8 ms·
Maybe. But it's hard to tell whether nobody died because the system was robust vs. nobody died because we got lucky. For example, there were several cases of b
by GMoromisato 2y ago
Maybe. But it's hard to tell whether nobody died because the system was robust vs. nobody died because we got lucky.
For example, there were several cases of burn-through on the O-rings before Challenger. The engineers thought there was enough margin to not worry about it, so they didn't
Similarly, when Columbia was hit by foam-ice on ascent no one worried because it had happened before and nobody had died.
- twh270 2y agoCorrection -- at least for Challenger, engineers did not think there was margin, and argued against the launch. At the technical level, both tragedies were caused by design flaws. Organizationally and culturally, multiple factors contributed, but an attitude of "nothing has happened yet, so this is fine" (normalizing risk) was a major one.
- Aeolun 2y agoNormalization of deviance is how my professor described it. At least it’s taught in school now.
- kqr 2y agoIn my mind I have stored this phrase that "production pressures move the Overton window of acceptable shortcuts closer to disaster." I think it captures several important nuances, like how it's a gradual process, how it ecpnomises/improves things at first, that there is a destination, that it covers even things such as discussions about shortcuts and not just their usage.