Published Date: 2013-10-02
| Postmortem Analysis | |
|---|---|
| Timeline | 1. The software failure incident happened in October 2013 [Article 22081, Article 22098, Article 22157, Article 22166, Article 22417, Article 22739, Article 22826, Article 22994, Article 23673]. |
| System | 1. Major software component designed by private contractors [Article 22417] 2. Online health exchanges computer underpinnings [Article 22418] 3. User interface [Article 22739] 4. Data center access [Article 22826] 5. Backup system [Article 22826] 6. Architecture of the system interacting with the data center [Article 22826] 7. Hardware and software defects [Article 22826] 8. Database technology [Article 22826] 9. Information technology system [Article 22994] 10. Online exchange [Article 23673] |
| Responsible Organization | 1. The Medicare and Medicaid agency assumed the role of project quarterback and had the responsibility for ensuring that each separately designed database and piece of software worked with the others, which was a critical decision that some doubted they had the capability to handle [22081]. 2. The Obama administration was criticized for project management issues, inexperience, and the inherent difficulty of software development [22098]. 3. CGI Federal, a major contractor involved in building the website, reported to the government that they did not have enough time to test their product and faced challenges accessing computer logs for testing [22166]. 4. A major software component designed by private contractors crashed under the weight of millions of users, resulting in technical problems in the online health insurance exchanges [22417]. 5. Contractors involved in building the website, such as QSSI and CGI, were responsible for specific functions like account registration and shopping/enrollment parts, which faced issues due to lack of coordination and testing [22256]. 6. Issues related to defective code and the inability to handle a high volume of users were reported by David Nelson, director of the office of enterprise management at CMS [22994]. 7. The feuding between contractors, infighting, and the need to replace successfully used software with untested versions contributed to the software failure incident [23673]. |
| Impacted Organization | 1. Users trying to access the HealthCare.gov website, as reported facing issues such as being unable to log in, encountering frozen pages, error messages, and long waits [22081, 22098, 22157, 22417, 22418, 22994]. 2. Contractors and companies involved in building the website, such as CGI Federal, Quality Software Services Inc. (QSSI), Development Seed, Oracle, and others, who faced reputational risks and had to publicly distance themselves from the troubled project [22081, 22098, 22256]. 3. The Obama administration, which expressed embarrassment over the technical problems and had to work hard to fix the glitches on the website [22098, 22157]. 4. The federal government, which faced criticism for project management issues and the failure of a major software component designed by private contractors [22098, 22417, 22826]. 5. The Centers for Medicare and Medicaid Services, which were involved in the project and faced challenges such as not having enough time for testing and issues with computer logs [22166, 22826]. 6. The state officials involved in the online health exchanges, who had to strengthen the computer underpinnings of the system due to inadequate handling of consumer inquiries [22418]. 7. The information technology team at the Centers for Medicare and Medicaid Services, who raised concerns about the system's ability to handle users and identified issues like defective code [22994]. 8. The project managers and key people involved in the project, who faced internal disputes, lawsuits, and challenges with the software used for testing and federal security requirements [23673]. |
| Software Causes | 1. The failure of a major software component designed by private contractors that crashed under the weight of millions of users [Article 22417]. 2. Bugs preventing the software from performing as intended [Article 22157]. 3. Adding new software improvements to the website while it was still running, exposing users to potentially insecure updates [Article 22166]. 4. Lack of testing resulting in issues in the shopping and enrollment parts of the process [Article 22256]. 5. Front-end issues related to the user experience, particularly with the Javascript code [Article 22739]. 6. Defective code causing the system to fail to handle the required number of concurrent users [Article 22994]. |
| Non-software Causes | 1. Politics and delays in issuing major rules until after elections [22081] 2. Lack of experience in managing large-scale software projects [22098] 3. Pressure on the administration to add new software improvements while the website was still running [22166] 4. Inadequate management of contractors and lack of coordination among them [22256] 5. Insufficient access to a data center and lack of a backup system [22826] 6. Feuding between contractors, key personnel quitting, and infighting leading to work stoppage [23673] |
| Impacts | 1. The software failure incident resulted in technical problems that hampered enrollment in the online health insurance exchanges, causing a major software component to crash under the weight of millions of users [Article 22417]. 2. The system was overwhelmed with traffic on its first day, leading to ongoing problems with responsiveness and functionality [Article 22250]. 3. The software issues caused frozen pages, error messages, and bugs that prevented the software from performing as intended, affecting the user experience and functionality of the website [Article 22157]. 4. The failure of the software led to network outages and a lack of confidence in the ability of the system to function properly, requiring significant efforts to fix the glitches and restore trust [Article 22166]. 5. The software failure incident resulted in a lack of coordination among the 55 contractors involved, leading to additional problems in the shopping and enrollment parts of the process [Article 22256]. 6. The software defects and design flaws contributed to a situation where the website was not able to handle the initial demand, causing frustration among users and government officials [Article 22418]. 7. Security vulnerabilities in the software exposed users to risks such as personal information theft, data modification, and potential infrastructure damage by hackers [Article 24053]. |
| Preventions | 1. Adequate time for testing: The software failure incident could have been prevented if there was enough time allocated for thorough testing to identify and correct any flaws [22098, 22166, 22256, 22739]. 2. Effective project management: Ensuring that all contractors involved in the project are coordinated and that all pieces are working together could have helped prevent the failure incident [22256, 22826]. 3. Addressing defects and issues early: Identifying and addressing defects, defective code, and issues like network outages early in the development process could have prevented the software failure incident [22157, 22417, 22994]. 4. Avoiding rushed schedules: Rushed schedules, such as the compressed schedule for opening the site on October 1, did not allow enough time for adequate testing, which could have been avoided to prevent the failure incident [22166, 22418, 22739]. 5. Prioritizing user interface testing: Ensuring that the user interface and front-end components of the software are thoroughly tested and done right could have prevented the software failure incident [22739, 23673]. |
| Fixes | 1. Conducting a punch list of fixes to address bugs preventing the software from performing correctly [Article 22157]. 2. Ensuring that all pieces of the software are working together and managing contractors effectively [Article 22256]. 3. Redesigning the architecture of the system that interacts with the data center where information is stored [Article 22826]. 4. Addressing issues like defective code and tuning problems to move beyond limitations on concurrent users filling applications [Article 22994]. 5. Resolving design flaws and software bugs, particularly in the front end or user experience, through proper testing and construction of the software [Article 22739]. 6. Fixing the major software component failure that crashed under the weight of millions of users by redesigning the poorly designed part of the website [Article 22417]. | References | <Article 22081> unknown</Article> <Article 22098>unknown</Article> <Article 22157>QSSI executive vice-president Andrew Slavitt</Article> <Article 22166>Mike Rogers of Michigan, CGI Federal, Centers for Medicare and Medicaid Services, contractor involved in building the website</Article> <Article 22250>unknown</Article> <Article 22417>Todd Park, Luke Chung</Article> <Article 22739>Software developer interviewed, company contracted to build the website - CGI Group Inc.</Article> <Article 22826>unknown</Article> <Article 22994>White House spokesman Eric Schultz, Chao, Akhtar Zaman</Article> <Article 23673>Washington Post review, current and former contractors, state officials, e-mails, internal reports, audits, court records, dozens of individuals involved in the project</Article> <Article 24053>Kennedy and other security experts</Article> |
| Category | Option | Rationale |
|---|---|---|
| Recurring | one_organization, multiple_organization | (a) In the articles, there is information about the software failure incident happening again at the same organization: 1. Article 22417 mentions that the technical problems with the online health insurance exchanges resulted from the failure of a major software component designed by private contractors, which crashed under the weight of millions of users. This incident reflects a software failure within the same organization responsible for the online health insurance exchanges. (b) The articles also provide insights into similar incidents happening at multiple organizations: 1. Article 22098 discusses how large-scale software projects are challenging, and failures or delays in schedule, budget, and functionality are common across various sectors. Examples are given, such as the combined reservation system after the United and Continental Airlines merger and software problems at Heathrow Airport and with Windows Vista, indicating that software glitches are not unique to a single organization. 2. Article 22250 highlights that the exchange may have deeper design flaws due to the interaction with various databases operated by federal and state agencies. It mentions that federal agencies have faced challenges with software projects in the past, indicating a broader issue beyond a single organization. 3. Article 23673 describes a software failure incident involving feuding between contractors hired to build an online exchange, lawsuits, key personnel quitting, and disputes over costs. This incident showcases challenges faced by multiple organizations involved in the project, leading to work disruptions and the need to replace software versions to meet security requirements. |
| Phase (Design/Operation) | design | (a) The software failure incident related to the design phase can be seen in Article 22826, where it is mentioned that the online exchange was crippled due to a |
| Boundary (Internal/External) | within_system, outside_system | (a) within_system: The software failure incident was influenced by factors originating from within the system. The failure of a major software component, designed by private contractors, led to technical problems that crashed under the weight of millions of users on the HealthCare.gov website [Article 22417]. Issues with defective code and the inability to handle a high volume of concurrent users filling applications were also reported as internal system issues [Article 22994]. (b) outside_system: The software failure incident was also impacted by factors originating from outside the system. The tight deadline and limited budget for the project were highlighted as external constraints affecting the system's operation [Article 22250]. Additionally, the article mentioned that the agency assumed the role of managing the contractors involved, indicating a potential external factor contributing to the failure [Article 22256]. |
| Nature (Human/Non-human) | non-human_actions, human_actions | (a) The software failure incident occurring due to non-human actions: - The technical problems that hampered enrollment in the online health insurance exchanges resulted from the failure of a major software component designed by private contractors that crashed under the weight of millions of users [Article 22417]. - The system was failing due to issues like defective code, which hindered the ability to move beyond 500 concurrent users filling applications [Article 22994]. (b) The software failure incident occurring due to human actions: - One key problem was that the agency assumed the role of managing the 55 contractors involved and had not ensured that all the pieces were working together, leading to additional problems in the shopping and enrollment parts of the process [Article 22256]. - The online exchange was crippled due to a huge gap between the administration’s grand hopes and the practicalities of building a website that could function on opening day, with vital components not secured and a poorly configured system architecture interacting with the data center [Article 22826]. |
| Dimension (Hardware/Software) | hardware, software | (a) The software failure incident occurring due to hardware: - The technical problems in the online health insurance exchanges were attributed to the failure of a major software component designed by private contractors, which crashed under the weight of millions of users [Article 22417]. - The system lacked computer capacity to handle the initial demand, which was seen as a shortfall that should correct itself in time and might be signs of design flaws or software bugs [Article 22418]. - The architecture of the system interacting with the data center storing information was poorly configured and needed to be redesigned, a process that typically takes months [Article 22826]. (b) The software failure incident occurring due to software: - The software failure was attributed to defective code causing issues like the inability to move beyond 500 concurrent users filling applications [Article 22994]. - The software bugs were preventing the system from performing as intended, with a punch list of fixes being worked on to address the issues [Article 22157]. - The online exchange was crippled due to a huge gap between the administration's grand hopes and the practicalities of building a functioning website, with over 600 hardware and software defects identified [Article 22826]. |
| Objective (Malicious/Non-malicious) | malicious, non-malicious | (a) In the software failure incident related to the HealthCare.gov website, there are indications of both malicious and non-malicious factors contributing to the failure: Malicious: - The article mentions concerns about security vulnerabilities in the HealthCare.gov website, with experts warning about the risk of system compromise and potential attacks by hackers [Article 24053]. Non-malicious: - The failure of the major software component of the online health insurance exchanges, which resulted in technical problems and crashes under the weight of millions of users, was attributed to poor design and inherent challenges in large-scale IT projects [Article 22417]. - Issues related to project management, lack of coordination among contractors, and inadequate testing were highlighted as non-malicious factors contributing to the software failure incident [Article 22081, Article 22098, Article 22256, Article 22826]. These articles provide insights into both malicious and non-malicious factors that played a role in the software failure incident. |
| Intent (Poor/Accidental Decisions) | poor_decisions, accidental_decisions | (a) The intent of the software failure incident related to poor_decisions: - The failure of the online health insurance exchanges, particularly HealthCare.gov, was attributed to a series of missteps - financial, technical, and managerial - that led to troubles. The administration's decision to delay issuing major rules until after elections, the Republican-controlled House blocking funds, and the refusal of more than 30 states to set up their own exchanges all contributed to the problems [Article 22081]. - The decision to have the Medicare and Medicaid agency assume the role of project quarterback, responsible for ensuring that all separately designed databases and software pieces worked together, instead of assigning that task to a lead contractor, was considered highly unusual and critical. Some individuals involved in the project doubted the agency's in-house capability to handle such a massive technical task of software engineering while supervising 55 contractors [Article 22081]. - The failure of the online health insurance exchanges was also attributed to the government's project management shortcomings. The contractors building HealthCare.gov couldn't control the budget or timing for regulations, which were influenced by Washington politics. The overall failure was seen as a result of project management issues on the part of the government [Article 22098]. (b) The intent of the software failure incident related to accidental_decisions: - The technical problems that hampered enrollment in the online health insurance exchanges were attributed to a major software component failure designed by private contractors, which crashed under the weight of millions of users. The failure occurred in the part of the website that lets people create user accounts at the beginning [Article 22417]. - The system's failure was also linked to issues like defective code, with the system not being successful in handling more than 500 concurrent users filling applications. The need to work through tuning issues was emphasized [Article 22994]. |
| Capability (Incompetence/Accidental) | development_incompetence, accidental | (a) The software failure incident related to development incompetence is evident in the articles. For example, in Article 22098, it is mentioned that the overall failure of the HealthCare.gov website was attributed to project management issues on the part of the government rather than incompetence of the contractors. Additionally, in Article 22826, it is highlighted that CGI software engineers walked out, stating it was impossible to produce good work under the cumbersome government decision-making process. This indicates a lack of professional competence in managing the project effectively. (b) The software failure incident related to accidental factors is also apparent in the articles. In Article 22417, it is mentioned that the technical problems in the online health insurance exchanges resulted from a major software component failure designed by private contractors, which crashed under the weight of millions of users. This indicates that the failure was not intentional but rather a result of the system being overwhelmed by user demand. Additionally, in Article 22994, issues like defective code were highlighted as contributing to the system's failure, suggesting accidental factors leading to the software issues. |
| Duration | temporary | (a) The software failure incident related to the HealthCare.gov website can be considered as a temporary failure. The incident was attributed to various contributing factors such as defective code, design flaws, tight deadlines, limited budget, lack of testing, and management issues [Article 22081, Article 22098, Article 22157, Article 22250, Article 22256, Article 22417, Article 22418, Article 22739, Article 22826, Article 22994, Article 23673]. These factors led to glitches, crashes, delays, and functionality issues on the website. The failure was not permanent but rather a result of specific circumstances surrounding the project's development and implementation. |
| Behaviour | crash, omission, value, other | (a) crash: The software failure incident related to a crash is evident in Article 22417, where it is mentioned that the major software component designed by private contractors crashed under the weight of millions of users, resulting in technical problems that hampered enrollment in the online health insurance exchanges [22417]. (b) omission: The software failure incident related to omission is highlighted in Article 23673, where it is described that the system could not fully send enrollment data to insurers or email Marylanders when they successfully selected a plan, indicating an omission in performing its intended functions [23673]. (c) timing: The software failure incident related to timing is discussed in Article 22098, where it is mentioned that the online insurance marketplace faced issues due to inadequate time for testing, leading to failures or delays in schedule, budget, and functionality [22098]. (d) value: The software failure incident related to performing its intended functions incorrectly is mentioned in Article 22994, where issues like defective code led to the system failing to move beyond 500 concurrent users filling applications, indicating a failure in performing its functions correctly [22994]. (e) byzantine: The software failure incident related to behaving erroneously with inconsistent responses and interactions is not explicitly mentioned in the provided articles. (f) other: The software failure incident related to other behavior, not falling into the defined categories, can be seen in Article 22250, where it is discussed that the exchange may have deeper design flaws, and the system is operating on a tight deadline and a limited budget, which could lead to further complications and failures [22250]. |
| Layer | Option | Rationale |
|---|---|---|
| Perception | processing_unit, embedded_software | (a) sensor: Failure due to contributing factors introduced by sensor error - No information found in the provided articles. (b) actuator: Failure due to contributing factors introduced by actuator error - No information found in the provided articles. (c) processing_unit: Failure due to contributing factors introduced by processing error - Article 22417 mentions a major software component designed by private contractors that crashed under the weight of millions of users, indicating a failure related to processing error. (d) network_communication: Failure due to contributing factors introduced by network communication error - No information found in the provided articles. (e) embedded_software: Failure due to contributing factors introduced by embedded software error - Article 22417 mentions a software failure in a major software component designed by private contractors, suggesting a failure related to embedded software error. |
| Communication | connectivity_level | (a) The failure was not directly related to the communication layer of the cyber physical system that failed. There is no specific mention of issues related to the physical layer or wired/wireless communication in the articles provided. (b) The failure was more related to connectivity issues and system integration problems rather than issues at the communication layer. For example, Article 22098 mentions the challenge of combining different components and ensuring they work together seamlessly. Additionally, Article 22418 discusses the complexity of the system requiring state and federal systems, as well as the work of myriad private contractors, to communicate as a seamless whole. These references point more towards connectivity-level issues rather than link-level issues. |
| Application | TRUE | The software failure incident related to the application layer of the cyber physical system that failed with contributing factors introduced by bugs, operating system errors, unhandled exceptions, and incorrect usage can be found in the following articles: 1. Article 22417 mentions that the technical problems in the online health insurance exchanges resulted from the failure of a major software component designed by private contractors, which crashed under the weight of millions of users. The president of a database company criticized the site, mentioning that it was poorly designed and that people higher up were given excuses for the problems, indicating issues with the software [22417]. 2. Article 22994 states that the system was failing due to issues like defective code, and they were not successful in moving beyond 500 concurrent users filling applications, highlighting problems related to the software code [22994]. Therefore, based on the information from these articles, it can be inferred that the software failure incident was related to the application layer of the cyber physical system, involving bugs, operating system errors, unhandled exceptions, and incorrect usage. |
| Category | Option | Rationale |
|---|---|---|
| Consequence | property, delay, theoretical_consequence | (a) death: People lost their lives due to the software failure - No information in the provided articles indicates any deaths resulting from the software failure incidents. (b) harm: People were physically harmed due to the software failure - No information in the provided articles indicates any physical harm to individuals due to the software failure incidents. (c) basic: People's access to food or shelter was impacted because of the software failure - No information in the provided articles indicates any impact on people's access to food or shelter due to the software failure incidents. (d) property: People's material goods, money, or data was impacted due to the software failure - The software failure incidents mentioned in the articles resulted in issues such as technical problems with the health insurance exchange website [Article 22098], failure of a major software component leading to enrollment problems [Article 22417], and issues in the shopping and enrollment parts of the process [Article 22256]. These incidents impacted people's ability to access and use the services provided by the software, potentially affecting their data and financial transactions. (e) delay: People had to postpone an activity due to the software failure - The articles mention delays in schedule, budget, and functionality being common in large-scale software projects [Article 22098]. Additionally, issues with testing and changing requirements contributed to delays or failures [Article 22098]. (f) non-human: Non-human entities were impacted due to the software failure - The software failure incidents described in the articles primarily focus on issues related to the functionality and performance of the software systems, with no specific mention of non-human entities being impacted. (g) no_consequence: There were no real observed consequences of the software failure - The software failure incidents described in the articles led to various consequences, including technical problems, delays, glitches, and issues in the functionality of the systems, indicating there were observed consequences of the failures. (h) theoretical_consequence: There were potential consequences discussed of the software failure that did not occur - The articles discuss potential consequences such as the system operating on a tight deadline and limited budget [Article 22250], and the risk of hackers exploiting vulnerabilities in the system [Article 24053]. These potential consequences were discussed but may not have fully materialized. (i) other: Was there consequence(s) of the software failure not described in the (a to h) options? What is the other consequence(s)? - The articles do not mention any other specific consequences of the software failure incidents beyond those related to delays, technical problems, glitches, and impacts on functionality and data. |
| Domain | health, government | (a) The failed system was related to the health industry, specifically the online health insurance exchanges under the Affordable Care Act [Article 22081, Article 22250, Article 22417, Article 22418, Article 22826, Article 23673]. (b) No information related to transportation. (c) No information related to natural resources. (d) No information related to sales. (e) No information related to construction. (f) No information related to manufacturing. (g) No information related to utilities. (h) No information related to finance. (i) No information related to knowledge. (j) The failed system was directly related to the health industry, particularly in the context of healthcare and health insurance [Article 22081, Article 22250, Article 22417, Article 22418, Article 22826, Article 23673]. (k) No information related to entertainment. (l) The failed system was associated with the government sector, specifically in the context of the Affordable Care Act and federal agencies managing the online health insurance exchanges [Article 22081, Article 22250, Article 22417, Article 22418, Article 22826, Article 23673]. (m) No information provided about other industries. |
Article ID: 22994
Article ID: 23718
Article ID: 22250
Article ID: 22081
Article ID: 24053
Article ID: 22417
Article ID: 22098
Article ID: 22256
Article ID: 24688
Article ID: 22418
Article ID: 22739
Article ID: 23673
Article ID: 22826
Article ID: 22157
Article ID: 22166