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> the staff had become “de-sensitized” to the risk of a serious accident. Yet again serious problems happen due to the Normalization Of Deviance. We really nee

by pdkl95 9y ago

> the staff had become “de-sensitized” to the risk of a serious accident. Yet again serious problems happen due to the Normalization Of Deviance. We really need to find a way to create working conditions that encourage correcting problematic situations immediately before the behavior becomes normalized. Regarding the management/other problems... I encourage everyone in ever industry that is ever involved with safety (i.e. most industries) to see Richard Cook's short talk about "Resilience in Complex Adaptive Systems"[1]. [1] https://www.youtube.com/watch?v=PGLYEDpNu60 https://www.youtube.com/watch?v=PGLYEDpNu60

cryptonector 9y ago
I'm picturing workers who have never spent time on wikipedia reading about nuclear accidents, much less in any books. The list of nuclear accidents is hair-raising. The thought that a co-worker might assemble a near-critical mass nearby is... beyond hair-raising. Where the heck are they getting these guys, and what are they telling them?!
- ncallaway 9y ago
  They are normal people, who follow normal psychological patterns. In your root cause analysis, 99% of the time the answer should not be "human error". An error that one human makes will be repeated in the future by another human. The problem is setting up patterns and processes in the working environment that are aware of these human limitations and that work around them. The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake.
  - ythn 9y ago
    > The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake. Contrast to my company: Our phones require you to dial "9" to get out of the building, and then "1" to dial long distance. A lot of my coworkers are foreign and in the process of trying to dial a cell phone number (international or otherwise) accidentally dial "911". When they realize their mistake, they hang up, not having grown up in America and learning to stay on the line and tell the operator that you made a mistake. Company response? Threatening emails, verbal and written company-wide wrist slaps, and stickers on every phone that say not to hang up if you dial 911 or you'll get in trouble. As a result people are now afraid of dialing long-distance numbers and so they simply avoid it. Imagine if the company had instead tried to correct the true issue causing the errors (poor phone routing numbers)?
    - ams6110 9y ago
      In many (all?) parts of the US, even if you stay on the line and tell the operator that the call was a mistake, you'll still get a visit from the police. The thinking is that someone who got a chance to dial 911 but then is discovered by a captor might be coerced into saying the call was a mistake. So they send the police to invesitigate ALL 911 calls -- hangups, mistakes, everything.
      - Spooky23 9y ago
        Another fun fact is that 911 in almost any dial sequence will dial 911. One of my colleagues discovered this when he was testing some dial plan thing years ago. I think he called 911 a few thousand times.
      - deleted 9y ago
        [deleted]
      - ncallaway 9y ago
        Interesting. I definitely made this mistake as a child. My dad's cell phone number started was 915-XXXX. I misdialed once and dialed "911". I explained that it was a mistake, and they said not to worry about it and hung up. No officer was dispatched. I wonder if something has changed since I made that mistake, if it's just inconsistent across the country, or if there is some discretion of the dispatcher to decide that the child probably did make a mistake.
        mjcl 9y ago
        I don't think anything has changed; I made test-calls to 911 (to confirm the call was routed properly) when commissioning new phone systems and never had police dispatched. I'd tell the operator that I was testing and wanted to confirm that they were showing the correct phone # and address.
        boomboomsubban 9y ago
        It is something that every state and county could decide.
stevenwoo 9y ago
This issue was covered in a NPR segment last year about an even older Harvard Business Review article. How to prevent the next oil rig disaster - solution - get the workers to admit vulnerability. http://www.npr.org/sections/health-shots/2016/06/17/482203447/invisibilia-how-learning-to-be-vulnerable-can-make-life-safer http://www.npr.org/sections/health-shots/2016/06/17/48220344... https://hbr.org/2008/07/unmasking-manly-men https://hbr.org/2008/07/unmasking-manly-men

by pdkl95 9y ago

cryptonector 9y ago

I'm picturing workers who have never spent time on wikipedia reading about nuclear accidents, much less in any books. The list of nuclear accidents is hair-raising. The thought that a co-worker might assemble a near-critical mass nearby is... beyond hair-raising. Where the heck are they getting these guys, and what are they telling them?!

ncallaway 9y ago
They are normal people, who follow normal psychological patterns. In your root cause analysis, 99% of the time the answer should not be "human error". An error that one human makes will be repeated in the future by another human. The problem is setting up patterns and processes in the working environment that are aware of these human limitations and that work around them. The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake.
- ythn 9y ago
  > The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake. Contrast to my company: Our phones require you to dial "9" to get out of the building, and then "1" to dial long distance. A lot of my coworkers are foreign and in the process of trying to dial a cell phone number (international or otherwise) accidentally dial "911". When they realize their mistake, they hang up, not having grown up in America and learning to stay on the line and tell the operator that you made a mistake. Company response? Threatening emails, verbal and written company-wide wrist slaps, and stickers on every phone that say not to hang up if you dial 911 or you'll get in trouble. As a result people are now afraid of dialing long-distance numbers and so they simply avoid it. Imagine if the company had instead tried to correct the true issue causing the errors (poor phone routing numbers)?
  - ams6110 9y ago
    In many (all?) parts of the US, even if you stay on the line and tell the operator that the call was a mistake, you'll still get a visit from the police. The thinking is that someone who got a chance to dial 911 but then is discovered by a captor might be coerced into saying the call was a mistake. So they send the police to invesitigate ALL 911 calls -- hangups, mistakes, everything.
    - Spooky23 9y ago
      Another fun fact is that 911 in almost any dial sequence will dial 911. One of my colleagues discovered this when he was testing some dial plan thing years ago. I think he called 911 a few thousand times.
    - deleted 9y ago
      [deleted]
    - ncallaway 9y ago
      Interesting. I definitely made this mistake as a child. My dad's cell phone number started was 915-XXXX. I misdialed once and dialed "911". I explained that it was a mistake, and they said not to worry about it and hung up. No officer was dispatched. I wonder if something has changed since I made that mistake, if it's just inconsistent across the country, or if there is some discretion of the dispatcher to decide that the child probably did make a mistake.
      - mjcl 9y ago
        I don't think anything has changed; I made test-calls to 911 (to confirm the call was routed properly) when commissioning new phone systems and never had police dispatched. I'd tell the operator that I was testing and wanted to confirm that they were showing the correct phone # and address.
        boomboomsubban 9y ago
        It is something that every state and county could decide.

stevenwoo 9y ago

This issue was covered in a NPR segment last year about an even older Harvard Business Review article. How to prevent the next oil rig disaster - solution - get the workers to admit vulnerability. http://www.npr.org/sections/health-shots/2016/06/17/482203447/invisibilia-how-learning-to-be-vulnerable-can-make-life-safer http://www.npr.org/sections/health-shots/2016/06/17/48220344... https://hbr.org/2008/07/unmasking-manly-men https://hbr.org/2008/07/unmasking-manly-men