System Failure

Boy, you let ONE four-year-old die horribly and everyone jumps down your throat!

OK, sorry, we even offended ourselves there. But the story in today's Times about Marchella Pierce, the aforementioned four-year-old, got us thinking about the nature of systems: Specifically, isn't "failure" just an unavoidable feature?

Marchella's story is horrific. The girl weighed 18 pounds at the time of her death; her mother apparently kept her tied to a bed to prevent her from taking food. The article outlines the various agencies and individuals who had opportunities to intervene--the details don't really matter: These stories of children who (cliche alert) fall through the cracks are always the same. Hindsight is always 20/20 (sorry, we forgot to sound the cliche alert that time), and one can always identify the egregious errors that were made.

This does not excuse individuals who failed to intervene on Marchelle's behalf. Our point is that the knee-jerk reaction--to shake one's head at bureaucratic ineptitude--is as cliched as the lazy writing in the previous paragraph. We suggest that the very fact that these stories continue to make news suggests that the system does work.

All stories of system failure are alike; every systemic success is successful in its own way. The irony is that the stories of success--despite their individual quirks--sell so many fewer papers.

Think about airplanes. These multi-ton behemoths sail through the air, thousands of moving and electronic parts firing precisely, avoiding treacherous weather patterns and other planes, to bring their passengers safely to land. And still there are accidents. And with every accident, investigations commence; recommendations appear; redundancies proliferate. Flying becomes safer until the system fails again. And the process repeats.

Zeno's paradox: A man stands at one end of a room. He travels halfway across. Then he covers half the remaining distance. Then half again. He keeps getting closer and closer, but he never reaches the other side.

Systems have inherent limits, and they will never reach the perfection of the other side of the room.