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This is one of the foundations behind aviation and nuclear power SOPs using mandatory checklists. You take decision-making out of the routine process mandate the checks every single time you perform an operation, and impose penalties if they are not performed even when nonperformance does not lead to a mishap. The real question in every mishap is not what processes and procedures you had in place to deal with them, but what processes and procedures you had in place to prevent them from happening in the first place.
In almost all instances where accident or disaster is found to have been caused by operator error, investigations eventually determine that proper procedure was not followed BEFORE the accident or disaster, when there was no situation of stress or emergency to tax peoples' abilities to follow procedure and training. I'll stick my neck out and predict that the Gulf oil spill will turn out to be no different.
Gene Kim-Eng
------- Original Message -------
On 6/11/2010 6:41 PM Sarah Stegall wrote:
We can take a lesson from this, particularly if we write training
manuals for hazardous situations. Most people, confronted with a
decision that weighs the statistically less probable consequence of a
fire, explosion and spill, against the absolute dead certainty of losing
a well-paying job in a tough market, will save the job. The job is a
real, actual thing; the disaster is a remote possibility. Most mature
adults will bet on the sure thing and not the remote possibility.
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