5 ms·

The path to a disaster has been compared to a tunnel [0]. You can escape from the tunnel at many points, but you may not realize it. Trying to find the 'real c

by csours 9y ago

The path to a disaster has been compared to a tunnel [0]. You can escape from the tunnel at many points, but you may not realize it. Trying to find the 'real cause' is a fool's errand, because there are many places and ways to avoid the outcome. I do take your meaning, reducing speed and following well established rules would have almost certainly have saved them. 0. PDF: http://www.leonardo-in-flight.nl/PDF/FieldGuide%20to%20Human%20Error.PDF http://www.leonardo-in-flight.nl/PDF/FieldGuide%20to%20Human... Amazon: https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/0754648257 https://www.amazon.com/Field-Guide-Understanding-Human-Error...

JshWright 9y ago
I've never heard the tunnel analogy. Seems odd, since tunnels generally only have one entrance and one exit... In a lot of fields where the stakes are high and mistakes are costly (aviation and emergency services are the two I'm most familiar with) the analogy used is a chain. Break any link in the chain and you prevent the event. https://www.aopa.org/asf/publications/inst_reports2.cfm?article=4401 https://www.aopa.org/asf/publications/inst_reports2.cfm?arti...
- csours 9y ago
  It's the perception tunnel. There are many branches, but only one route is followed. In hindsight, you can see all the branches and call out everything that went wrong.
  - tantalor 9y ago
    Normally that is called "tunnel vision". https://en.wiktionary.org/wiki/tunnel_vision https://en.wiktionary.org/wiki/tunnel_vision (figuratively) The tendency to focus one's attention on one specific idea or viewpoint, to the exclusion of everything else; a one-track mind.
- mustacheemperor 9y ago
  I think the idea is that if you are stuck in a dark train tunnel and there's a train coming towards you, there may be doorways, recesses, etc in the walls that are invisible without the proper tools (flashlight, etc).
  - deleted 9y ago
    [deleted]
- blattimwind 9y ago
  > I've never heard the tunnel analogy. Seems odd, since tunnels generally only have one entrance and one exit... Road and train tunnels have many emergency exits...
  - JshWright 9y ago
    Generally they have a parallel tunnel (either for traffic in the other direction, or specifically for emergency egress), and connections between them. They still take you to the same general place.
- Piskvorrr 9y ago
  Urban tunnels have many regular entries and exits, as well as emergency exits, not to speak of emergency crossovers.
mostlyskeptical 9y ago
As we say when teaching new riders to ride a motorcycle, a crash is often an intersection of factors. If you remove even one of those issues it likely would have prevented it.
- pbhjpbhj 9y ago
  I've noticed a lot of learners (eg in YouTube videos) crash because they grab at the handlebars, grabbing the throttle and inadvertently accelerating. Is there a reason the throttle can't be reversed so that grabbing would reduce throttle and slow the bike? (FWIW, I'm a fully licensed motorcyclist, don't currently ride.)
mjlee 9y ago
I prefer the swiss cheese model. https://en.wikipedia.org/wiki/Swiss_cheese_model https://en.wikipedia.org/wiki/Swiss_cheese_model "In the Swiss Cheese model, an organisation's defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system produces failures when a hole in each slice momentarily aligns, permitting (in Reason's words) "a trajectory of accident opportunity", so that a hazard passes through holes in all of the slices, leading to a failure." A series of minor failures that combine for a serious crisis seems very relatable.
- civilian 9y ago
  Yup! My cousin & cousin-in-law work to maintain human health at some nuclear power plants in Canada. They use the swiss-cheese model, and whenever they notice that one layer missed something, they do a re-evaulation of that safety layer.
- jabl 9y ago
  Aha! I sense an opportunity for an enterprising statistical physicist to model this with https://en.wikipedia.org/wiki/Percolation_theory https://en.wikipedia.org/wiki/Percolation_theory :)
drdrey 9y ago
Are you recommending the 2nd edition specifically? There is a 3rd edition available: https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058 https://www.amazon.com/Field-Guide-Understanding-Human-Error...
- csours 9y ago
  No, I just didn't notice (speaking of confusing UI, Amazon seems to do everything possible to move UI elements small and large on a basis so arbitrary as to seem completely random)

by csours 9y ago

JshWright 9y ago

I've never heard the tunnel analogy. Seems odd, since tunnels generally only have one entrance and one exit... In a lot of fields where the stakes are high and mistakes are costly (aviation and emergency services are the two I'm most familiar with) the analogy used is a chain. Break any link in the chain and you prevent the event. https://www.aopa.org/asf/publications/inst_reports2.cfm?article=4401 https://www.aopa.org/asf/publications/inst_reports2.cfm?arti...

csours 9y ago
It's the perception tunnel. There are many branches, but only one route is followed. In hindsight, you can see all the branches and call out everything that went wrong.
- tantalor 9y ago
  Normally that is called "tunnel vision". https://en.wiktionary.org/wiki/tunnel_vision https://en.wiktionary.org/wiki/tunnel_vision (figuratively) The tendency to focus one's attention on one specific idea or viewpoint, to the exclusion of everything else; a one-track mind.
mustacheemperor 9y ago
I think the idea is that if you are stuck in a dark train tunnel and there's a train coming towards you, there may be doorways, recesses, etc in the walls that are invisible without the proper tools (flashlight, etc).
- deleted 9y ago
  [deleted]
blattimwind 9y ago
> I've never heard the tunnel analogy. Seems odd, since tunnels generally only have one entrance and one exit... Road and train tunnels have many emergency exits...
- JshWright 9y ago
  Generally they have a parallel tunnel (either for traffic in the other direction, or specifically for emergency egress), and connections between them. They still take you to the same general place.
Piskvorrr 9y ago
Urban tunnels have many regular entries and exits, as well as emergency exits, not to speak of emergency crossovers.

mostlyskeptical 9y ago

As we say when teaching new riders to ride a motorcycle, a crash is often an intersection of factors. If you remove even one of those issues it likely would have prevented it.

pbhjpbhj 9y ago
I've noticed a lot of learners (eg in YouTube videos) crash because they grab at the handlebars, grabbing the throttle and inadvertently accelerating. Is there a reason the throttle can't be reversed so that grabbing would reduce throttle and slow the bike? (FWIW, I'm a fully licensed motorcyclist, don't currently ride.)

mjlee 9y ago

I prefer the swiss cheese model. https://en.wikipedia.org/wiki/Swiss_cheese_model https://en.wikipedia.org/wiki/Swiss_cheese_model "In the Swiss Cheese model, an organisation's defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system produces failures when a hole in each slice momentarily aligns, permitting (in Reason's words) "a trajectory of accident opportunity", so that a hazard passes through holes in all of the slices, leading to a failure." A series of minor failures that combine for a serious crisis seems very relatable.

civilian 9y ago
Yup! My cousin & cousin-in-law work to maintain human health at some nuclear power plants in Canada. They use the swiss-cheese model, and whenever they notice that one layer missed something, they do a re-evaulation of that safety layer.
jabl 9y ago
Aha! I sense an opportunity for an enterprising statistical physicist to model this with https://en.wikipedia.org/wiki/Percolation_theory https://en.wikipedia.org/wiki/Percolation_theory :)

drdrey 9y ago

Are you recommending the 2nd edition specifically? There is a 3rd edition available: https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058 https://www.amazon.com/Field-Guide-Understanding-Human-Error...

csours 9y ago
No, I just didn't notice (speaking of confusing UI, Amazon seems to do everything possible to move UI elements small and large on a basis so arbitrary as to seem completely random)