Meltdown

January 15, 2018
Clearfield, a former derivatives trader, and Tilcsik, a management academic, share cautionary tales of disaster resulting from small vulnerabilities in large systems. Their analysis is enlightening but they flounder in translating their insights into usable takeaways. Clearfield and Tilcsik’s approach centers on sociologist Charles Perrow’s 1984 theory that as a system’s complexity and “tight coupling” (a lack of slack between different parts) increase, the “danger zone” does as well. Clear, well-paced storytelling around diverse events, including a fatal D.C. Metro train accident, Three Mile Island, the collapse of Enron, Volkswagen’s emissions cheating, the Flint water crisis, the 2017 Oscars mix-up, and the commandeering of a Starbucks hashtag by the company’s critics, will keep readers interested, whether or not they are invested in the organizational lessons. The solutions offered, however, tend toward the less-than-revolutionary: keeping decision-making parameters clear, increasing workforce diversity, and building organizational cultures in which dissent is genuinely encouraged. Clearfield and Tilcsik’s most important warning is about the “normalization of deviance,” when people come to redefine commonly encountered risks as acceptable, as can occur when automated warnings constantly cry wolf in hospitals. This manual articulates the ubiquitous nature of system failure well, but its approaches to “reducing complexity and adding slack” are too vague to be practically implementable.