One of the things that strikes me in so many news stories about preventable disasters is that the decision-makers not only had all the information they needed to take correct and timely preventive action, they were specifically warned when red flags started to wave.
George W. Bush and 9/11 is often cited as the modern-day example, but it keeps happening. Like right up to today.
Ebola guy, for example. When this man first visited the hospital in Dallas, two days after he became ill, a nurse asked if he’d been in West Africa and he said yeah, he’d just come from there. The nurse reported his response, but no one above her heard the warning siren and he was sent home. He came back two days later, even sicker, and was finally diagnosed and quarantined. For a four-day period, then, he was suffering Ebola symptoms and was, according to the CDC, actively contagious. During those four days, he came in contact with twelve to eighteen people, including five children (each of whom subsequently went to school).
CDC officials are trying to contain panic by saying they’ve got a handle on it, but you and I know they must privately feel like the fictional CDC Doctor Goodweather on TV’s The Strain, watching vampires breed like rabbits. If they can round up those who came in contact with the Ebola patient after he developed symptoms and became contagious, and isolate them before they themselves begin to exhibit symptoms and expose others, good. If, that is, the CDC’s assurances that someone with Ebola can’t give it to others until he or she exhibits symptoms are true.
The lack of internal communication at the Dallas hospital is bad enough. What about the lack of coordination between the CDC and US Customs and Immigration? People can freely enter the USA after stepping off flights from Liberia? With all the information at our disposal about the spread of Ebola in Liberia and West Africa, it’s not as if we didn’t know there was a risk Ebola would hop a flight to the USA. Couldn’t we have put some controls in place before it got here?
The guy who jumped the White House fence and made it all the way to the East Room? We’re now told he had run-ins with law enforcement and the Secret Service before the fence-jumping incident. Virginia police arrested him this summer, finding in his car “a mini-arsenal of semiautomatic weapons, a sniper rifle and a map clearly marking the White House’s location.” They let him go, but did alert the Secret Service. Then, just last month, Secret Service agents detained him in front of the White House. At the time he had a hatchet. They let him go, seemingly unaware of the earlier incident with Virginia police.
And now we learn that the intruder alert system inside the White House was on mute!
I was going to go on to cite other examples, but really, that’s enough, especially the detail about the intruder alert alarm being set to mute. You know what all this reminds me of? The classic story about the pilot who landed gear-up because he got distracted trying to silence the gear warning alarm.
When I studied safety engineering, we learned there are three basic ways to keep pilots from screwing up:
- Write checklist procedures that, if properly followed, will prevent operator error
- Add warning bells & buzzers to let pilots know when they are approaching or pushing beyond safe limits
- Design airplanes so that they will take over and save the pilot’s ass when he or she screws up.
Not surprisingly, the easiest and cheapest way is the first one. It’s also the most ineffective. The second costs more but is often just as ineffective (see Figure 1, above). The third is expensive but in many cases technologically possible. It is also the most effective, because it removes the human from the works … when humans are involved, checklists and red flags are too easy to ignore.
I’ll close with two personal observations:
- Those folks at the CDC had better be right about how Ebola is passed on from human to human
- It’s good to know there are still public servants like Julia Pierson who will step down when their agencies fail