The focus seems to be that we didn’t do anything wrong, just some “human” made an error, which seems to be implied is out of their control. Why would the organization not be responsible for the people and the system working together? Management needs to create systems that works. That system includes people and equipment and process management and suppliers
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If management tries to claim a failure was due to "human error" they have to provide me a great deal more evidence on why the system was designed to allow that error (given that they say the error is "human" implies that they believe the system should have been able to cope with the situation). Requesting that evidence is the first thing reporters should ask any time they are given such excuses. At which time I imagine the response options are:
- no comment
- we had considered this situation and looked at the likelihood of such an event, the cost of protecting against it (mistake proofing) and the cost of failure meant and decided that it wasn't worth the cost of preventing such failures
- we didn't think about it
- we think it is best not to design systems to be robust and mistake proof but rather rely on people to never make any mistakes
What they will likely say is we have these 3 procedures in place to prevent that error.
Are they every followed? You have something written on paper, big deal? What actually happens?
Yes they are always followed by everybody, this one time was the only time ever that it was not followed. Why?
This person made a mistake.
Why did the system allow that mistake to be made?
What? You can't expect us to design systems that prevent mistakes from being made.
Yes I can. That is much more sensible than expecting people never to make a mistake.
continue reading: European Blackout: Human Error-Not