That's a lot of words and prevarication about a simple process. But then, it's also a post that starts with a story about squirrels and illustrates it with a marmot.

The squirrels don't illustrate an accountability sink, the squirrels indicate that KLM's board were a bunch of cowards. They chose to throw the deck employees under the bus even though they were perfectly clear to throw the government under the bus which is the sort of thing that happens when you're letting the king LARP around as an airline pilot.

The gate attendant doesn't illustrate an accountability sink, the gate attendant illustrates a deflection point. Some airlines give exquisite control to their staff on the ground, some airlines bury things deep in process. Delta, for example, doesn't have much power at the gate but your Skymiles concierge can work a level of magic commensurate with your VIP status. American uses an algorithm that compensates for their overbooking by ranking passengers on their likelihood to fly American again. Alaska and Southwest empower their gate attendants with a great deal more power because as smaller airlines they recognize that a human face is their superpower.

The credit card character count is some made-up bullshit, near as I can tell, and if it's not Mr. Sustrik should post a source. American Express, famously, put first initials only on their credit cards for several decades.

Tim Snyder wrote a whole-ass book about how the majority of the Holocaust wasn't gas chambers, it was Polish farmers shooting their neighbors. Given a choice between "shoot your neighbor and take his land" or "get in the trench, Kowalski" the majority of Poles made the understandable (and haunting) choice. Hannah Arendt regretted coining the phrase "the banality of evil" for the rest of her life because the reality is the Nazis knew they were perpetrating evil but were also in a mutual support structure designed to alienate them from anyone but evildoers.

Yet, the vague feeling of arbitrariness about Nuremberg trials persists. Why blame these guys and not the others?

1) Woodrow Wilson told Harry Truman that he could have vengeance against the Axis powers for WWII, or he could have peace.

2) There was no time to stand up an entire industrial base in Germany so much of it was reconstituted with the existing players in place, as catalogued by David De Jong.

3) it is necessary to post show-trials against hiding Nazis because the whole purpose of Nuremberg was to perform a healing ritual between the victors and the villain vanquished. By passing judgement on the vanquished they were processed into victor society. By avoiding judgement the fugitives were prolonging the conflict.

The Nazi trials post-Nuremberg served the following purposes:

- They reinforce the narrative that the world can move on from the Nazis

- They reward the vanquished for stepping forward to be processed back into society

- They remind the populace that genocide isn't okay

It could be argued that the rise of AfD and National Front are a direct consequence of the cessation of Nazi trials - with no reminder of "Nazis bad" a generation of post-expansion citizens doing worse than their parents ask "Nazis bad?"

The purpose of bureaucratic overhead is to ensure that no single person has the power to destroy everything. This is where Robert's Rules of Order come from - they allow a bunch of people who fucking hate each other to get shit done. Every HOA hates the shit out of Robert's Rules until Joe flies off the handle about Bob's Trump flag and all of a sudden, it's great to have rules. We're in this ridiculous tariff mess because the president of the United States can't arbitrarily cook up a bunch of tariffs without an emergency declaration and the Republican congress is so beholden to their populist that they rolled over and agreed that he had one.

The purpose of corporate overhead is to ensure that no single person has to accept responsibility for any wrongdoing. In the KLM example, the board members could have signed a statement saying "situation sucks, but it is what it is" without having PETA throw stuffed woodchucks at their villas or whatever. Instead they rolled over on their customs team because they're feckless shitheads. There's a great bit in The Corporation where the former chairman of BP talks about sitting down with the protestors on his lawn over a spill, saying "look, man, I'm not a fan of oil spills either, all I can do is try to steer a bunch of people towards making the right decision who can try to steer a bunch of shareholders towards making the right decision" for which he was ousted by corporate raiders. The corporate raiders were smart enough to not make any public statements about oil spills while also championing a corporate culture that wanted less safety, not more.

In any organization, incentives to replace human judgement by process are strong.

This, right here, is where things are wrong: the incentive is to replace human responsibility, not judgement. The Las Vegas hospital and its utter reversion to immediate life-saving practices happened because of primum non nocere - the ethical guideline all healthcare practitioners sign onto says "first, do no harm" and that means "first, don't sit around waiting for EPIC to tell you what to do if your patient is obviously bleeding out." Every hospital guideline in the United States has all sorts of backstops to support practitioners who think they're doing the right thing - every medical malpractice suit you've ever seen takes some form of "the doctor did the wrong thing even though he knew better."

The air traffic controller example is another stupid misunderstanding of how things work - that was an incident review, not a blame-seeking event. The other air traffic controllers rallied around Wascher because (A) she made an honest mistake that she owned up to (B) every other air traffic controller knew that's the sort of honest mistake that can easily happen due to process.

Several events then occurred in quick succession. First, the second Metroliner tuned in to the wrong frequency, and she had to track it down and reissue its clearance to cross the runway. Then a Southwest flight announced that it was ready to enter runway 24L, so she told it to hold short. And finally, another SkyWest flight took off on runway 24R and had to be handed to the next controller. Unfortunately, amid these multiple distractions, she simply forgot that SkyWest 5569 was still sitting on runway 24L, awaiting takeoff clearance. Moments later, she cleared USAir flight 1493 to land, unaware that she was making a catastrophic error.

That was such a process-driven accident that LAX added a second goddamn control tower four years later. The fact of the matter was, they doubled the size of the airport for the olympics and there were areas of the runway that were hard to see from the existing tower. LAX is a monster. Compare and contrast with the 2018 false missile alarm in Hawaii where the initial rumors were "Jerry's a fuckup." Jerry lost his job because he wouldn't cooperate with the investigation because he's a fuckup but also the process experienced some real changes so even if you end up with another Jerry in the seat, you don't send false missile warnings to everyone's cell phones.

My wife has taken part in two separate types of incident reviews - in California they did monthly peer review, where everyone brought cases to say "did I fuck up?" Everyone bent over backwards to say "well you could have done this" instead of "yeah you fucked up" because there but for the grace of god go I and on the day, you don't have time to phone a friend. In Washington it's called incident review and it's protected under official state confidentiality. It's also required for licensure. There's a list of "sentinel events" that require incident review and most of them are "this happened" not "you did this." Part of incident review is "did you fuck something up so badly that in the opinion of your peers, this case needs to be officially investigated by the state." A bigger part of incident review is "this shit comes up and here's the successful way to deal with it."

The author seems to be blown away by the idea that the engineers behind Google were allowed to do whatever was necessary at the moment to keep Gmail running. how is that not an "accountability trap?" That means if the engineer fucks up, the engineer gets blamed. But just like Southwest, it comes down to a confidence in your team to solve the problems in front of them. The people at CMS got out of their accountability trap - they were requisitioners, not engineers, and it wasn't until they were officially ordered to let the engineers cook that they were able to resurrect Obamacare. Prior to that, it was all about their fuckups. That's not "sidestepping" accountability, that's giving it to someone else: The buck stops here. Boris Johnson took the minor responsibility of letting a mercy flight travel to China and back; Congress knows that these aren't their tariffs, they're Trump's and whatever blowback they face from supporting them is vastly less than whatever vengeance they'll face from opposing Trump.

We need an "accountability trap" in Congress. It would be a good thing.

But then this is a guy who called a marmot a squirrel and who thinks VCs are good but the free market is bad.