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The post's title references an article on aircraft safety procedures or rather it becoming normal over time for a certain group to ignore those procedures. I d

The post's title references an article on aircraft safety procedures or rather it becoming normal over time for a certain group to ignore those procedures. I don't think the author is (necessarily) saying this is how everything is. He is just describing how a culture of X being broken can propagate.

musha68k 7y ago
Just putting this excerpt from the cited paper on "Normalization of Deviance" for people who skim the comments only (I would recommend reading the whole article, this one is for once worth it IMHO): A catastrophic negligence case that the author participated in as an expert witness involved an anesthesiologist's turning off a ventilator at the request of a surgeon who wanted to take an x-ray of the patient's abdomen (Banja, 2005, pp. 87-101). The ventilator was to be off for only a few seconds, but the anesthesiologist forgot to turn it back on, or thought he turned it back on but had not. The patient was without oxygen for a long enough time to cause her to experience global anoxia, which plunged her into a vegetative state. She never recovered, was disconnected from artificial ventilation 9 days later, and then died 2 days after that. It was later discovered that the anesthesia alarms and monitoring equipment in the operating room had been deliberately programmed to a “suspend indefinite” mode such that the anesthesiologist was not alerted to the ventilator problem. Tragically, the very instrumentality that was in place to prevent such a horror was disabled, possibly because the operating room staff found the constant beeping irritating and annoying. ... What these disasters typically reveal is that the factors accounting for them usually had “long incubation periods, typified by rule violations, discrepant events that accumulated unnoticed, and cultural beliefs about hazards that together prevented interventions that might have staved off harmful outcomes”. Furthermore, it is especially striking how multiple rule violations and lapses can coalesce so as to enable a disaster's occurrence.

musha68k 7y ago

Just putting this excerpt from the cited paper on "Normalization of Deviance" for people who skim the comments only (I would recommend reading the whole article, this one is for once worth it IMHO): A catastrophic negligence case that the author participated in as an expert witness involved an anesthesiologist's turning off a ventilator at the request of a surgeon who wanted to take an x-ray of the patient's abdomen (Banja, 2005, pp. 87-101). The ventilator was to be off for only a few seconds, but the anesthesiologist forgot to turn it back on, or thought he turned it back on but had not. The patient was without oxygen for a long enough time to cause her to experience global anoxia, which plunged her into a vegetative state. She never recovered, was disconnected from artificial ventilation 9 days later, and then died 2 days after that. It was later discovered that the anesthesia alarms and monitoring equipment in the operating room had been deliberately programmed to a “suspend indefinite” mode such that the anesthesiologist was not alerted to the ventilator problem. Tragically, the very instrumentality that was in place to prevent such a horror was disabled, possibly because the operating room staff found the constant beeping irritating and annoying. ... What these disasters typically reveal is that the factors accounting for them usually had “long incubation periods, typified by rule violations, discrepant events that accumulated unnoticed, and cultural beliefs about hazards that together prevented interventions that might have staved off harmful outcomes”. Furthermore, it is especially striking how multiple rule violations and lapses can coalesce so as to enable a disaster's occurrence.