3 ms·
I'm not sure the term has ever been extended to multi-generational problems, though it very well could be. The traditional, aerospace human factors explanation
by inamberclad 6y ago
I'm not sure the term has ever been extended to multi-generational problems, though it very well could be.
The traditional, aerospace human factors explanation occurs over timescales from weeks to years.
It normally starts with something incorrect (the deviation) that doesn't cause an immediate problem. Examples would be O-ring burnthrough on Space Transportation System Solid Rocket Booster segments, or maybe a pilot who is always a few knots too fast over the threshold on his approaches. Both are problems - everyone knows it - but since it hasn't cause a problem yet its allowed to slide until it just becomes common practice.
The key point here is that the system (machine, human, organization) has acquired a deviation that means it no longer operates like it was designed and is not fixed because everyone becomes accustomed to the deviation. This degraded state is now the new normal.
One day the weather is too cold, and another assumption about how the system operates is violated. The O-rings don't seat properly when the boosters are fired. The runway has ice on it. Hot gasses escape through the booster joint and impinge on the LH2 tank, and the aircraft finds its braking authority is insufficient, and a runway overrun occurs.