too.

    The local manager should work at a systems level with the team to improve the system at their level. They can’t wait for the TSA to fix all global issues. Just like we don’t want managers and supervisors in our companies waiting for the executives to make all the decisions. They have to work at a systems level with the resources they have. That might involve many different solutions, but they have to find a way to get to root cause and develop systematic solutions at their level. Everyone has a role.

  11. Mark Graban
    Twitter:
    says:

    Hey Jamie – thanks for the comments. Didn’t mean to accuse you of taking an extreme or unreasonable position at all. Lots of grey area here, was just trying to flesh out different ends of the spectrum, as the answer is most likely somewhere in the middle on these issues. You make a lot of good points. Not having capital certainly shouldn’t be an excuse for not making other improvements. I’m with ya on that.

  12. Adam Zak says:

    “Who are they going to blame for this one?”, you ask…

    Well, it doesn’t much matter. As, of course, as it’s not someone who can actually do something about the problem, because solving the problem is not a first priority. I suggest that, like with pretty much everything else since January, we just call it a legacy problem left over from the Bush administration. I guarantee the media will agree on this and the issue will go away.

  13. Amiel says:

    Piggyback on Jamie’s emphasis on local-level solutions, if I were a supervisor, I’d be curious not only “Why did this failure happen?”, but “What makes us successful the other 99.9% of the time?” Given the mind numbing nature of the task and the lack of error-proofing system features, why doesn’t an error like this happen more often? How do staff stay alert most of the time? Better yet, here’s another creative provocation: what about some way to transform the appearance of a person going the wrong way into a puzzle the staff person has to solve? This isn’t a solution but a starting point…

  14. Mark Graban
    Twitter:
    says:

    Building on the ideas from the book “Drive” by Daniel Pink (I’m seeing him give a talk in Cambridge tonight), I’m sure the last thing Pink would recommend is financial incentives for catching people or financial penalties for letting people in the out door.

  15. Mark Graban
    Twitter:
    says:

    Turns out my earlier comment turned out to be true

    “Now if the agent intentionally walked away and left the door unattended, that’s different than if they were distracted or spaced out. We’re human, that happens.”

    According to this, the agent left his post:

    http://us.mobile.reuters.com/mobile/m/AnyArticle/p.rdt?URL=http://www.reuters.com/article/idUSTRE60654M20100107

    “The video shows the TSA officer leaving his desk and walking toward the airport concourse.”

    Here is the video, and CNN says he was “distracted” by somebody asking a question.
    http://www.cnn.com/2010/TRAVEL/01/07/nj.security.breach/

    Time to hold someone accountable. And fix the system.

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