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> errors and unsafe acts will not be punished if the error was unintentional. No sane organization would ever implement this. If someone repeatedly makes mista
by burnerburnson 3y ago
> errors and unsafe acts will not be punished if the error was unintentional.
No sane organization would ever implement this. If someone repeatedly makes mistakes, they're going to get fired even if the mistakes are unintentional. Anything else is going to cause more safety issues in the long-term as inadequate employees are allowed to proliferate.
- zettabomb 3y agoEvery sane organization implements this. Failure to do so leads to fear of reporting mistakes, and you get Boeing. This isn't news.
- jjk166 3y agoIf it's possible for an employee to unintentionally make the same mistake twice, that's purely management's failure. It's impossible to make systems completely fool proof, but once you know of a specific deficiency in your process you fix it. If you've corrected the issue, it should take deliberate effort for someone to do it again. An organization that knows its processes are deficient but makes no changes and expects a different result is insane.
- deleted 3y ago[deleted]
- byteknight 3y agoFurthering the insinuation that everyone has the right to work every job. Sometimes people suck at their job.
- error_logic 3y agoAs your sibling comments mentioned, there's a difference between giving a chance for someone to learn from a single mistake without punishment, and allowing them to make the same mistake twice without taking matters out of their hands after. If it's a really critical role, the training will have realistic enough simulation for them to make countless mistakes before they leave the training environment. Then you can assess their level of risk safely.
- hinkley 3y agoThis whole thread is missing the fact that the NTSB had a theory that transparency leads to safer airplanes, they tried it, and it works. People hesitate to self-report when it comes with punishment (fines, demotions, or just loss of face among peers). You need a formal “safe space” where early reporting is rewarded and late reporting is discouraged. Safety is a lot about trust, and there is more than one kind of trust. At a minimum: are you capable of doing this thing I need you to do? Will you do this thing I need you to do?
- zettabomb 3y agoIt's not just the NTSB, it's part of things like the Toyota Production System. There's ample evidence to show both that punishment discourages safety and that lack of punishment encourages safety, across multiple industries.
- ethanbond 3y agoBut but but what about my intuition and gotcha questions about how this could never work in practice?
- hinkley 3y agoThe dirty secret of why traffic circles reduce accidents? Stoplights feel safer than they actually are, while circles feel more dangerous than they actually are. That nervousness becomes vigilance, which reduces accidents. It’s also why people intuitively hate them. They’re actually right, but also wrong. Feeling safe is an illusion that governments try to maintain for their people. It’s one of their biggest jobs. But the illusion has dimensions and it’s hard to keep several going at once.
- nyrikki 3y agoYes this is cross industry best practices. Goodhart's law also applies, as in the case of the edoor bolts, Spirit intentionally bypassed safety controls to meet performance metrics. The Mars Climate Orbiter is another example. While unit conversion was the scapegoat, the real cause of the crash is that when people noticed that there was a problem they were dismissed. The Andon cord from the Toyota Production System wasn't present due to culture problems. Same thing with impact scores in software reducing quality and customer value. If you intentionally or through metrics incentivize cutting corners it will be the cost of quality and safety. I am glad they called out the culture problem here. This is not something that is fixable under more controls, it requires cultural changes.
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- icegreentea2 3y agoJust culture doesn't prevent you from firing someone who makes repeated mistakes. In fact, Just Culture in itself provides the justification for this. As the next line says "However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action". A person who repeated makes mistakes is an unjustifiable risk.
- hinkley 3y agoWhen a punishment is applied with more deliberation, it can also be more severe.
- wolverine876 3y agoWhy is severity desirable? Or if it's not desirable, so what?
- sokoloff 3y agoSeverity is desirable iff it's justified. I wouldn't ever sign off on a policy that says "you'll be fired for a single mistake" (that would be a severity of punishment out of proportion to the risk/underperformance). But a policy that never provided for the possibility of termination (insufficient maximum severity) is also not desirable.
- wolverine876 3y ago> Severity is desirable iff it's justified. It's necessary if it's (necessary & efficient & justified); it's never desirable IMHO. Doing severe things because they are justified is just acting out on a desire or drive - internal anger - but now we can 'justify' the target and feel ok about it. Lynch mobs think they are justified.
- sokoloff 3y agoDesigning severe things to be included as part of a process is a desirable property of that system if the severe thing is sometimes required. No one is designing a formal system that includes lunch mobs. But a formal system of repercussions for employee behavior that does not include firing is an incomplete system. It’s not that firing itself is ever desirable, but rather that its inclusion in a disciplinary progression is desirable.
- buttercraft 3y agoThat's quite a leap from "unintentional" to "repeatedly."
- wolverine876 3y agoNot at all: Systemic problems will result in repeated errors until the system is changed.
- applied_heat 3y agoYou can really dumb it down to why didn’t you follow the checklist? If someone makes the same mistake after being corrected three times and the proper procedures exist for the worker to follow then the safety culture provides the structure and justification for their dismissal
- buildsjets 3y agoNo, you really need to smarten it up, and start off by making sure that your checklist is correct. Is it the correct checklist for the airplane model that you are building? Are all the right items on the checklist? Are they being done in the correct order? Do you have the correct validation/verification steps in your checklist? Does your checklist include all the parts that will need to be replaced? If the mechanic finds a quality issue while working the checklist and a job needs to be re-done, which checklists then need to be re-done? What other jobs are impacted by the rework? All indications here (from the NTSB prelim and the widely reported whistleblower account) are that during rework for a minor manufacturing discrepancy, the mechanics on the shop floor followed bad manufacturing planning / engineering instructions to-the-letter, then the ball was dropped in error handling when the engineering instructions did not match the airplane configuration, because Boeing was using two different systems of record for error handling that did not communicate with each other except though manual coordination. That's not the fault of the front-line assembly worker not following a checklist.
- applied_heat 3y agoI agree with you. If the systems/procedures/checklists are bad it is not the fault of a front line worker. I thought I was replying more to a parent comment addressing the inability to people go who repeatedly make mistakes, which is acceptable unless they are not following procedures.
- empath-nirvana 3y agoThis is just blameless post mortems and many, many many places implement this. There are always going to be some level of "inadequate" employees, and also perfectly adequate employees that sometimes make mistakes in any organization and if your organization requires that no employees ever make mistakes in order to operate safely, then you have serious problems. The purpose of a statement like that is that you don't just have a post-mortem that is like: "Our company went off the internet because an employee had a typo in a host name. We fired the employee and the problem is solved." When in reality the problem is that you had a system that allowed a typo to go all the way into production.
- error_logic 3y agoIt's like that story of the pilot who, after his refueling technician almost caused a crash by using the wrong fuel, insisted that he always have that technician because they'd never make that mistake again.
- s1artibartfast 3y agothe question is what do you do with the technician after the 2nd mistake. that is to say, When does this logic break down?
- lucianbr 3y agoIf you implemented some changes so the mistake is caught before disastrous consequences, you're already doing better. Well enough to let the 2nd one slide. Even the 3rd. After that, action seems reasonable. It's no longer a mistake, it's a pattern of faulty behavior.
- s1artibartfast 3y agoThat is a big IF. At some point it comes down to the error type, and if it is a reasonable/honest mistake. The situation is very different if the fuel cans are hard to distinguish vs if the tech is lazy and falsifying their checklist. Underlying any safety culture is a one of integrity. No safety culture can tolerate a culture of apathy and indifference.
- beaeglebeached 3y ago[flagged]
- gklitz 3y agoWhat a reductive attitude. If your planes fall from the sky because a single employee is negligent. The ones to blame isn’t the worker, the union or the state. It’s your business that has key deficiencies in implementing safety. Your QC process has to be able to catch these things. It’s not like you can avoid any reliability in your process and just lean back and be like “don’t worry bro, it’ll fly, we hired all non-union workers”
- beaeglebeached 3y agoWhat a reductive attitude. Nah not just one negligent worker. Many, including QC staff.
- hinkley 3y agoThis also sounds like someone in the New Boeing management chain. A lot of these culture problems were already evident during the 787 program, which is when MD’s mismanagement started to fester. And when the hardon for union busting first came to my attention.
- ethbr1 3y ago> The ones to blame isn’t the worker, the union or the state. It’s your business that has key deficiencies in implementing safety. I don't think you're charitably reading parent. Sometimes, the employee is the problem. And sometimes, union contracts preclude changing processes (or make change unnecessarily burdensome) to improve outcomes. Introducing another party into agreements doesn't come free. I'm as pro-union as anyone around here... but it is another level of bureaucracy. And sometimes, protecting "our people" can include not letting go people who should be let go (e.g. decreasing headcount in assembly to hire more professional QA people). That said, solutions do need to come from all levels, and I think unions do provide a necessary counter-pressure to management deciding only employees need to bear the brunt of change.
- dclowd9901 3y agoI think the wording is clumsy, but this is analogous no-blame processes. The wording is just accounting for the possibility of wontonly malicious or recklessly negligent work quality. Think someone either sabotaging the product, or showing up to work very high or drunk.
- inglor_cz 3y agoThis. A mistake like "accidentally turning the machine off when it shouldn't be" is a fixable problem. If someone has attitude like "fuck the checklist, I know better", it is not really a mistake, and that person should be rightfully fired or at least moved to a position where they cannot do any harm.
- ClumsyPilot 3y agoWho do you think came up with this rule, bleeding heart liberals’? Stop and think for a second, why does that rule exist? You described a fantasy world, in the real world everyone makes mistakes, and if the mistakes are punished, then there are no mistakes because no one reports them. That is until the mistake is so catastrophic, it cannot be covered up- that’s how you get Chernobyl or Boeing max
- shiroiushi 3y agoBoeing max (if you mean the crashes caused by MCAS) wasn't due to a "mistake" not being reported, it was deliberate and intentional on the part of company management. The system was designed badly and without redundancy, and without any information available to the pilots about its very existence, specifically because management wanted it that way. It wasn't caused by some kind of accident.
- ThrowawayTestr 3y agoI once destroyed $10k worth of aerospace equipment. I admitted it immediately and my only reprimand was that my boss asked me if I learned my lesson. (I did)
- Log_out_ 3y agoOnce destroyed a industrial manufacturing site with a unfinished robot program that ran because I allowed myself to be distracted mid alterations.
- wolverine876 3y agoAnd what happened?
- inglor_cz 3y agoIdeally, as a result of the post-mortem, the same mistake shouldn't even be repeatable, because mechanisms should be introduced to prevent it. And if someone keeps making new original mistakes, revealing vulnerabilities in your processes, I would say that it is a very valuable employee, a lucky pen-tester of sorts.
- idontpost 3y ago[dead]
- deleted 3y ago[deleted]
- WheatMillington 3y agoWowwww never become a manager please.