Chapter 3. Operator Error

Owing to its location across the street from the firm’s headquarters, O’Gradys was such a part of the social fabric of the firm that it was referred to as “the dining room.” As Linda made her way to the second floor of the bar, she nodded and waved to her colleagues packed in small groups around tall tables cluttered with beer glasses.

The second floor was far more subdued. Linda saw Bill and Ollie sitting across from each other in a booth. As she slid into her seat next to Ollie, Bill was shaking his head.

“The thing that makes absolutely no sense is, does anyone really believe that now that Mike is gone, we’re never going to have network outages?”

“Of course not,” said Ollie.

“We’re not even a little bit less likely to have these incidents,” Bill continued. “In fact, we’ve just fired the guy who knows the most about our network.”

“He’s certainly the expert in these particular incidents, having caused them,” said Ollie.

“You’re right. Mike was the guy who could have made the network better and more resistant to these types of errors.”

“No one is arguing that Mike was a great engineer,” said Linda. “But we have to hold people accountable for their actions.”

“What does that even mean, ‘accountable’?” Bill said, a little too loudly.

Linda was taken aback by Bill’s anger. “You know what it means. We need to hold someone responsible so that people think twice before doing these kinds of things again.”

“Which kinds of things?” Bill asked.

“Is there any disagreement,” Linda said, “that it was Mike who took down the network more than once?”

“Yes, he did take down the network,” Bill said, “but not on purpose. He wasn’t being malicious—he was trying to do his job. The best job he could, given what he knew at the time. He was trying to fix it, not to make it worse. It was an accident.”

“An accident that cost the firm money,” Linda said. “He should have been more careful, since he knew he was working on our live network.”

“Mike is one of the most careful and experienced engineers that I’ve ever worked with. Strangely, no one is talking about all the times that Mike kept the network running.”

“Again,” Linda said, “the point is, Mike took down the network. He’s responsible for that. He caused this outage.”

“Is he the root cause, though?” asked Bill, staring at Linda.

Linda shifted in her seat. “I guess he is. Without Mike and what he did, we wouldn’t have had this outage. As you said to Roger, it was an ‘operator error,’ and Mike is unquestionably the operator here.”

“Ah, right,” Bill said. “‘Operator error.’ That’s just something that sounds like a good answer to Roger’s question of who we’re going to fire. So the logic goes, if Mike’s the root cause, the operator, let’s fire him, and we’ll never have network outages again.”

“Well, we’ll have outages, just not outages caused by Mike.”

“That’s right,” Bill said, “they’ll be caused by other engineers being ‘careless and irresponsible,’ as Roger says. In fact, I won’t be surprised if we have an outage similar to this one in the future. Any other engineer, regardless of experience, would have made the same mistake that Mike did. I can’t even call it a mistake; he was doing the right thing—the thing that normally works—but it didn’t work as expected under these particular circumstances.”

“OK, Bill. So if Mike—or operator error—are not the root cause, what is?” asked Ollie.

“I don’t know, Ollie,” Bill said. “But one thing is for sure: if there is a single root cause, we haven’t found it yet, and I don’t know if we will.”

Ollie’s eyes narrowed. “What do you mean, if there is a root cause? Things don’t happen randomly, right? You can’t be an engineer without believing in cause and effect.”