smugly smugging "whoopsie daisy, one guy fucked up" is *exactly* how you create a culture of continuous "surprising" "accidents". - ThreadSky

amyhoy.bsky.social • 32 days ago

smugly smugging "whoopsie daisy, one guy fucked up" is *exactly* how you create a culture of continuous "surprising" "accidents".

Reposted from Amy Hoy

one of the smartest things i ever read was a post from an old engineer on the airstream forum:

he said "there are no such things as accidents."

that there is always a multi-factorial, multi-step process that creates the opportunity for something bad to happen.

Comments

friction.bsky.social•32 days ago

Finding the highest ranked supervisor on site and asking why they killed that person.

amyhoy.bsky.social•32 days ago

it's a federal agency. the person responsible is most likely not on-site.

hurricanexyz.bsky.social•32 days ago

Right, the way you make it so that this never ever happens is by having people who feel like it's their fault if it ever happens once, so they go to unreasonable lengths to ensure that it doesn't

pwnallthethings.bsky.social•32 days ago

a fuckup is when two disjoint safety systems kick-in to shut it down but the third safety system doesn't

hurricanexyz.bsky.social•32 days ago

Exactly

apearlma.bsky.social•32 days ago

I don't think a lot of regular people understand how much of Musk's advantage in SpaceX is removing multiple safety systems and basically saying, what's the worst that can happen. And then he did it to Twitter. And now USG.

hurricanexyz.bsky.social•32 days ago

See when you do it with a rocket with nobody on the rocket, that's one thing

apearlma.bsky.social•32 days ago

Yeah, he's just figuring he can make a more stable rocket with better computer controls for liftoff and landing — and once he does that, who needs the extra systems?

insavga.bsky.social•32 days ago

Flouting laws and regulations is like a moral first principle for him. His entire business empire is founded on it!
https://bsky.app/profile/insavga.bsky.social/post/3klz3zqs3622m

leonenglish.bsky.social•32 days ago

The moment I realized he was a moron was when I read about him headbutting a car on an assembly line to demonstrate that some well established safety procedure was unnecessary.

amyhoy.bsky.social•32 days ago

you mean decisionmakers i assume and not individual workers

hurricanexyz.bsky.social•32 days ago

I mean to some extent both, but yeah, principally

troutgirl.bsky.social•32 days ago

So many people think they're "systems thinkers" and so few really are.

amyhoy.bsky.social•32 days ago

SO FUCKIN TRUE

frconil.bsky.social•32 days ago

That’s why I think “human error” is the worst excuse. No one wakes up and thinks “I’m going to do my absolute worst today and cost millions of dollars in damages/lost time”. Something in the wider org set up circumstances for it to happen, it’s only luck it didn’t before.

amyhoy.bsky.social•32 days ago

"we did this before and it was fine" is how you create a culture of continuous "one-off" "accidents"

everything works fine until it doesn't. that's how the endless march of time works.

alexhammy209.bsky.social•32 days ago

If the result of your root cause analysis is human error you have not completed your root cause analysis

cjmoose.bsky.social•32 days ago

Example: Franchise owner ranting on a message board about how “stupid” her hourly wage workers are at a particular task. Gets told to sit tf down by multiple other franchise owners pointing out multiple flaws in the task process/methodology established by owner. Congratulations. You are the problem.

amyhoy.bsky.social•32 days ago

a lot of these fuckwits wouldn't know a proximal cause vs a root cause if it rose up and bit them in the ass repeatedly

amyhoy.bsky.social•32 days ago

well said

ludflu.bsky.social•32 days ago

organizations become prone to surprising accidents when they neglect to learn safety engineering!

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