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Indeed, the whole press release brings to mind a couple of points from "Engineering a Safer World" which, if you're interested in this stuff, I can't recommend
by _sh 8y ago
Indeed, the whole press release brings to mind a couple of points from "Engineering a Safer World" which, if you're interested in this stuff, I can't recommend enough[0].
In the section "Questioning the Foundations of Traditional Safety Engineering":
Old Assumption
Most accidents are caused by operator error. Rewarding safe behaviour and punishing unsafe behaviours will eliminate or reduce accidents significantly.
New Assumption
Operator error is a product of the environment in which it occurs. To reduce operator "error" we must change the environment in which the operator works.
And:
Old Assumption
Major accidents occur from the chance simultaneous occurrence of random events.
New Assumption
Systems will tend to migrate toward states of higher risk. Such migration is predictable and can be prevented by appropriate system design or detected during operations using leading indicators of increasing risk.
In the press release we see both the "operator error" and "random events" hand-waving. Regardless of the fiduciary duty of this man, this is just not good enough.
[0] Open Access PDF: https://mitpress.mit.edu/books/engineering-safer-world https://mitpress.mit.edu/books/engineering-safer-world
- acqq 8y agoThe same quotes in an easier to read format, and I agree with them: "Old Assumption - Most accidents are caused by operator error. Rewarding safe behaviour and punishing unsafe behaviours will eliminate or reduce accidents significantly. New Assumption - Operator error is a product of the environment in which it occurs. To reduce operator "error" we must change the environment in which the operator works. --- Old Assumption - Major accidents occur from the chance simultaneous occurrence of random events. New Assumption - Systems will tend to migrate toward states of higher risk. Such migration is predictable and can be prevented by appropriate system design or detected during operations using leading indicators of increasing risk." Just a day ago, user Gibbon1 also posted a link to a talk by the author of that book: https://www.youtube.com/watch?v=WBktiCyPLo4 https://www.youtube.com/watch?v=WBktiCyPLo4
- OneWordSoln 8y agoWhat a fantastic talk! Witty, well-paced and truly insightful. "Operator error is a symptom, not a cause." Ms. Leveson's book "Engineering a Safer World" has a free PDF download at http://sunnyday.mit.edu/safer-world.pdf http://sunnyday.mit.edu/safer-world.pdf
- scirocco 8y agoAlso related is "Extreme Ownership"