Can things ever get better?

Does it ever seem to you like things are getting slowly worse all the time? It can't be just me. And last week I finally saw a video that explains why.

It's a joke, of course. The video purports to show us "A Day in the Life of an Ensh*ttificator," someone whose job it is to make every product and service a little bit worse. The main character addresses the audience directly, explaining that he inherited his calling from his father before him. And at first he starts off small: cutting holes in the toes of socks, and sawing half an inch off one table leg so that the table rocks. But the Internet allows him to expand his operations. Soon he offers online services for free—just long enough to get users hooked on them—and then incrementally degrades the services to encourage customers to pay for "Premium" status (viz., the same level of service that was free last year). I won't give away the punchline, but the ending is perfectly in line with the dark humor that pervades the rest of the video. It's well worth the four minutes.

Wow, that sounds cynical! Who made it? Some disgruntled undergraduate? 

The "Breaking Free" report

Actually, no. The video was produced by NewsLab, a Norwegian communications agency; but it was commissioned and publicized by Forbrukerrådet, the Norwegian Consumer Council. Their point is to advertise a new report which highlights that this drift towards "enshittification" is a conscious, deliberate policy of the major firms in Big Tech. The report, entitled "BREAKING FREE: Pathways to a fair technological future," spells out the exact steps by which major tech firms hook customers with free or discounted services, and then squeeze them for payment once the cost of leaving the service is too great. Nor do they stop there. Forbrukerrådet winds up the report by identifying a slate of legislative measures to protect consumers from this predatory behavior. And in a logical next step, they and other allied consumer organizations have already sent letters to legislators in Norway, in the European Union, and in the United States urging adoption of these measures.

In case it's not clear in what follows, I wish them well. I agree that life is worse when online services are designed so that you can't easily switch between providers. And it could be interesting to study the slate of concrete measures proposed in the report, to understand how likely they are to achieve their stated goal. If you want me to drill into the details in a future post, please tell me in the comments. What is certain is that even with the best measures, bringing the corporations to heel won't be easy. (Consider the "Alternative to fines" discussion in this post from two years ago.) But what I want to ask right now is a far more basic question. Once the legislators get these letters and read them, what motivation do they have to act on the proposals? What's in it for them?

Finn Lützow-Holm Myrstad,
Director of Digital Policy,
Norwegian Consumer Council

I don't know how politics works in Norway, nor at the pan-European levels of the EU. But in the United States, legislators are generally motivated by re-election. They support measures that will get them re-elected, and they oppose measures that would prevent their re-election. The Big Tech firms contribute generously to the campaign funds of legislators who are disposed to help them. Who contributes to their opponents? Who is out there in the public square, capitalizing on the attention earned by this funny video, mobilizing voters to throw out the rascals who protect Big Tech and to replace them with insurgents defending the Common Man? Can you think of a name? Anyone?       

Because without such mobilization, I think the measures are going nowhere. If legislators are motivated by re-election, then the surest way to make progress on this topic is to convince those legislators that supporting consumers against the depradations of Big Tech is essential to getting re-elected. It might be possible to make such an argument some day, with enough organization. But up till now I have not heard it made.

Maybe it sounds like I'm ranting, or preaching cheap gloom-and-doom. But I'm not. There's an important Quality lesson here, one that applies to every improvement project you undertake—in the office, on the shop floor, or anywhere. The point is this: 

• Every improvement project requires someone in authority to say, "Do it."
• Therefore, every improvement has to look good to the person who authorizes it.
• This means that no matter how much benefit the improvement might bring, it won't happen unless you can persuade the person in authority that he or she is better off approving the project than rejecting it. At some level, there has got to be something in it for him or her.   

Often that "something" is just that your improvement will make things run smoother in the office or on the shop floor, and naturally the boss wants things to run smoother. That might be enough. In other cases, you might have to be a little more persuasive. But the point is that there has to be something. And my biggest concern about the package of reforms that the Forbrukerrådet has proposed to protect common consumers against Big Tech is that these measures benefit everyone except the tech executives themselves and the legislators who have to pass the laws. 

      

It doesn't take a conspiracy!

Last month, Southern California was hit by a battery of wildfires. Los Angeles County alone was struck by at least nine (two of them crossing the border to Ventura County as well), of which three—the Hughes Fire, the Eaton Fire, and the Palisades Fire—each burned over 10,000 acres. The Eaton and Palisades Fires each started on January 7, and were still burning three weeks later (though by then they were mostly contained).

There may be more to say about these fires from the perspective of problem-solving and preventive action, once there has been time for more of the analysis to be done. But for the moment I want to address a different kind of discussion, one that broke out almost as soon as the fires did.

Social media conspiracy theories

Pretty much as soon as the first homes went up in smoke, people on social media blamed it all on a wicked conspiracy. The gist of the argument seemed to be that:

• if you take too long to rebuild your home (some posts said the limit was two years, while others said it was three) then you lose the protection of Proposition 13 to keep your property tax rates low; 
• and for people whose net worth is all tied up in their home, higher property taxes could force them to sell at ruinous prices; 
• but the number of permits required by the State of California to build in these exclusive areas is so great that building is sure to take too long; 
• and therefore the fires must have been set by Bad Guys who wanted to scoop up a lot of prime real estate at bargain prices.

Maybe I don't need to say this, but the social media posters who jumped on this bandwagon didn't get all of their facts quite right. 

• Yes, it's true that there are some restrictions on what kind of a replacement structure you can build while keeping your old tax base—if you replace a doghouse with a mansion, you can expect a reassessment—and some of those restrictions also take account of how fast the rebuilding happens. 
• But the formulas are more complex than the doomsayers claimed, and more generous. (The current rules were implemented by Proposition 19, passed in 2020, and you can find more information at this website here.)
• 
  And yes, it's true that the State of California normally requires a lot of permits to build in some of these areas, specifically so that you don't ruin a neighborhood that's already there (inhabited by people who moved there before you did) by putting up something that doesn't fit the natural or social environment.
• But when everything has burned to the ground, those considerations aren't as relevant. As a result, California Governor Gavin Newsom issued an executive order on January 27 suspending permit requirements under the California Coastal Act and directing the Coastal Commission not to interfere. (Although in fairness to the social media warriors, this executive order came more than two weeks after they started alleging conspiracies. So maybe that delay played a part in motivating them.)   

January 27 was also the day that evacuees from the Palisades Fire were allowed to return to their homes, just three days after President Trump visited Los Angeles to urge expeditious rebuilding and to promise federal aid. So on the whole, the government's response has been a little better than the doomsayers feared.  

Bad Guys are no smarter than the rest of us

But suppose they had been right. Suppose the rules were as bad as they said, and pretend for the moment that nobody had lifted a finger to invoke emergency powers or to speed these processes along. In that case, could we have legitimately inferred a conspiracy?

No such luck. Even in that case, we might well be looking at no more than bad process management.

Where conspiracy theories go astray is to assume the Bad Guys are smarter in carrying out their Evil Deeds than we are in handling normal problems at work or at home. Product development in the technology sphere routinely faces unplanned delays and sudden changes in the scope of work. And yet somehow we hear that the Bad Guys pull off their plans without clumsy mistakes or slipping schedule. Really? Where can we find these guys? I guarantee they'd make more money from legitimate jobs!

On the other hand, if you accept that even the Bad Guys are just normal humans, then they make the same mistakes the rest of us make. And what that means is that when things go wrong, the problems are more likely to result from normal human ineptitude or bad luck than from malice.*

Better process management

Fine, if it wasn't the work of Bad Guys, then how exactly did it get so hard to acquire the permits to build a house along the California coast? I don't know the real answer, and won't without doing some research into the history of the California Coastal Commission. But I assume that this situation is just the result of bad process management.

Once upon a time, someone must have noticed a risk that something bad could happen if a person tried to build a house without checking for some condition first: maybe it meant checking that the ground was solid enough to build on. So the state implemented a procedure that you have to check the ground before you build. Later, someone else noticed a risk that something else bad could happen if you didn't check for another condition first: maybe this time it had to do with making your house out of flammable materials. So sure enough, the state implemented another procedure to check your materials before you start. That meant two checks before you start building, and two permits to prove that you did the checking. 

And so on. 

This is the lesson for process management. Let's say you have defined a process to do something, and it's working well enough, but then a new situation comes along. The easiest thing in the world is to write a new process and overlay it on top of the first, to deal with the new circumstance. Now someone has to follow them both. Then another new situation comes along, and another, and another. Are you going to keep writing new processes, and force people to follow one after another after another? Too many people do just that, and it can grind your operations to a halt.** 

The real answer is, Don't do this! Instead, rethink your whole system from the beginning. Start over from scratch and work out a single process that accommodates all the subtleties and special cases that you are now aware of. Anything else will bog your people down and immobilize them. But the point of a process is to get things done. 

The State of California may have created a situation where the only way to build a house expeditiously in certain areas is through executive orders and emergency action. When it comes to your own work, learn from that example instead of imitating it. 

__________

* Hanlon's Razor encodes this insight as: "Never attribute to malice that which is adequately explained by stupidity."

** This is part of why I have argued before that "Procedures which are easy to write, are hard to implement."

     

Embrace your failure!

Earlier this month, I published two posts that were directly connected to current political issues in the United States, first here and then (as a follow-up) here. The political issue in question was illegal immigration. My focus in the articles was: first, to review the results of the Administration's recent "root cause" policy on immigration; and second, to suggest how the Administration's root cause analysis could have been improved—possibly to support a more effective policy, but at any rate to be completer than it was. And my overriding imperative was to handle the subject in a non-political way.

After I published the first article, a good friend argued that if I really thought I could keep the discussion non-political, then I was fooling myself. More exactly, her argument was as follows:

• Since Vice President Harris was put in charge of the "root cause" policy, any evaluation of the policy will necessarily be construed by others as an evaluation of her. If I say that the policy failed, readers will construe me to mean that she personally failed.
• Any personal evaluation of the success or failure of a candidate for the Presidency—if expressed during the middle of a campaign—will necessarily be construed by others as a partisan statement, either an endorsement or an attack. If I say that a candidate failed at something, readers will construe me to have attacked the candidate.
• Therefore I shouldn't publish such an article unless I am prepared for my writing to be used as artillery in the campaign by one side or the other.

We talked about it for a while, and I told her I disagree for at least two reasons. In the first place, I simply don't have that wide a reach. Mostly my posts are read by a small pool of people interested in aspects of the Quality business. And it's highly unlikely that anything I say about the technicalities of root cause analysis will drive you to change your vote. I assume you already know how you are going to vote, and nothing I say will make the slightest difference.

More importantly, the whole point of Quality analysis is that we can learn from our mistakes by analyzing them, so that we do better next time. In this sense, it is critical to embrace your failures, and not hide them! Because when we fail at something, it's never on purpose. Always we think we are doing the right thing; we have a plan of some kind, and we are following it with the intention of reaching a goal. This is what deliberate behavior looks like. But the consequence is that the very next time we have another goal, we'll do exactly the same thing—unless something stops us. Unless we intervene with ourselves to make a change.

If our plan is right and we succeed, of course that's fine. But if we fail—that's when it gets important to pay attention. If we fail, that means the plan wasn't right, which in turn means that there was something we missed when we analyzed the situation. If we aren't careful, we'll miss the same thing again next time and fail in the same way. Conversely, if we don't want to fail the same way next time, we have to figure out what we missed last time and take care not to miss it again.

This is why we have to own our failures and understand them.

As for the Administration's "root cause" policy on immigration, when I say that it failed that's no more than a historical fact. The plan was that by taking these actions, the Administration intended to bring about those outcomes. But in fact the actual outcomes were very nearly the opposite of what the Administration had in mind. (I explain the details in my article, and give links to external documentation that substantiates all the historical data.) 

OK, fine. This happens all the time, to administrations from both parties. There's nothing partisan in recognizing the facts. The next step should be to look at the analysis and find the flaw, so that the next time around will be better.

Of course, there are a lot of moving parts in any political situation. And right now we are facing an election. It is unlikely that today's Administration will launch a major new initiative in the last months of this year. Maybe something will be done next year, but at this point we don't know who will be responsible then. So it's hard to know what to expect.

But understanding your failures is still a really valuable thing to do.    

                

Root causes on the back of an envelope

Two weeks ago, I posted an article in this space about the "Root causes of illegal immigration." I started from a Congressional Research Service report entitled "Central American Migration: Root Causes and U.S. Policy"; and I argued that the Administration's root cause analysis went astray by failing to distinguish between bounded cases (where the number of causes is strictly limited) and unbounded cases (where solving some causes just makes room for others). Then I asked readers whether they would like to see me work out my own root cause analysis of the same problem.

At this writing, seven readers have said "Yes." So I'm going to give it a shot—partly to respond to their interest. 

But the exercise drove home for me another important fact about problem-solving. Finding the root cause is only half the battle! After your analysis has generated a list of potential causes (and for many complex problems there are more than one), you then have to decide which causes you can address. And from that smaller list, you may have to filter again to find which causes you are willing to address! Admittedly if your widget-stamping machine is out of alignment, this last part is easy. Of course you're willing to re-align the widget stamping machine. But in other kinds of complex problems—especially in system problems, of which political problems are prime examples—every action taken over here will have some unintended side effect over there. So before you charge in to fix stuff, you have to weigh what it is worth fixing.

This is important, and I ran smack-dab into it while working through this example.

With that said, let me make a couple of apologies and disclaimers.

Nothing here is brilliant. My earlier post sparked a discussion in the myASQ community, and Jason Wesolowski of TX-RX Systems made all the same points I'm going to make here, with breathtaking elegance, in a couple of paragraphs. My version is longer so I can show my work; but my hat is off to Jason for seeing the issues right away, and for expressing them with admirable concision. 

I am no expert on illegal immigration. There will be points that I miss. This article is a back-of-the-envelope calculation, nothing more. All I really know is the logic of root cause analysis. So if you understand illegal immigration as a subject-matter expert, please take the systematic method that I show you here and flesh it out with better real-life information.

I said this before, but it bears repeating: This is not a post about immigration, nor about the election! In the first place, as noted, I am no expert on these topics. I have no idea what the best immigration policy should be. In the second place, there is lots to discuss here at the level of data and logic, without letting political opinions slow us down. I will keep my opinions out of the conversation.

The discussion unfolds in three steps. First, is there a problem? Second, what are the potential causes? Third, let's evaluate those causes to see which we want to address.  

Is there a problem?

First we have to check whether we have a problem at all? Don't go to a lot of effort to find the root cause for something that's not a problem. So, ... Is illegal immigration a problem?

I think the answer has to be Yes, for at least two reasons.*

From a procedural point of view, it is always bad when an organization's written procedures say one thing, and people in their daily work do something else. (And in civil society, the laws are our "procedures.") When the written procedures and the daily work disagree, it's at best confusing. Nobody knows what the real rules are. Also there is a risk that you'll get punished today for doing what got you praised yesterday. It's maddening.

The solution, when there is a gap between the written procedures and the daily work, is always—always!—to bring them back together. Maybe you enforce the procedures as written. Maybe you rewrite them to match the familiar habits. Maybe you meet in the middle. But tolerating a situation where the organization is chronically out of compliance with its own procedures degrades performance, degrades trust, and degrades morale. It is poisonous. (I talk more about the role of procedures in this post, among other places.)  

From a humanitarian point of view, when someone enters the country without the protection of the law, unscrupulous people can abuse or exploit him. His landlord or his employer can mistreat him, and he has no recourse. If he complains, the authorities discover that he is here illegally, and deport him. So the landlord and the employer are free to do a lot of bad things.

Temporary foreign workers clear
a field west of Montreal. (CBC)

Abuses can turn up even when a migrant enters the country legally. Just a few days ago, the United Nations issued a special report on Canada's Temporary Foreign Worker (TFW) program, comparing it in some instances to a "contemporary form of slavery."** However the case may turn out with Canada's TFW program once the dust settles, it is at any rate a legal public program. How much greater are the opportunities for abuse when the migrant worker has entered the country illegally and can claim no public protection!    

What are the root causes?

This post is already too long, so I have pushed the details of the analysis to another page. YOU CAN SEE THE ANALYSIS BY CLICKING HERE!

Also, when I started work on this I began trying to arrange the root causes on an Ishikawa diagram. I didn't get very far, but you can see the results at the bottom of this page.

But here is the list of potential root causes coming out of that analysis:

• Things are bad in a migrant's home country.
• The US is a big country with a large population.
• The US has very long land borders.
• The US has very long coastlines.
• The US is a good place to live.
• Lots of people find jobs in the US.
• Sometimes the filters at the border might fail to detect an illegal entrant.
• Sometimes the procedures at the border might fail to detain an illegal entrant.
• There is no reliable way to track someone once he is out of official sight.
• The legal entry procedure is very difficult and takes a long time.

If anything here doesn't make sense, the analysis goes through the reasoning in detail.

Now we get to the hard part.

Evaluating root causes, deciding where to act

Some of these points are not actionable. Of the rest, most are facts we probably don't want to change. There is one point that holds promise, but even it is tricky. Let's look at them.

Facts we can't change

The first four points on the list are simple facts that are out of our power.

Things are bad in a migrant's home country.

My last post explained that this fact is the one the Administration tried to change in their "Root Cause" initiative. And they succeeded in improving conditions in three countries. But bad conditions in other countries meant that the next year saw more migrants anyway. Pragmatically, the world is too large and there are too many countries where people are suffering for this to be a useful line of approach. 

That doesn't mean we should never help other countries! I take no position in this article either for or against foreign aid. But we can't expect foreign aid to reduce the immigration pressure.

The US is a big country with a large population.

Yes it is.

The US has very long land borders.

If you want barriers along our borders, that might have a deterrent effect in some places. But there are a lot of miles to cover.

The US has very long coastlines. 

You can't build walls in the water, and there's a lot of coastline.

Facts we (probably) don't want to change

Now we get to points that are more actionable. But we might want to think twice before acting.

The US is a good place to live. 

If we deliberately made the US a post-apocalyptic wasteland, no one would want to come here. But that's crazy. Let's not do that, OK?

Lots of people find jobs in the US.

Norway is a nice place to live, but there are very few illegal immigrants because it is almost impossible to find a job if you don't have legal status. An article from 2017 explains that "'Norway must be one of the most transparent societies in Europe.' It’s also highly regulated, where residents’ addresses are registered with local authorities and banks can’t open accounts for people lacking official identification numbers." Or consider New Zealand: an online discussion thread on exactly this topic explains that New Zealand prosecutes employers who hire illegal immigrants, and the fines are devastating. 

In principle we could do the same in the US, but do we want to? That depends. Most of my professional work has been in high-tech, and whenever I have taken a new job I have been required to show proof that I can legally work in the US.*** But I'm pretty sure there are industries or professions where the rules are not so strict, and I think there is a limit beyond which more rules would feel burdensome. If you ask the teenager down the street to babysit for a couple of hours, do you really have to check that her papers are in order first? (And then keep records to prove that you checked!) Or where is the line? There may be a little room on this front, but I expect not a lot.

Sometimes the filters at the border might fail to detect an illegal entrant.

I don't know if this ever happens, but logically it has to be evaluated. The problem is that every detection system has a failure rate. If we increase the sensitivity of the detection system used at the border, there will be more false positives. In other words, a more sensitive system is more likely to deny entry to normal citizens returning from vacation! Such an "improvement" won't be popular for long.

Sometimes the procedures at the border might fail to detain an illegal entrant.

Again, I don't know if this ever happens, but logically it has to be evaluated. But supposing it were true, what then? Are we asking for sturdier holding facilities at each port of entry? Are we asking for officials to deploy tougher methods? I don't know, but none of that is likely to look good on the evening news. So again, such an "improvement" won't be popular for long.

There is no reliable way to track someone once he is out of official sight.

Here's another point that is in principle easy to fix. Just make the US a police state, where no one can go anywhere without official papers and permission. Every time you arrive in a new town, check in with the Secret Police before you even find a room for the night. Then if anyone does slip past the border illegally, it will be child's play to track him down.

But who wants to live in a country like that?? I don't. You don't. Nobody does. So again, let's not do that! 

This leaves one last cause to consider.

The last root cause

The legal entry procedure is very difficult and takes a long time.

Honestly I think this one looks the most promising, if only because the others look so bad. In principle, "all it takes" to fix this is for Congress and the President to agree on something simpler than what we have now. (Quit snickering! 😀) And it's a common­place of process management that you get people to follow your processes by arranging things so that compliance is easy and noncompliance is hard. Make following the procedure the easiest way to do something, and everyone will follow the procedure. It's the same here. If it is easier to obey the law than to break it, everyone will obey the law. That's what we want.

Or maybe not. Maybe getting that agreement is hard. Maybe we as a country haven't come to a consensus on what we want here. That's not a problem that root-cause analysis can solve. The best I can do is to expose the problem, so that at least we know what we have to answer. But actually to answer it requires political work, and not Quality work.

Don't forget that a complete solution might involve several initiatives at once. Notwithstanding everything I said about the other root causes, they might be involved in partial measures that overlap each other to keep the problem from getting worse while a full solution is implemented.

But, speaking purely from the perspective of this Quality analysis, I think that tackling the last root cause—i.e., reforming immigration law—comes the closest to a winning play.

That doesn't mean it will be easy.

__________

* If you think there are more reasons than these two, that's always possible. I don't claim this is a complete list. 

** You can find the UN report here. For news reports, see here and here. The Canadian government responded on August 16 with a blistering news release accusing that the UN "special rapporteur" "spoke to no employers, did not visit a single farm, and spoke only with 100 workers." Up till now I have been able to find this news release only on LinkedIn, here.  

*** Since I am a citizen, that has not been hard to do.    

 

Root causes of illegal immigration

Whenever I hear someone use technical Quality terminology in an unexpected venue, my ears perk up. So I sat up sharp a few days ago, when I was reading an article about the upcoming election and it mentioned that Vice-President Harris was given an assignment back in 2021 to address "the root causes that drive migration to the United States." [Emphasis mine.] Really? I thought. We tackled the root causes of something? Cool. I wonder how that turned out? 

[You might guess that I don't always keep up with the news.]

Before I go on, let me be clear. This is not a post about immigration, nor about the election! My interest here is in the application of root-cause analysis as a problem-solving tool, because I think this story highlights a useful point. As for the political questions … you don't need my opinions because you've got your own, and yours are probably better. I'll keep mine to myself.

In some ways we should expect it to be very difficult to identify root causes for a large-scale social phenomenon. The classic understanding of a root cause is that when you turn it on and off, the effect turns on and off as well—like a light switch. But social groups are systems in the technical sense, and systems involve delays. So even if you find a root cause and switch it off, it might take a while for the effect to disappear. 

On the other hand, it is tempting to look for root causes of social phenomena, for the same reason that we look for the root causes of more tractable problems. If you solve a root cause, the problem goes away and you don't have to keep fixing it. This is a powerful inducement. 

So what was done? 

On February 2, 2021, President Biden signed an Executive Order that called for the development of a Root Causes Strategy. (You can find the full document here.) A month later, he asked Vice President Harris to lead this effort diplomatically and organizationally. The analysis did not start from zero, but built on earlier analyses carried out under the Obama administration. (See references in, for example, here and here.)

What root causes were identified in this analysis? 

A Congressional Research Service report by Peter J. Meyer, "Central American Migration: Root Causes and U.S. Policy," acknowledges that "motives [for migration] vary by individual," but identifies four broad categories of root cause: socioeconomic conditions, natural disasters, security conditions (this means crime and violence in the home countries), and governance (which covers such topics as autocratic rule, low public investment, and systemic corruption). 

What was the action plan?

Not only did the responsible team look for root causes for migration, but they carried out a Pareto analysis to identify the countries-of-origin providing the most migrants. The answer was that—after Mexico (with whom other programs were already in place)—the largest numbers of migrants came from Guatemala, El Salvador, and Honduras. (See this document for detailed statistics.) Therefore the Administration focused its efforts on a combination of humanitarian assistance, direct investment, and government-to-government initiatives with these three countries. [source] In addition, the Administration "created more legal pathways of entry for migrants …. [and implemented] harsher punishments … for crossing illegally." [source]

How did it work out?

Not as planned. Initiatives were put in place promptly in 2021. The next year, total apprehensions at the border hit record numbers.

It would be tempting to wave away these results by pointing out (as we noted above) that there are delays built into any complex system, so perhaps the high numbers in 2022 reflected some causal activity from before the program even started. But the details don't support that simple an answer. In fact, migration from Guatemala, El Salvador, and Honduras dropped significantly between 2021 and 2022. But increased numbers from other countries—notably Venezuela, Nicaragua, Cuba and Haiti—more than made up the difference.

Where did the analysis go wrong?

Wait—maybe that question is premature. Did the analysis go wrong?

At the most basic level, yes it did. The analysis predicted that a certain course of action would have a certain result; and while the narrow result fit expectations, the overall result did not. Illegal migration from Guatemala, El Salvador, and Honduras dropped, but overall illegal migration into the United States rose. The empirical data show that something has to have been left out of the original planning.

To be clear, I recognize that these phenomena are enormously complex, and that we cannot expect the kind of precision we would demand in a laboratory experiment. I hope it is equally clear that I am saying nothing either for or against the specific policies that were implemented. Even if the reasons behind a policy are weak, that says nothing about whether the policy itself is helpful or harmful. Sometimes people do the right things for the wrong reasons.

But the reasoning here was weak in at least one spot: the application of the Pareto analysis was premature.

It was a nice idea, to be sure. In industrial manufacturing, if most of your mechanical failures come from the same step in the process, and if you can fix that step, then you have gone a long way to fixing all your mechanical failures. But that only works when the universe of failures is bounded. Then you can nibble away at one cause after another until you've solved them all.

In the unbounded case, eliminating one source of problems simply makes room for another source of problems to elbow its way in. Gardeners are familiar with this. Years ago my mother's garden was being crowded out by some aggressive ivy; once she had the ivy removed, that made room for a ficus vine to do the same thing.

The Administration's strategy on managing immigration recognized that people come to the United States for reasons including socioeconomic conditions, natural disasters, security conditions, and governance. But many countries in the world suffer from these same problems. Therefore a strategy focused on improving conditions in only a few countries while ignoring the others is not really addressing an actionable root cause. And root causes have to be actionable.

Two final thoughts

First, from the pure problem-solving perspective these empirical results are a good thing, because they teach us more about the problem. Remember that in processing an 8D, after you finish the action plan in D6 you have to check whether the implementation was effective. Did you make the problem go away? If yes, you can proceed to D7. If not, go back to D4, using the new information that you have just learned (namely, that your action plan didn't work) to re-do your root cause analysis. In this case, the results of the Administration's strategy at the border help us to figure out (as we saw above) that their application of the Pareto analysis was premature. That information should help make future analyses stronger.

Second, does anyone want me to try to sketch out what a full root-cause analysis of immigration ought to look like? (I mean one that incorporates the lessons learned that we discussed above.) I won't generate anything useful, of course. The issue is far too complex for any back-of-the-envelope scribbling to be practical. But if you think it would be conceptually helpful, leave me a comment. 

         

"The system is broken!"

As Quality professionals, we get into the habit of thinking along certain lines. Often these lines are very useful, which is why we develop the habits. And even when we knock off work to go home, it can be a huge benefit in our daily private lives not to blame people when things go wrong, to use incremental improvement to get better at golf, or to remember the process approach when negotiating with unhelpful Help Desks.

But every so often those habits can trip us up, when they encourage us to assume things that aren't really there. A couple of days ago I was talking to an official from ASQ, and questioned why I hadn't gotten a certain mailing. I was sure this was a sign that there was a bug in the routine that generated mailing lists, and asked for a bunch of information to help locate the error: "Which mailing list did you use? What email address does that list show for me?" After a while the answer came back, and it turned out that mailing hadn't gone out to anybody yet. Maybe I could afford to be a little more patient? 😀

The same thing can happen in bigger cases.

Last Friday, April 5, some 60,000 households in the Province of Alberta lost power in rolling blackouts, starting at 6:49 am and continuing over four hours until about 11:00.* Fortunately this was in April, so temperatures were a little warmer than they were back in January—the last time that Alberta's power grid almost failed. (I discussed that failure at the time in this post.) This time, thermometer readings hovered cozily right around freezing: from 28°F-32°F in Calgary, and from 30°F-32°F in Edmonton. Even the rural town of Conklin in the north-east experienced temperatures in the same range. Still, the unplanned blackouts caused understandable alarm across the province, and many people rushed to assign blame.

• Premier Danielle Smith said the blackouts were all because the market doesn't encourage natural gas plants to stay operating, so that they can pick up the slack in a moment when other sources fail. "This is at the heart of everything that we've been saying for the last year, that the system is broken."
• On the other hand, Marie-France Samaroden, the vice-president of grid reliability operations with the Alberta Electric System Operator (AESO), pointed out that gas plants aren't simply a panacea, because they are as subject to disruption as any other type of generator. And in fact one of the immediate triggers for Friday's blackouts was that the 420-megawatt Keephills 2 natural gas power plant went offline unexpectedly. (At the moment it is not clear why.)  
• Andrew Leach, an energy and environmental economist and professor at the University of Alberta, said that the whole market structure misallocates energy production, because it has been set up inflexibly. 
• Blake Shaffer, an associate professor of economics at the University of Calgary, summarized the situation by remarking, "People like to assign blame on power system woes to their least favorite generation technology. And the reality is, all generation technologies have reliability challenges." 

The last time I wrote about Alberta's power grid, I discussed the kind of analysis and planning that we might expect: FMEAs for individual components of the system, plus an overall system analysis for the entire grid. And I assumed that such an analysis, if it were thorough enough, would highlight exactly where Alberta has to take action to improve weaknesses, in order to prevent future failures. But I overlooked one huge fact that makes the entire problem far more difficult. It is only a small consolation to reflect that everyone else who has commented on the problem has made the same mistake.

The critical mistake we all have made is that we think of Alberta's electric grid as one large system. But it's not.

Think about it for a minute. The grid consists of producers (who generate power) and consumers (who use it). The producers are plants powered by natural gas or coal; wind turbines; banks of solar cells; and so forth. The consumers are private homes, businesses, and in fact even the production plants themselves to the extent that they need electricity to power their own operations. 

But now, what is a system? According to Wikipedia,** a system is "a group of interacting or interrelated elements that act according to a set of rules to form a unified whole"; and for the concept of system planning to make any sense at all, the planner has to be able to intervene in the system to adjust it in any spot where it is not running correctly. That's how a machine works, and it's how a factory works. All our Quality tools are designed to analyze systems that look like this.

And this is exactly what the Province of Alberta cannot do! Each of those producers is a private company. Each of the consumers is a private company or else a private citizen. The Province of Alberta has no authority to tell the owners of those power plants how to run their businesses, nor to tell private homes how much electricity they are allowed to use. But this means that the Province is powerless to reach in and adjust this or that element of the "system" in order to make the whole thing run better. (Or to keep it from breaking down!) The most they can do is to provide information and offer incentives in the hope of coordinating and influencing the behavior of the "system components." But those "components" remain stubbornly independent.

Of course I have overstated the situation when I say that Alberta's electric grid is "not a system." There are plenty of other systems that have the exact same features: the economy is one of them, and a natural ecosystem is another. Sellers and shoppers are "system components" in the economy; animals and plants are "system components" in a natural ecosystem. In both cases, the "components" do what they want, and not what we tell them to; but we still talk about both the Economy and Nature as "systems." All the same, it is important to recognize that they are systems of a very different kind than a machine or a factory, precisely because the "system components" can do what they want and ignore all our good planning. I won't enumerate examples when an attempt to plan the economy (or an ecosystem!) has had unexpected or unfavorable results, because you can probably come up with plenty of examples on your own. What is important is to recognize that Alberta faces the same kind of challenge in planning the electrical grid.

Does this mean blackouts are inevitable? Not exactly. But so long as the system is structured the way it is today, it is probably not possible to guarantee that future blackouts have been prevented.

Well, is it possible to restructure the system to prevent blackouts? Maybe, but take it slowly here. When I say that the current structure cannot guarantee an end to blackouts, I'm talking about the structure where producers and consumers are all independent. Theoretically I could imagine trying to "simplify" the system by giving the provincial government full authority over all the power companies and all the consumers. Then they could adjust the system wherever needed, to make sure it runs smoothly. But that's a lot of authority. 

Does anyone really want the provincial government telling them how many hours they are allowed to keep their lights on, or what days they are allowed to recharge their phones? Probably not. 

Or if you own a power company, do you want the provincial government to tell you how much you can produce and when you have to produce it, even if their decisions mean you lose your shirt? Again, probably not. 

Of course the whole question is a political one, to be answered by the voters of Alberta and not by me. But I can imagine an outcome where the voters decide that they'd rather put up with the risk of future blackouts, because the available alternatives are even worse. 

Like I said at the beginning, sometimes our habits as Quality professionals can mislead us. Our familiarity and facility with technical tools can make us think that enough technical skill can solve any problem. But sometimes the most difficult issues are not technical ones. 

_____

* You can google the event to find coverage. Here are some of the articles I consulted in writing this piece:
https://www-cbc-ca.cdn.ampproject.org/c/s/www.cbc.ca/amp/1.7165290
https://www.theenergymix.com/rotating-brownouts-in-alberta-highlight-need-for-more-flexible-grid/
https://tnc.news/2024/04/08/alberta-to-modernize-power-grid/
https://calgary.ctvnews.ca/alberta-s-second-grid-alert-in-2-days-leads-to-rolling-blackouts-1.6835023
https://globalnews.ca/news/10405013/alberta-electric-system-grid-alert-april/   

** https://en.wikipedia.org/wiki/System        

                    

Alberta gets cold in the winter

Alberta gets cold in the winter. Maybe you already knew that.

Last weekend it got cold enough that the Alberta Emergency Management Agency issued an alert: the electric grid was overtaxed, and was in danger of implementing rotating power outages unless Albertans cut back on their electricity usage immediately. The good news is that enough people responded right away to avert the crisis. The Globe and Mail reports on the story here, and YouTube has reported on it in a number of videos (for example, here).

How cold is "cold"? Calgary (in the south of the province) recorded temperatures as high as -17°F on Saturday, January 13; that same day, Fort Chipewyan (in the north) recorded temperatures as low as -49°F. (Neither of these numbers takes account of wind chill.) At those temperatures, a power outage could have been devastating, perhaps even lethal. It is tremendously fortunate that there was no need for one.

But it's hard to think that this weather—not to mention the consequent demand on the electric grid—was unexpected. As I suggested above, everybody knows that Alberta gets cold in the winter! So how did things get to the point where there was a serious risk of rotating outages? How could the system be functioning this badly?

A real answer requires real data, which is more than I have. The most I can do is to sketch how an analysis should be structured, and maybe incidentally to advance a hypothesis or two. If any of my readers live in Alberta, or are otherwise close enough to the event to have good data on what happened, please comment to set me straight! I would love to know the answer; and if my hypotheses turn out to be no more than hot air (excuse the pun), that's a small price to pay to get the facts.

The first step in an analysis is to understand the components that make up the system. According to the website of the AESO (Alberta Electric System Operator), 60% of Alberta's electricity comes from burning natural gas; 20% from wind turbines; 7% from coal; 6% from solar power; 5% from hydro power; and 2% from other sources. Last weekend, though, several of those sources were interrupted.

• According to The Globe and Mail, two of the natural gas plants were offline: one for maintenance, and the other (ironically) because of weather.
• According to EnergyNow.ca, the wind farms were shut down—even though there was wind—because in temperatures that low there is a high risk that the steel turbines will shatter.
• And several sources have pointed out that the biggest demand hit after dusk, when solar cells weren't collecting any sunshine.
• One report says that the coal-fired plants worked just fine; but at only 7% of the total supply (at least theoretically) they could only contribute so much. 

The second step is to understand the failures in those components that failed. Of these, I find the wind farms most interesting. I assume that there was some kind of FMEA done when the wind turbines were designed, and that it was this analysis which discovered the risk that steel parts shatter when they get too cold. Probably the shutdown protocol was defined as a protective measure, to reduce the risk of damaging or destroying the wind turbines.

In isolation from other factors, the logic here is impeccable. But in the context of the entire system, this "protective measure" means that when the weather gets very cold—in other words, precisely when we should expect the demand for electricity to spike—20% of Alberta's electric supply goes offline. Is that right? Is that how we want the grid to work?

This leads us to the third step of any analysis, and the one most likely to turn up unexpected conclusions: look at the system design as a whole to understand how failures might arise even when each component is behaving perfectly as designed. (See, for example, the discussions here and here.) Looking at the system also means understanding how it responds when individual components fail, as of course they are sure to do from time to time. And if you discover any critical points—places where the system is particularly fragile, or where it is highly likely to fail—those are the points you especially have to strengthen or stabilize. (Among other things, the system's capacity should be enough greater than demand that it can keep functioning even when some components fail.)

There is one more factor which will have to be part of any analysis, though it is not so much a separate step as a consideration that may affect the analysis in multiple places. Any decision made by or about a public utility is inherently a political decision, even if the utility is nominally private. This means that there will inevitably be factors involved in the decision quite different from those of pure design and operational functionality, and these factors cannot be ignored. As we have seen before: when the Quality process conflicts with the political process, the political process usually wins.   

The encouraging side to this last reflection is that it is to nobody's political advantage for the lights to go out in the middle of winter. So there is no reason to suppose that politics will get in the way of a proper root-cause analysis of last weekend's near-failure. 

               

Does ISO 9001 need a regulation about ethics?

"The key principle in selling is honesty. Once you know how to fake that, you’ve got it made."
— from Richard M. Huber, The American Idea of Success, cited by Quote Investigator.

Back in 2020, the ISO Technical Committee 176—they are the ones responsible for publishing ISO 9001 and its family of related standards—wrote a planning document N1308, called Future concepts. It identifies and explains a number of concepts which have to be considered in future revisions of ISO 9001, either because they have not been mentioned before (like "emerging technologies") or because stakeholders have found the existing treatment too thin (like "knowledge management"). Fair enough. This is exactly the kind of planning that you would hope to see.

But one of the topics listed is "Ethics and integrity." And I have to admit, I didn't expect to see that. It made me wonder, Does ISO 9001 need a regulation about ethics?

The report gives five reasons that ethics and integrity are important to Quality management:

• If people in the organization lie to each other (or, especially, if they lie to their managers) then top management won't know what is really going on and will have trouble making good decisions.
• If people in leadership roles do not model ethical behavior (if they are not seen to be ethical), then internal and external stakeholders won't trust them.
• Auditors have to be able to provide audit results to top management without partiality or bias and without fear of retribution, or their audits are worthless.
• If internal and external communications aren't honest, there is no way to maintain the effectiveness and integrity of the organization's activities and systems.
• No organization can ever have enough resources to force its people to comply with the Quality Management System if they don't approach their jobs with basic integrity. 

All of these statements are true. All of them are perfectly valid reasons why a concern for ethics and integrity has to be at the root of any Quality system.

So where's the issue?

There are three things about the proposal to add ethical requirements into ISO 9001 that give me pause. I don't exactly disagree, but the proposal raises some questions for me.

My first concern is the simplest: The assumption of truthfulness and integrity is already implicit in the current standard. 

• When clause 4.1 says, "The organization shall determine external and internal issues that are relevant to its purpose and its strategic direction and that affect its ability to achieve the intended result(s) of its quality management system," that requirement is formally synonymous with saying, "The organization shall determine external and internal issues that are relevant to its purpose and its strategic direction and that affect its ability to achieve the intended result(s) of its quality management system, and shall not lie about them."
• When clause 9.1.3 says, "The organization shall analyse and evaluate appropriate data and information arising from monitoring and measurement," that requirement is formally synonymous with saying, "The organization shall analyse and evaluate appropriate and truthful data and information arising from monitoring and measurement, that have not been twisted or misreported by unethical employees or other intermediaries."

For that matter, when a cake recipe in a cookbook lists the required ingredients, there is never a note saying, "Do not substitute flour with sawdust, and do not substitute vanilla extract with battery acid." In general, whenever we read any kind of instruction or requirement anywhere, I think we always assume that the meaning is that we should really do whatever the thing is we are being told to do, and not just pretend. So it's fair to ask, What makes ISO 9001 any different? Why do we have to make the requirement for ethical behavior explicit here, when we never think of doing the same thing in a cake recipe?

My second concern is a little more delicate: How do we plan to audit ethical requirements, and to avoid the risk that ethical topics become politicized? Audits, after all, require objective evidence so that any observer can agree on the facts. But some ethical topics (at least in the United States) are also political topics, where such agreement cannot be assumed in advance. For example, the document Future concepts states that one element of ethical behavior is to "treat others fairly, courteously, with dignity, and without prejudice or discrimination." I assume everyone agrees with that principle. But this country has seen some difficult and painful litigation around the question of exactly what behavior counts as treating others "without prejudice or discrimination." And I do not look forward to a time when individual auditors might feel authorized to rush in where the courts fear to tread. We auditors are like everyone else: our personal opinions are all over the map. So if we are allowed to write audit nonconformities against ethical topics, I hope that we can be given some kind of guidance to ensure we do it in a uniform way.

My third concern is maybe the most fundamental one: With respect to the topic of ethics and integrity, if you have to spell out the requirements in words, you've already lost the battle. We all know that as soon as any requirement is codified in words, people will start weighing the words on a balance scale to figure out how little they can get away with and still comply. We have all seen this, one time or another, whenever there is a written Quality Management System. I'm not saying that every organization just skates by! Not when you look at the big picture. (Of course there are always a few that do.) But even in the best organization, somebody in some department is having a bad day ... and is feeling overworked ... and is asking himself what's the bare minimum he has to do before he can go home. It's the way of the world. Put ethical requirements into the standard, and they become just one more requirement to be niggled to death. It's like the quote at the top of this essay.

Of course, maybe we've gotten to the point that we really need to require ethics and integrity in the standard, because we can't take them for granted otherwise. In other words, maybe the proposal to add ethical requirements should be seen as a symptom of a larger picture about the condition of organizations as a whole. But if that were true, it would make me very sad. And I think that's the kind of situation that no written standard can overcome, precisely because people treat standards as obstacles to be parsed and niggled and lawyered. I hope that ethics and integrity are broader and grander than that, but I might be disappointed.

"When the great Tao is in decline,
Benevolence and loyalty appear.
As wisdom arises, so does hypocrisy.
Only in a feuding family do filial piety and parental doting become conspicuous.
Loyal ministers emerge whenever the country is in chaos."

"When Tao is lost, there is goodness.
When goodness is lost, there is kindness.
When kindness is lost, there is justice.
When justice is lost, there is [compliance to standards]."

— from Lao Tzu, Tao Te Ching, chapter 18 [translated by Han Hiong Tan] and chapter 38 [translated by Gia-fu Feng and Jane English, 1989]