9 ms·

My best guess is that it's the result of 20-30 years of never accepting "shit happens, we looked and everything seems basically fine, we're not changing anythin

by ashark 9y ago

My best guess is that it's the result of 20-30 years of never accepting "shit happens, we looked and everything seems basically fine, we're not changing anything" as an answer when something bad happens and someone asks "so what are you doing to make sure this doesn't happen again?"—even when that answer's actually appropriate. The consequences are so bad if you make the do-nothing call and get it wrong (or are just unlucky) that everyone does a whole bunch of stuff to ensure they can say "look at all the things I did!" if lightning strikes twice (or if they were simply wrong and something did need to be done, but it wasn't clear until a pattern emerged) Instead we always freak out and add a bunch of new policies/guidelines, some more mandatory educational videos or classes, and maybe bring down the hammer on some people as well. [EDIT] in fact it may be yet another symptom of post-Nixon-era cynicism. We expect institutions to lie to us about everything (which, to be fair, they often do and often have), so we (rather, the media) dig into any problem expecting criminality and neglect and generally bad behavior (and a great story!), so institutions have to go nuts to make sure it never looks like there's anything there worth reporting as maybe-sort-of-kind-of any of those bad things.

turbulents 9y ago
The FAA, NTSB, and airlines have made air travel incredibly safe over the years by operating the way you described.
- CaptSpify 9y ago
  I am by no means an expert on this subject so correct me if I'm wrong but.... The exception that I've noticed from the airline-industry, is that they actually want to solve problems systemically and don't care who has to take the blame. For something to go wrong, multiple failures have to happen, and there's not a lot of blame put on individuals, as much as "the process". In most other organizations, IME, fixing "the process" is expensive. It takes time, and effort, and it's quicker and easier to blame "those idiots in IT/accounting/HR/etc". Most of those types of organizations don't actually want to solve problems, they just want the problem to go away. So they end up choosing the easier option, rather than dealing with the problem systematically. /bitter rant
  - jfoutz 9y ago
    NTSB, i think, no one takes the blame. For example, if the error is something like "Mechanic didn't tighten bolt to appropriate torque." So, what's wrong? maybe they forgot and need a checklist item? Maybe the reading on the wrench should be recorded in the log? should there be a second person that verifies? They know they ask a lot of people, and it has to be right, every time. People get sick, tired, distracted, whatever. we're people. People are the least reliable part of the system. I think blame only falls to a person when they've lied. Falsified a log, claimed to do something they didn't etc.
    - pbecotte 9y ago
      That's the thing. In the Air Force (at least)- there is no thought of cost/benefit analysis. A single machine fails once because a bolt wasn't torqued and causes $5000 of damage ... So they add the checklist item, and the second person, and an extra training item, and a log record that has to be maintained. The list of special rules and required documentation only ever gets longer. Eventually, you spend all your time on the checklists and maintaining the documentation, and none on actually doing whatever procedure you were originally messing with that bolt for.
      - stinkytaco 9y ago
        As someone who was a mechanic in the Army, I feel that checklists more often helped then harmed. Many mechanical problems we saw in the shop were easily attributable to an operator skipping a step on their PMCS. Doing something relatively dangerous or confusing could be error prone, especially for people who haven't done it much, and a checklist can help ensure the safety of everyone in the shop. A good example is running an engine indoors. Before you did it, there were a serious of steps you had to walk through before you turned it on, that reduced people getting sick from carbon monoxide quite a bit.
        zimpenfish 9y ago
        "The Checklist Manifesto" is an -excellent- read on the helpfulness of checklists in preventing problems and mistakes (primarily from a surgeon and medical viewpoint but he covers airlines as well.) http://atulgawande.com/book/the-checklist-manifesto/ http://atulgawande.com/book/the-checklist-manifesto/
- ashark 9y ago
  I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp.
  - AnthonyMouse 9y ago
    > I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp. The problem being that the ass-covering is a predictable response to known stimuli. What do you propose to do to get them to stop doing that?
- raverbashing 9y ago
  Not accepting "shit happens" makes sense in aviation, and you're right about that But taking out decision control and relying on automation has had its problems.
cakedoggie 9y ago
Yeah, I think the big problem is trying to come up with the one big issue and change that, as if that will not have a whole bunch of issues. People want one answer on what the problem is, because then the most amount of people can understand it in a tweet. They don't want complicated solutions. You say it yourself, it is one problem.
matt4077 9y ago
I believe you're being slightly unfair to those institutions. As one example: the US Government, as a policy, never lies to the American press (and, by extension, the people). They may sometimes do so to the foreign press, or they'll deny comment, or they'll give you an answer that doesn't actually answer your question. But there used to be a line they dared not to cross. There are many reasons for this. Some will insist it's the morally right thing to do. But a better explanation is usually that it's in no one's interest: Career bureaucrats are simply never in a position where lying is a good option unless they're trying to cover up a crime they committed. They're risking their job, and possibly criminal prosecution, without any real potential upside. For elected officials, the same is usually true–with the potential exception of a lame-duck President who has nowhere to go but retirement. But at that point, they've probably gotten used to managing their office without lies. Of course that's a description of the past, and the lower reaches of elected executive office (but not employees) have a worse track record, where many a town mayor with a coke habit has lied to cover his creative accounting. Nixon also comes to mind. But before you say "Iraqi WMDs", I'd say that was arguably a case of a government convincing themselves through wishful thinking. Maybe they're just really good at lying? It's the old problem: is the revelation of a scandal proof of spreading corruption, or does it show that the system is working, and the bad apples are caught? It really seems to come down to personal judgement. I can only say that having interacted with governments on multiple levels, and seen a lot of, for example, the vast amounts of data they produce and decisions they make that are never the subject of the news, I have come away with the impression that the Government is usually trustworthy, and that decisions are often made with a surprising lack of emotions. For example, I once won a lawsuit against a local government. Yet a few months later, we won a tender that we deserved to win, even though the decision was made by the very same people we had previously fought in court. If all else fails: even if government were corrupt to its core, saying so would be less effective than acting as if it weren't, and focussing on specific incidents. Because faced with a public that believes only the worst of every politician removes all incentives for them not to become exactly that sort of thoroughly corrupt politician. And if it's part of society's lore that all powerful people lie, that becomes a self-fulfilling prophecy when people new to government just follow the clues they got from popular culture.
- jacquesm 9y ago

by ashark 9y ago

turbulents 9y ago

The FAA, NTSB, and airlines have made air travel incredibly safe over the years by operating the way you described.

CaptSpify 9y ago
I am by no means an expert on this subject so correct me if I'm wrong but.... The exception that I've noticed from the airline-industry, is that they actually want to solve problems systemically and don't care who has to take the blame. For something to go wrong, multiple failures have to happen, and there's not a lot of blame put on individuals, as much as "the process". In most other organizations, IME, fixing "the process" is expensive. It takes time, and effort, and it's quicker and easier to blame "those idiots in IT/accounting/HR/etc". Most of those types of organizations don't actually want to solve problems, they just want the problem to go away. So they end up choosing the easier option, rather than dealing with the problem systematically. /bitter rant
- jfoutz 9y ago
  NTSB, i think, no one takes the blame. For example, if the error is something like "Mechanic didn't tighten bolt to appropriate torque." So, what's wrong? maybe they forgot and need a checklist item? Maybe the reading on the wrench should be recorded in the log? should there be a second person that verifies? They know they ask a lot of people, and it has to be right, every time. People get sick, tired, distracted, whatever. we're people. People are the least reliable part of the system. I think blame only falls to a person when they've lied. Falsified a log, claimed to do something they didn't etc.
  - pbecotte 9y ago
    That's the thing. In the Air Force (at least)- there is no thought of cost/benefit analysis. A single machine fails once because a bolt wasn't torqued and causes $5000 of damage ... So they add the checklist item, and the second person, and an extra training item, and a log record that has to be maintained. The list of special rules and required documentation only ever gets longer. Eventually, you spend all your time on the checklists and maintaining the documentation, and none on actually doing whatever procedure you were originally messing with that bolt for.
    - stinkytaco 9y ago
      As someone who was a mechanic in the Army, I feel that checklists more often helped then harmed. Many mechanical problems we saw in the shop were easily attributable to an operator skipping a step on their PMCS. Doing something relatively dangerous or confusing could be error prone, especially for people who haven't done it much, and a checklist can help ensure the safety of everyone in the shop. A good example is running an engine indoors. Before you did it, there were a serious of steps you had to walk through before you turned it on, that reduced people getting sick from carbon monoxide quite a bit.
      - zimpenfish 9y ago
        "The Checklist Manifesto" is an -excellent- read on the helpfulness of checklists in preventing problems and mistakes (primarily from a surgeon and medical viewpoint but he covers airlines as well.) http://atulgawande.com/book/the-checklist-manifesto/ http://atulgawande.com/book/the-checklist-manifesto/
ashark 9y ago
I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp.
- AnthonyMouse 9y ago
  > I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp. The problem being that the ass-covering is a predictable response to known stimuli. What do you propose to do to get them to stop doing that?
raverbashing 9y ago
Not accepting "shit happens" makes sense in aviation, and you're right about that But taking out decision control and relying on automation has had its problems.

cakedoggie 9y ago

Yeah, I think the big problem is trying to come up with the one big issue and change that, as if that will not have a whole bunch of issues. People want one answer on what the problem is, because then the most amount of people can understand it in a tweet. They don't want complicated solutions. You say it yourself, it is one problem.

matt4077 9y ago

I believe you're being slightly unfair to those institutions. As one example: the US Government, as a policy, never lies to the American press (and, by extension, the people). They may sometimes do so to the foreign press, or they'll deny comment, or they'll give you an answer that doesn't actually answer your question. But there used to be a line they dared not to cross. There are many reasons for this. Some will insist it's the morally right thing to do. But a better explanation is usually that it's in no one's interest: Career bureaucrats are simply never in a position where lying is a good option unless they're trying to cover up a crime they committed. They're risking their job, and possibly criminal prosecution, without any real potential upside. For elected officials, the same is usually true–with the potential exception of a lame-duck President who has nowhere to go but retirement. But at that point, they've probably gotten used to managing their office without lies. Of course that's a description of the past, and the lower reaches of elected executive office (but not employees) have a worse track record, where many a town mayor with a coke habit has lied to cover his creative accounting. Nixon also comes to mind. But before you say "Iraqi WMDs", I'd say that was arguably a case of a government convincing themselves through wishful thinking. Maybe they're just really good at lying? It's the old problem: is the revelation of a scandal proof of spreading corruption, or does it show that the system is working, and the bad apples are caught? It really seems to come down to personal judgement. I can only say that having interacted with governments on multiple levels, and seen a lot of, for example, the vast amounts of data they produce and decisions they make that are never the subject of the news, I have come away with the impression that the Government is usually trustworthy, and that decisions are often made with a surprising lack of emotions. For example, I once won a lawsuit against a local government. Yet a few months later, we won a tender that we deserved to win, even though the decision was made by the very same people we had previously fought in court. If all else fails: even if government were corrupt to its core, saying so would be less effective than acting as if it weren't, and focussing on specific incidents. Because faced with a public that believes only the worst of every politician removes all incentives for them not to become exactly that sort of thoroughly corrupt politician. And if it's part of society's lore that all powerful people lie, that becomes a self-fulfilling prophecy when people new to government just follow the clues they got from popular culture.

jacquesm 9y ago