I was struck by this example from Practical Engineering of a bridge that collapsed.

The bridge had been reviewed many times by many agencies and problems had been identified.

The bridge had obvious structural deficiencies: one of the key supports had rusted through and no longer connected at all to the foundation.

Still, it wasn't until the bridge collapsed when a bus (with multiple cameras, capturing dramatic footage) drove over it.

How did this happen? The bureaucracy was aware of the deficiencies and information was flowing through the process.

A bureaucracy is a machine that takes alive responsibility and turns it into dead process.

If there is a gap in the machine's process, a wire that is crossed or where an alert signal doesn't make it, nothing alive will run into it.

"I just ran the report, and am graded on how many I produce a quarter, I'm not empowered to ensure the dire recommendations are followed"

A living structure and a dead one look totally similar but work for totally different reasons.

The bureaucracy process morphs a living, possibly unfair process to a dead, fair one.

The process is highly structured and humans are disempowered in it.

No one can say "guys, the steel has rusted and no longer connects to the concrete footing, obviously shut it down"

What Dan Davies would call an accountability sink.