5 ms·

Is the idea of blameless postmortem that exotic in the general public? If I hear that a critical safety system failed, my first association isn't "find the indi

Is the idea of blameless postmortem that exotic in the general public? If I hear that a critical safety system failed, my first association isn't "find the individual closest to responsibility, and look into whether a criminal prosecution is feasible". - "We have the ability to prosecute under the radiation safety act and we will certainly look at such prosecutions, and we've done that in the past," [Chief Health Officer Andy Robertson] said." - "The Prime Minister, Anthony Albanese, this morning joined those disappointed to learn the maximum penalty for mishandling radioactive material in such a manner was $1,000."

JauntyHatAngle 4y ago
I suspect he is talking about fining the company for a safety lapse, not individuals.
- deleted 4y ago
  [deleted]
- mulmen 4y ago
  The same incentives apply.
ChrisMarshallNY 4y ago
That was the reasoning behind the Truth & Reconciliation Commission, in South Africa. It was difficult, seeing admitted thugs, walking free, but I think most folks think it actually worked out well. https://wikipedia.org/wiki/Truth_commission https://wikipedia.org/wiki/Truth_commission
dtech 4y ago
It is still good to place (organizational) blame and fines on such a thing, otherwise it's financially the most attractive option to take inappropriate risks.
- ChrisMarshallNY 4y ago
  A lot of corporations actually budget for fines. People can really suck. It may be a corporation, doing the crime, but an individual made the decision to do it. I remember a DJ, in Washington DC, talking about parking fines. Parking in DC is expensive, with monthly passes, costing hundreds of dollars a month. His reasoning was that he parked illegally in lots around the studio, and occasionally got tickets, that he paid without issue, and it cost him far less than getting a pass. I assume these were not “tow away” lots.
  - sokoloff 4y ago
    In college, a resident parking violation in Cambridge was $10, while garage parking in Harvard Sq was $12 or more. Going out to dinner in the area, using the stochastic parking “garage” was the obvious choice.
  - ravi-delia 4y ago
    I mean, obviously that just means the fine isn't high enough. If it's within fine budget range rather than fine insurance, that's your problem right there.
mrpopo 4y ago
Not to mention that higher fines and prosecution could easily lead to the opposite effect in such a case, namely hiding the fact that they lost the capsule. It was extremely likely no one would have found it for years anyway.
- perihelions 4y ago
  - "lead to the opposite effect in such a case, namely hiding the fact that they lost the capsule." If you think about it, the impact's more pervasive and serious than that. Even simply saying, "hey, isn't there a potential issue with this bolt" shifts the appearance of blame on the person who's asking. When something does go wrong, the lawyer-attitude types can point to your words, and say "look: they were aware of possibility X at time Y, and they failed to stop it. They were negligent". "If you raised issue A, why then did you fail to take actions B, C, and D, and document them appropriately? You were negligent". To discuss Issue A is high-friction and risky -- for all values of A. That's at the core of legal culture: "don't put it in writing"; "don't talk to the opposing counsel"; "don't make public statements unless we vetted them (to be as vague as possible)". Opacity. What aspect of human nature underlies this? It's this: blame is nebulous, and it attaches to whatever's most visible. Guileless honesty is a *hazard* in a culture of suspicion. Obviously that's the exact opposite of what you want from an engineering culture! You want anyone to be able to raise issues freely, fearlessly. That's the true cost of a blaming-people culture. You're not merely disincentivizing communication at the very final stage ("cover up the disaster"); you disincentivize all communication about risk, at any time. Anything that places you visibly closer to responsibility is a peril.
  - dsfyu404ed 4y ago
    The part that really drives me up the wall is when people complain about this kind of "don't ask don't tell" ass covering behavior and then turn right around and confirm it was the right course of action by calling for the book to be thrown left and right in every case of wrongdoing. Naturally HN often has me doing laps on the ceiling.
igbk 4y ago
I suspect the extend and target of postmortem blame varies considerably from culture to culture. An anecdote from the railroad traffic between Germany and Denmark: "[In 2019, a DB Cargo freight train in Denmark caused an accident with a passenger train on its way to Copenhagen after a truck trailer flew off the freight train due to high winds. The German side was keen to find out who was responsible at the lowest level, i.e. the wagon inspector who had not adequately secured the freight on the freight train. The Danish side didn't care, the local authorities were concerned with structural responsibility. Not who caused the accident, but why could it happen! So in Denmark, the motto is: the process is the cause.]" - https://www.wiwo.de/unternehmen/dienstleister/zugunglueck-bei-garmisch-partenkirchen-die-deutsche-bahn-ist-zu-gestrig/28406710.html https://www.wiwo.de/unternehmen/dienstleister/zugunglueck-be... (German source)
- mieko 4y ago
  > keen to find out who was responsible at the lowest level It's funny how profit flows up, but legal responsibility trickles down.
  - bell-cot 4y ago
    There are some old stereotypes of detail-obsessed Germans - far too busy measuring the growth rings of a tree with micrometers, and wondering why those are so close together - but never noticing that the tree is small, and growing in a well-shaded part of a large forest.
    - egberts1 4y ago
      The absolute worse case of "not seeing the forest for the tree".
- SnowHill9902 4y ago
  Both are important.
- aeharding 4y ago
  https://www.simonandschuster.com/books/There-Are-No-Accidents/Jessie-Singer/9781982129668 https://www.simonandschuster.com/books/There-Are-No-Accident...
oliver910 4y ago
I think the response is pretty reasonable. Fines/punishments from regulators internalise externalities and disincentivise antisocial behaviour. If Rio just writes off the fine without improving its processes in tandem then it could make sense for the regulator to intervene further, but in either case Rio should be on the hook for damages rather than WA taxpayers.
twawaaay 4y ago
Yeah, exactly. What an engineer thinks: "Why not attach this thing to a beacon so that it can't be lost?" What everybody else thinks: "Why not persecute everybody responsible to the fullest possible extent?" Which is just our reptilian brain looking for somebody to blame but isn't actually helping anything.
- mhb 4y ago
  > What an engineer thinks: "Why not attach this thing to a beacon so that it can't be lost?" Or put cameras everywhere to deter crime.
  - twawaaay 4y ago
    I am not asking to limit anybody's freedom. A beacon would be attached to radiation source. Unless you are an individual who walks around with a highly toxic, highly dangerous radiation source, requiring it to have a beacon will not limit your freedom. As to putting cameras to deter crime, they are shown not to work. The crime just moves to where there are no cameras. Or stupid people will crime anyway. US is leading or close to leading in both crime rates and incarceration rates, at least in the western world. Suggesting the basic premise of what US is doing may be flawed, from engineering standpoint.
    - deleted 4y ago
      [deleted]
    - mhb 4y ago
      Right. but things they have in common are questionable cost/benefit, and, undoubtedly, unintended consequences. It also is not a better way to solve the problem. Now someone has to replace the batteries of the "beacon" or remember to charge it? How are they going to remember? Why not just have that same person remember to check that the source is secured properly?
      - twawaaay 4y ago
        > Right. but things they have in common are questionable cost/benefit, and, undoubtedly, unintended consequences. Attaching a beacon to highly dangerous radiation source is questionable, and has "undoubtedly" unintended consequences? Looks like searching for a problem where there isn't one.
deleted 4y ago
[deleted]
mardifoufs 4y ago
That's an especially prevalent attitude in Australia for some reason. Even the US usually leaves the aggressive prosecution tough guy threats to prosecutors/police instead of politicians.
Merad 4y ago
At what point do you think punishment is warranted when companies or individuals break regulations resulting in people being placed at risk? This isn't software where the impacts are some user inconvenience and maybe a bit of lost revenue. If this incident had gone just a little differently it could easily have resulted in deaths, people receiving massive radiation doses, or even hundreds or thousands of people getting enough exposure to raise their risk of cancer. Regulations around handling radioactive material are a lot like aviation regulations, they tend to be written in blood. This is a short list of major radiation exposure incidents in the past few decades: https://en.wikipedia.org/wiki/Ciudad_Ju%C3%A1rez_cobalt-60_contamination_incident https://en.wikipedia.org/wiki/Ciudad_Ju%C3%A1rez_cobalt-60_c... https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident https://en.wikipedia.org/wiki/Kramatorsk_radiological_accident https://en.wikipedia.org/wiki/Kramatorsk_radiological_accide... https://en.wikipedia.org/wiki/Theft_of_radioactive_material_in_Tammiku https://en.wikipedia.org/wiki/Theft_of_radioactive_material_... https://en.wikipedia.org/wiki/Acerinox_accident https://en.wikipedia.org/wiki/Acerinox_accident https://en.wikipedia.org/wiki/Samut_Prakan_radiation_accident https://en.wikipedia.org/wiki/Samut_Prakan_radiation_acciden... https://en.wikipedia.org/wiki/Lia_radiological_accident https://en.wikipedia.org/wiki/Lia_radiological_accident

JauntyHatAngle 4y ago

I suspect he is talking about fining the company for a safety lapse, not individuals.

deleted 4y ago
[deleted]
mulmen 4y ago
The same incentives apply.

ChrisMarshallNY 4y ago

That was the reasoning behind the Truth & Reconciliation Commission, in South Africa. It was difficult, seeing admitted thugs, walking free, but I think most folks think it actually worked out well. https://wikipedia.org/wiki/Truth_commission https://wikipedia.org/wiki/Truth_commission

dtech 4y ago

It is still good to place (organizational) blame and fines on such a thing, otherwise it's financially the most attractive option to take inappropriate risks.

ChrisMarshallNY 4y ago
A lot of corporations actually budget for fines. People can really suck. It may be a corporation, doing the crime, but an individual made the decision to do it. I remember a DJ, in Washington DC, talking about parking fines. Parking in DC is expensive, with monthly passes, costing hundreds of dollars a month. His reasoning was that he parked illegally in lots around the studio, and occasionally got tickets, that he paid without issue, and it cost him far less than getting a pass. I assume these were not “tow away” lots.
- sokoloff 4y ago
  In college, a resident parking violation in Cambridge was $10, while garage parking in Harvard Sq was $12 or more. Going out to dinner in the area, using the stochastic parking “garage” was the obvious choice.
- ravi-delia 4y ago
  I mean, obviously that just means the fine isn't high enough. If it's within fine budget range rather than fine insurance, that's your problem right there.

mrpopo 4y ago

Not to mention that higher fines and prosecution could easily lead to the opposite effect in such a case, namely hiding the fact that they lost the capsule. It was extremely likely no one would have found it for years anyway.

perihelions 4y ago
- "lead to the opposite effect in such a case, namely hiding the fact that they lost the capsule." If you think about it, the impact's more pervasive and serious than that. Even simply saying, "hey, isn't there a potential issue with this bolt" shifts the appearance of blame on the person who's asking. When something does go wrong, the lawyer-attitude types can point to your words, and say "look: they were aware of possibility X at time Y, and they failed to stop it. They were negligent". "If you raised issue A, why then did you fail to take actions B, C, and D, and document them appropriately? You were negligent". To discuss Issue A is high-friction and risky -- for all values of A. That's at the core of legal culture: "don't put it in writing"; "don't talk to the opposing counsel"; "don't make public statements unless we vetted them (to be as vague as possible)". Opacity. What aspect of human nature underlies this? It's this: blame is nebulous, and it attaches to whatever's most visible. Guileless honesty is a *hazard* in a culture of suspicion. Obviously that's the exact opposite of what you want from an engineering culture! You want anyone to be able to raise issues freely, fearlessly. That's the true cost of a blaming-people culture. You're not merely disincentivizing communication at the very final stage ("cover up the disaster"); you disincentivize all communication about risk, at any time. Anything that places you visibly closer to responsibility is a peril.
- dsfyu404ed 4y ago
  The part that really drives me up the wall is when people complain about this kind of "don't ask don't tell" ass covering behavior and then turn right around and confirm it was the right course of action by calling for the book to be thrown left and right in every case of wrongdoing. Naturally HN often has me doing laps on the ceiling.

igbk 4y ago

I suspect the extend and target of postmortem blame varies considerably from culture to culture. An anecdote from the railroad traffic between Germany and Denmark: "[In 2019, a DB Cargo freight train in Denmark caused an accident with a passenger train on its way to Copenhagen after a truck trailer flew off the freight train due to high winds. The German side was keen to find out who was responsible at the lowest level, i.e. the wagon inspector who had not adequately secured the freight on the freight train. The Danish side didn't care, the local authorities were concerned with structural responsibility. Not who caused the accident, but why could it happen! So in Denmark, the motto is: the process is the cause.]" - https://www.wiwo.de/unternehmen/dienstleister/zugunglueck-bei-garmisch-partenkirchen-die-deutsche-bahn-ist-zu-gestrig/28406710.html https://www.wiwo.de/unternehmen/dienstleister/zugunglueck-be... (German source)

mieko 4y ago
> keen to find out who was responsible at the lowest level It's funny how profit flows up, but legal responsibility trickles down.
- bell-cot 4y ago
  There are some old stereotypes of detail-obsessed Germans - far too busy measuring the growth rings of a tree with micrometers, and wondering why those are so close together - but never noticing that the tree is small, and growing in a well-shaded part of a large forest.
  - egberts1 4y ago
    The absolute worse case of "not seeing the forest for the tree".
SnowHill9902 4y ago
Both are important.
aeharding 4y ago
https://www.simonandschuster.com/books/There-Are-No-Accidents/Jessie-Singer/9781982129668 https://www.simonandschuster.com/books/There-Are-No-Accident...

oliver910 4y ago

I think the response is pretty reasonable. Fines/punishments from regulators internalise externalities and disincentivise antisocial behaviour. If Rio just writes off the fine without improving its processes in tandem then it could make sense for the regulator to intervene further, but in either case Rio should be on the hook for damages rather than WA taxpayers.

twawaaay 4y ago

Yeah, exactly. What an engineer thinks: "Why not attach this thing to a beacon so that it can't be lost?" What everybody else thinks: "Why not persecute everybody responsible to the fullest possible extent?" Which is just our reptilian brain looking for somebody to blame but isn't actually helping anything.

mhb 4y ago
> What an engineer thinks: "Why not attach this thing to a beacon so that it can't be lost?" Or put cameras everywhere to deter crime.
- twawaaay 4y ago
  I am not asking to limit anybody's freedom. A beacon would be attached to radiation source. Unless you are an individual who walks around with a highly toxic, highly dangerous radiation source, requiring it to have a beacon will not limit your freedom. As to putting cameras to deter crime, they are shown not to work. The crime just moves to where there are no cameras. Or stupid people will crime anyway. US is leading or close to leading in both crime rates and incarceration rates, at least in the western world. Suggesting the basic premise of what US is doing may be flawed, from engineering standpoint.
  - deleted 4y ago
    [deleted]
  - mhb 4y ago
    Right. but things they have in common are questionable cost/benefit, and, undoubtedly, unintended consequences. It also is not a better way to solve the problem. Now someone has to replace the batteries of the "beacon" or remember to charge it? How are they going to remember? Why not just have that same person remember to check that the source is secured properly?
    - twawaaay 4y ago
      > Right. but things they have in common are questionable cost/benefit, and, undoubtedly, unintended consequences. Attaching a beacon to highly dangerous radiation source is questionable, and has "undoubtedly" unintended consequences? Looks like searching for a problem where there isn't one.

deleted 4y ago

[deleted]

mardifoufs 4y ago

That's an especially prevalent attitude in Australia for some reason. Even the US usually leaves the aggressive prosecution tough guy threats to prosecutors/police instead of politicians.

Merad 4y ago

At what point do you think punishment is warranted when companies or individuals break regulations resulting in people being placed at risk? This isn't software where the impacts are some user inconvenience and maybe a bit of lost revenue. If this incident had gone just a little differently it could easily have resulted in deaths, people receiving massive radiation doses, or even hundreds or thousands of people getting enough exposure to raise their risk of cancer. Regulations around handling radioactive material are a lot like aviation regulations, they tend to be written in blood. This is a short list of major radiation exposure incidents in the past few decades: https://en.wikipedia.org/wiki/Ciudad_Ju%C3%A1rez_cobalt-60_contamination_incident https://en.wikipedia.org/wiki/Ciudad_Ju%C3%A1rez_cobalt-60_c... https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident https://en.wikipedia.org/wiki/Goi%C3%A2nia_accident https://en.wikipedia.org/wiki/Kramatorsk_radiological_accident https://en.wikipedia.org/wiki/Kramatorsk_radiological_accide... https://en.wikipedia.org/wiki/Theft_of_radioactive_material_in_Tammiku https://en.wikipedia.org/wiki/Theft_of_radioactive_material_... https://en.wikipedia.org/wiki/Acerinox_accident https://en.wikipedia.org/wiki/Acerinox_accident https://en.wikipedia.org/wiki/Samut_Prakan_radiation_accident https://en.wikipedia.org/wiki/Samut_Prakan_radiation_acciden... https://en.wikipedia.org/wiki/Lia_radiological_accident https://en.wikipedia.org/wiki/Lia_radiological_accident