Why Hierarchy Creates Clusterfucks

At Unqualified Offerings, thoreau devotes a post to "an important point about organizing a bureaucratic organization." Most of my post will consist of the money quote from thoreau's original, inspired piece, and a digest of the debate that ensued in the comment thread. My development of the issues, which follows, is a minority of the whole thing. But I strongly recommend you read the first part in full, because it's one of the most intellectually engaging debates I've read in a long time.

Thoreau, in the body of his post:

If you make it costly to go through Official Channels, people will find ways to do things outside of Official Channels. Most of what they do will be harmless. However, some of it won’t be. By driving the activity underground you guarantee the following:

1) Harmful activities will not be spotted except through chance or when there’s An Incident. And we all know what bureaucracies do when there’s An Incident.

2) There will be no chance to work with people on making their activities safe, because they won’t come to you in advance. The only chance you’ll have to talk to them is when they get caught by chance (at which point they’ll be more focused on doing a better job of keeping secrets) or when there’s An Incident (at which point their main concern will be deflection of blame).

3) The institutional culture will develop an even greater disdain for Rules and even (in many cases) for Safety. Given the realities of how these things work out so frequently, disdain for Rules and even Safety (in most cases) is largely a healthy thing. However, to the extent that a bureaucrat actually values these things, that bureaucrat should try to make it so that doing things through Official Channels is cheaper than skipping Official Channels. That’s your only hope of getting people to actually respect these things. Well, there’s also fear, but fear isn’t respect. It’s mindless, panicked compliance, and it can fade over time, or motivate people to find even better evasive tactics.

Another thought on when there’s An Incident: Besides all of the usual problems with incentives and information in large institutions, it occurs to me that size guarantees that the people responsible for Safety, Compliance, and related matters will be separated from the people on the ground doing whatever it is that the organization is allegedly there to do. Consequently, the person who enforces a ridiculous rule, or who makes you sit through a useless presentation full of statements that are at best insulting and at worst factually wrong, will not be having lunch with you. Often the local enforcers (especially people whose primary task is something other than Safety) are more reasonable than the distant enforcers because, frankly, they need to be. Yes, their access to local information leads to smarter decisions, and they have at least some sort of incentive to see that the job gets done (whereas the distant enforcers only care about Compliance). But they also can’t afford to piss everyone else off (too much) because they will be having lunch with everyone else. If they insult everyone else with a boring and factually wrong Powerpoint, they’ll be ostracized.

This elicited an immediate response from Eli Rabett -- the first in the comment thread:

Obviously you never had to clean up after a big one, like one where a) people get seriously hurt and b) the potential for more to get hurt and buildings to go blooey is not zero.

Let Eli tell you a story about a physicist who thought he knew what he was doing, and was sucking silane into a cryopump, until the pump blew up and took most of a student’s hearing and almost the student, and there was a second cryopump in the system that had not YET blown up.

Clowns who think safety is a joke are auditioning for a Darwin test.

As you might expect, a vigorous debate ensued. First, thoreau's rejoinder:

I don’t think that safety in the lab is a joke, Eli.

I think that most of the safety training sessions that I’ve sat through were worthless, that many of the procedures are more focused on covering bureaucratic ass than on helping people do things safely, and that anybody who relies on the safety officers to tell him how to be safe (as opposed to learning everything he can about the apparatus that he’s using, and learning from other people’s experiences with similar apparatuses) is the one auditioning for a Darwin Award.

I think that clowns who say “Look! Somebody almost died in some other context!” as soon as somebody criticizes a safety rule (I’ve dealt with such people) are the ones who lack the critical thinking ability to think through a situation and make good choices.

A student once left a harmless chemical in a refrigerator that had food. This refrigerator was NOT in a lab. Again, the refrigerator was NOT in a lab. Please re-read that sentence as many times as you deem necessary.

I will be the first to say that the student should be severely chastised and learn a very harsh lesson. Not because there was anything remotely dangerous about the situation, but because the student needs to learn good habits if he is going to avoid truly dangerous situations. (In fact, I was hoping that Samuel L. Jackson might get involved, and say something about the path of the righteous man, just to really make the lesson as dramatic as possible.)

Instead, the response was to take away the refrigerator. A refrigerator that was NOT in a laboratory room. A refrigerator that was in fact in an office. One joker even tried to ban food from the room before I pushed back. Again, the room was NOT a laboratory. It was a shared office area.

And when I said that this was stupid, do you know what the response was? Some idiot pointed out that a student had died in a fire in a chemistry lab at another school. As if that had anything to do with this.

What did the student learn? The student learned that if you get caught people will do stupid things. The teachable moment was tainted.

At this point it is customary for somebody to point out that a person once died or nearly died in some other situation. As if that had anything to do with this....

And of course, I had to jump in:

The point is not that safety considerations are a joke. It’s that if pointy-haired bosses several steps of bureaucratic hierarchy removed from the actual situation make safety rules that are effective, it will be by accident.

The best preventative measure against the kind of incident you described would have been collective policing within the department, by colleagues who actually understood the technical issues involved. If the physicist who thought he knew what he was doing really didn’t, what makes you think some fucking pointy-haired boss insulated from direct contact with the situation by several layers of bureaucracy would know?

Ever play the telephone game? It results in fucked up communication filtering even without power relationships coming into consideration. As R. A. Wilson pointed out, hierarchies are a cybernetic nightmare with one-way information flow.

Information is systematically filtered as it travels up a hierarchy, because power relationships distort communications. Everyone self-censors in talking to a superior, so that the person at the top of a hierarchy lives in a completely imaginary world. According to Wilson, rational behavior requires accurate feedback about the actual effects of one’s decisions — i.e., two-way communications between equals. A decision-maker who is cut off from accurate feedback by the unidirectional communication in a hierarchy becomes functionally insane.

In short: a boss or bureaucrat wouldn’t know an effective safety rule if it bit him on the ass.

Let me pause here to insert Wilson's remarks on Proudhon, because they're so damned brilliant.

A civilization based on authority-and-submission is a civilization without the means of self-correction. Effective communication flows only one way: from master-group to servile-group. Any cyberneticist knows that such a one-way communication channel lacks feedback and cannot behave "intelligently."

The epitome of authority-and-submission is the Army, and the control-and-communication network of the Army has every defect a cyberneticist's nightmare could conjure. Its typical patterns of behavior are immortalized in folklore as SNAFU (situation normal—all fucked-up), FUBAR (fucked-up beyond all redemption) and TARFU (Things are really fucked-up). In less extreme, but equally nosologic, form these are the typical conditions of any authoritarian group, be it a corporation, a nation, a family, or a whole civilization.

Or as he put it in Illuminatus!:

A man with a gun is told only that which people assume will not provoke him to pull the trigger [or fire them--K.C.]. Since all authority and government are based on force, the master class, with its burden of omniscience, faces the servile class, with its burden of nescience, precisely as a highwayman faces his victim. Communication is possible only between equals. The master class never abstracts enough information from the servile class to know what is actually going on in the world where the actual productivity of society occurs.... The result can only be progressive deterioration among the rulers.

The innominate one added some experiences of his/her own illustrating the idiocy of the bureaucratic safety process:

Our yearly safety training meetings are heavy on chemical hazards, despite the fact that our university has a web-based centralized inventory records system for hazardous chemicals. So, in theory, the safety people could do what I suggested in writing year before last and check the chemical inventory of all labs in our department and then tailor the safety training meeting to something useful. Guess what didn’t happen. We heard the same spiel about hydrofluoric acid and P-listed wastes (no definition or explanation of what the hell a P-listed waste is). We’re a biology department, heavy on ecologists. I bet no one in our department uses that crap.

This year, at least, they added a section on dealing with biohazardous wastes, which if memory serves was another suggestion I made two years ago (though this might be a memory of convenience). However, we are still instructed to dispose of materials which are not biohazardous in the biohazardous waste disposal, which is a waste (no pun intended) of money.

I did learn from the biohazard disposal training that all rDNA organisms must be deactivated before disposal. No definition of what an rDNA organism is was provided. After the lesson I asked the obviously clueless trainer for a definition and he stated that he thought it was an organism with ribosomal DNA. I said, so, all organisms everywhere? But not viruses, which arguably aren’t organisms and definitely don’t have ribosomal DNA. Viruses must not need to be deactivated before disposal.

Eli made it clear he wasn't having any of it:

1. There was NO ONE in the department who understood the danger. When the EE and I on the investigation committee heard about what was being done we turned white and he is black. We also closed the lab down immediately because of the remaining pump.

This later became an issue years later when the clown sued for persecution. As it happened I had retained the investigation report, so yes, record keeping is important.

2. It is the responsibility of the DEPARTMENT to work with the ES&H office to tailor safety training to risks in the department.

3. On the refrigerator thing, you can look at it another way. From the viewpoint of ES&H it had already been shown that there was a failure of safety training, and given that safety for undergrads should be much more failsafe, the fridge was a risk. You had to do much more than say we ain’t gonna do it again to get that fridge back.

4. A lot of this is the same idiocy as the PFM thing. If you want safety training to be tailored, you are going to have to work with the safety trainers. That means hours of soul deadening meetings, written reports, taking responsibility if bad things happen (we said do it this way and we were wrong) and more.

You guys appear to think that Osha is a village in Wisconsin....

5. Think of it as training your students for industrial and government lab jobs.

The innominate one explained what "working with the safety trainers to tailor safety training" translated to, in practice:

“It is the responsibility of the DEPARTMENT to work with the ES&H office to tailor safety training to risks in the department.”

ES&H has to be willing to do so. Since ES&H has responsibility for conducting safety training, why don’t they take the initiative in getting the department to work with them to customize the training into something useful? I bet it’s because:

1. most ES&H people aren’t hired with an eye toward having expertise in the various areas needed to be aware of safety concerns in such differing areas as chemistry, biology and physics (not even counting the range of variation within just one of those sciences)

2. in my experience most ES&H people don’t know anything more than what the regulations are, no real lab experience. As an example, I refer you to my anecdote above about rDNA organism deactivation.

3. it’s easier to just keep doing what you’re doing and give the same, general training instead of doing the work to develop customized training. just do the same thing that’s always been done, and your ass is covered until someone screws the pooch, then just add a few minutes to your training session the next time to explain the newly discovered problem.

Hey, you want to see some truly useless training? Get MSHA safety certification.

And thoreau added some comments on the same theme:

Your attitude seems to be that we exist to serve the safety office, not that the safety office exists to serve us....

A system where the Safety Office provides training that is unresponsive and useless (as in TIO’s case), and where they recommend unnecessary, expensive, and possibly even inadequate procedures (e.g. TIO’s example of treating chemical waste as biohazardous waste, despite the differences between the two types) is a system that will NOT lead to safe outcomes. It will NOT avoid An Incident. I care about safety enough to want intelligent rules that lead to safe practices. I care enough about safety to want teachable moments to be used productively.

In my example, I was not the one primarily interacting with the students who put the chemicals in the fridge–I only got involved because the fridge was in an office that my students shared with the students in question–and I was out of town when it happened (so I was putting out fires via email). Had I been in front of the students, I would have delivered a lesson on habits, and how they were lucky that it was a completely benign chemical in a sealed container. I would have pointed out what could have happened if they had gotten into the habit of putting chemicals next to food, what could have happened if they did not have well-honed habits and multiple layers of safeguards. And then I would have read them the riot act and pointed out the other things that could have gone wrong, i.e. the possible administrative consequences. In other words, I would have been factual rather than capricious.

I could give other examples where I’ve seen IT, Conference Services, and other support departments act like we exist to serve them, and make cooperation expensive, and the consequence has been that people keep their activities (mostly harmless, but not always) hidden. You can take the moral stance that we just ought to do things the right way, and you aren’t even wrong. However, you are not designing a system with incentives that get good results from real people in the real world.

Since we were all sharing stories about specific examples of Pointy-Haired Bossism in the safety field, I reentered the fray with some juicy ones of my own:

I’ll give a couple examples of my own.

At the hospital where I work the Infection Control policy is to wear gowns and gloves in the rooms of patients on contact isolation (as well as masks if it’s droplet isolation). But when we transport them through the halls, the patients are not to wear isolation gear of any kind. Why? It might alarm visitors and other patients.

The written policy re masks for droplet isolation is to wear them at all times in the room. Then take them off outside the room and deposit them in the trash can outside the door. After all, it wouldn’t make much sense to wear the mask in the room till you finished your task, and then take it off and walk the eight feet from the patient’s trash can to the door unprotected — right? Only we don’t have trash cans outside the door, because there are extremely detailed bureaucratic rules on what can be in the halls — it’s a JCAHO fire safety thing.

I would also add that the safety departments in most large organizations are a stovepiped bureaucracy whose policies aren’t coordinated with those of the other bureaucracies. Their main purpose is to have a safety policy on paper so their asses are covered, and they can point to it to impress the visiting JCAHO inspectors (who, despite supposedly accrediting hospitals for safety and quality, never never ask how the patient care floors are staffed).

Meanwhile, on the patient care floors, the orderlies have ten or upwards patients apiece, and nurses stay over two or three hours finishing paperwork they couldn’t get done on-shift because of patient load and acuity. Half our patients have bed alarms because they are confused and get up by themselves. Now, imagine that you’re one of two orderlies on a floor with 20 patients, your coworker is tearing her hair out trying to run to three call lights at once, and you’re tied up in with a patient on contact isolation. If several bed alarms start going off around the floor, and you’ve got to get out of the isolation room and get to them before the patients fall down and crack their skulls, what’s gonna give? If you guessed “handwashing and other contact precautions,” you win the kewpie doll!

I’ll close with an example from the news. Several years back a PETA activist took a job undercover at Tyson and filmed chickens being manually decapitated when the machines got jammed up. The boys in the C-suite (of course) screamed “Foul!” and pointed to their written policies and training films on humane measures that prohibited manual decapitation. “But we have a written policy! We told him!”

The PETA activist said, yeah, I saw those films. And then my supervisor told me, when the machine’s jammed, this is how we do it manually (wink, nudge). But all that mattered was that senior management’s asses were covered because they had a written policy.

Auschwitz probably had a “written policy” against killing Jews.

Poor Eli, having suffered about all the abuse he was willing to take, took a Parthian shot:

No, Eli’s attitude is that you, or your students can not exist if you don’t have a functioning safety culture.

Let me tell you a story about a long time friend and megabigshot who told Eli what he did on his first day of retirement. He said: “I went to my new office which they gave me for being emeritus, I put up my feet on the desk and relaxed and gave thanks that none of my students or co-workers had ever been hurt when I was in charge.”

Running a lab is an immense responsibility for the lives and safety of others and the kind of attitudes being displayed here are invitations to disaster. The tension is that you can’t have a failsafe environment, but have to build on and rely on good judgement for many things. The mismatch with ES&H is that they are built to ensure failsafe.

And thoreau presented the closing argument for the prosecution:

So, let’s talk about the attitudes that we’ve been displaying toward safety:

1) In the refrigerator incident, I specifically said that instead of insulting the students’ intelligence and pretending that the chemical in question was dangerous, we should have made it clear that the HABITS (i.e. part of a functioning safety culture) that they were displaying were dangerous. The reason to never, ever leave any chemicals in the fridge, even benign ones, is that it develops a bad habit.

So far, I’m all about safety culture.

2) Several of us said that safety training sessions should focus on things that are actually relevant to the real hazards in the department. This way people see the safety training as something useful, rather than a wasted hour. Again, a functioning safety culture requires productive discussions of safety issues.

3) TIO pointed out that EH&S couldn’t even be bothered to consult an existing chemicals inventory, to make sure that the actual chemical hazards in the department were addressed. Paying attention to documented hazards is another important part of a functioning safety culture.

4) TIO also pointed out that EH&S urged a blanket policy of disposing of everything as biohazardous. In a functioning safety culture, you sort out materials according to hazard type and dispose of each accordingly, rather than mixing different categories.

5) Kevin Carson pointed out a complete lack of attention to critical chokepoints in the safety procedures at his hospital, specifically inadequate staffing. In a lab, the number one rule is never work alone. In a larger operation, the generalization of that rule would be to never work when there are too few people to address a dangerous situation. Again, safety culture.

6) I specifically said that a person using a piece of equipment has an obligation to research that piece of equipment, and learn about hazards that others have encountered with similar equipment, rather than relying on that 1 hour powerpoint presentation. Again, that’s part of a functioning safety culture.

Your only point in this entire thread has been that we should have more respect for the bureaucracy, even though we have repeatedly given examples of how bureaucratic thinking was at best orthogonal to good safety culture and at worst counter-productive.

Maybe your EH&S department is so superbly competent and useful that you cannot imagine any of the problems that we have described. Or maybe you are having an affair with the head of EH&S at your institution and consequently you cannot tolerate any criticism of the person supplying you with blowjobs. Either way, you need to stop and actually think about the experiences that we are describing.

Now, this is going to be me typing from here on out.

I think Eli writes from an implicit Weberian/Taylorist perspective embedded in the original Progressivist ideology of the early 20th century, which was very heavy on apolitical, immaculate expertise as a way of transcending the irrationality of "mere" politics and class conflict. See, for example, here and here.

To someone working from Eli's perspective, the functionaries in the office with a plate on the door reading "Safety" 1) really are motivated primarily by a desire to promote safety, and 2) are the best judges of how to accomplish this. In short, the pointy-haired bosses mean well, and they don't have their heads up their asses. It follows that if you make snide comments about any "duly constituted authority" with X in its title, you are opposed to X.

Analysis of Point 1. Any office, regardless of its ostensible official purpose, will be headed by functionaries whose primary skill is advancing up a hierarchy through bureaucratic infighting. The ostensible purpose of their office will always take (at best) second place to ladder-climbing. That was the argument of Robert Shea, in "Empire of the Rising Scum":

Every combination of two or more human beings has both a useful aspect and a political aspect. These tend to conflict with each other. As the political aspect becomes more and more influential, the organization ceases to be useful to its members and starts using them.

Why does this happen? Because the better an organization is at fulfilling its purpose, the more it attracts people who see the organization as an opportunity to advance themselves.

The ability to get ahead in an organization is simply another talent, like the ability to play chess, paint pictures, do coronary bypass operations or pick pockets. There are some people who are extraordinarily good at manipulating- organizations to serve their own ends. The Russians, who have suffered under such people for centuries, have a name for them-- apparatchiks. It was an observer of apparatchiks who coined the maxim, "The scum rises to the top."

The apparatchik's aim in life is to out-ass-kiss, out-maneuver, out-threaten, out-lie and ultimately out-fight his or her way to the top of the pyramid-any pyramid. Appropriately, Russia produced a superb specimen of homo apparatchikus--Josef Stalin.... Niccolo Machiavelli wrote a handbook for apparatchiks that is unsurpassed to this day--The Prince. But the most successful of this breed need neither exemplars or hand-books; they seem to know instinctively what to do....

Unfortunately, the existence of this talent means that every successful organization will sooner or later be taken over by apparatchiks. As such people achieve influence within the organization, whenever there is a conflict between their own interest and the interest of the organization, their interests will win out. Thus, over time, the influence of apparatchiks will deflect the organization further and further from its original intent....

Any policy they adopt in the name of their ostensible purpose -- "safety" or whatever -- will have the primary purposes of: 1) covering their asses and deflecting blame in the event of (thanks, thoreau) An Incident by having an impressive-looking policy in place on paper -- regardless of whether or not it works; 2) minimizing the autonomy and discretion of their subordinates; and 3) maximizing the flow of money and perks upward.

Analysis of Point 2. The cognitive and information-flow problems inherent in hierarchy mean that -- even if the bosses really did genuinely want to maximize the ostensible goal of "safety" or whatever -- they still wouldn't know an effective policy if it bit them in the ass. It's almost guaranteed that whatever policy they adopt will be directly counterproductive to their stated purposes.

People who advance in bureaucratic hierarchies tend to be those who started out learning to shut off their capacity for critically evaluating the statements of those in authority in terms of evidence or logic (see here and here). As such, a person at any level in a hierarchy above the bottom rung is likely predisposed to evaluate all statements based on the authority of their source.

In addition, the higher one advances in a hierarchy, the more likely they are to be surrounded by people who are afraid to tell them anything except what they want to hear. Any subordinate who points out possible unintended consequences of a policy proposal, or who points out unforeseen consequences of an actual policy in place, will be perceived as a "troublemaker" or "not a team player." This is what Irving Janis called "groupthink."

Consequently, the people who make "safety" or any other policy will almost certainly be operating on the ingrained assumption that "executive-type hair" is a badge of superior knowledge on any subject for which they are making policy. They will, therefore, see any questioning of the effectiveness of a policy as a sign of a "bad attitude," and will label as "noncompliant" any attempt by those in contact with the situation to mitigate the clusterfuck that would result from strictly adhering to management policy.

Take another look at my comments above on R.A. Wilson and Proudhon.

We can state, as a general rule, that -- as a result of both the incentive-alignment and cognitive problems outlines above -- the intrusion of authority into any organizational relationship will produce suboptimal results. Any attempt by those in authority and removed from a situation to interfere with the judgment of those directly engaged and experienced in it will result in irrationality.

Organizations continue to function only because those directly engaged in the situation treat intrusions of management irrationality as an obstacle to be routed around -- just as the Web treats censorship as damage and routes around it. The fastest way for subordinates to destroy an organization is by always adhering to official policy in preference to their own judgement. This is the basis of the devilishly effective labor tactic known as working-to-rule.