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 circumstances.
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.
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