3 ms·

And in this case we can identity the multiples causes adding up to the catastrophe such as the complexity of the system, the lack of training of the operator, a

And in this case we can identity the multiples causes adding up to the catastrophe such as the complexity of the system, the lack of training of the operator, and their lack of sleep due to a long shift. It's interesting because it fits perfectly well with the _How Complex Systems Fail_[1] article, often shared on HN. A timeless valuable lesson for engineering, and any human activity really. [1] https://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20Fail.pdf https://web.mit.edu/2.75/resources/random/How%20Complex%20Sy...

briefcomment 7y ago
For this complex system, I guess the best way to minimize catastrophe is to have several guards independently checking the alert (away from each other) and sending a unique person to investigate. Best case, a bunch of people end up at the right place. Worst case, no one ends up at the right place. Most likely case, at least one person ends up at the right place. This increases costs, but for situations where mistakes can be catastrophic, it's probably wise to bear the cost.
- bumby 7y ago
  Adding more people to a bad system rarely corrects the issues. It’s akin to increasing inventory to cover for the fact that a manufacturing process produces a high level of defects. E.g., If we need 900 widgets an hour and we have a capacity of 1000 widgets but 20% defect rate, just spend money to increase the capacity. You’re generally better off reducing waste rather than increasing capacity. In this case, if there’s a lot of human factor issues, it would be better to identify them directly and creates a process/system that mitigates each.[1] Yes, excess people can be a mitigation but, as you say, it’s an expensive one and a type that tends to be on the chopping block as soon as we get complacent. [1] https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20HFACS.PDF https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20...
- beerandt 7y ago
  Imo, this is wrong, and would lead to ignored alarms. (Who's old enough to) Remember waiting for someone else to answer the landline? Versus it ringing when you're home alone and know no one else is going to get it? Multiple alarm monitors might result in a lack of urgency (ie, someone else is closer, so no rush) or even shrugging off the responsibility all together (ie, someone else will get it, I don't need to go).

briefcomment 7y ago

For this complex system, I guess the best way to minimize catastrophe is to have several guards independently checking the alert (away from each other) and sending a unique person to investigate. Best case, a bunch of people end up at the right place. Worst case, no one ends up at the right place. Most likely case, at least one person ends up at the right place. This increases costs, but for situations where mistakes can be catastrophic, it's probably wise to bear the cost.

bumby 7y ago
Adding more people to a bad system rarely corrects the issues. It’s akin to increasing inventory to cover for the fact that a manufacturing process produces a high level of defects. E.g., If we need 900 widgets an hour and we have a capacity of 1000 widgets but 20% defect rate, just spend money to increase the capacity. You’re generally better off reducing waste rather than increasing capacity. In this case, if there’s a lot of human factor issues, it would be better to identify them directly and creates a process/system that mitigates each.[1] Yes, excess people can be a mitigation but, as you say, it’s an expensive one and a type that tends to be on the chopping block as soon as we get complacent. [1] https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20HFACS.PDF https://www.public.navy.mil/NAVSAFECEN/Documents/WESS/DOD%20...
beerandt 7y ago
Imo, this is wrong, and would lead to ignored alarms. (Who's old enough to) Remember waiting for someone else to answer the landline? Versus it ringing when you're home alone and know no one else is going to get it? Multiple alarm monitors might result in a lack of urgency (ie, someone else is closer, so no rush) or even shrugging off the responsibility all together (ie, someone else will get it, I don't need to go).