--- to_be_filed/sf_code/esrgweba/htdocs/devels/quote_farm/quote_farm.htm 2017/06/14 02:03:18 137
+++ to_be_filed/sf_code/esrgweba/htdocs/devels/quote_farm/quote_farm.htm 2017/07/02 03:14:26 138
@@ -17,6 +17,7 @@
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- "Many accident investigations make the same mistake in defining causes.
+ They identify the widget that broke or malfunctioned, then locate the person most closely connected with the
+ technical failure: the engineer who miscalculated an analysis, the operator who missed signals or pulled
+ the wrong switches, the supervisor who failed to listen, or the manager who made bad decisions
+ When causal chains are limited to technical flaws and individual failures, the
+ ensuing responses aimed at preventing a similar event in the future are equally limited:
+ they aim to fix the technical problem and replace or retrain the individual responsible.
+ Such corrections lead to a misguided and potentially disastrous belief that the underlying
+ probem has been solved."--This appeared in a CRM book by Earl L. Wiener, Barbara G. Kanki, Robert L. Helmreich
+ and cites a 2003 NASA item, need to locate the item
- "She's got what I call bobsled looks: going downhill fast."--Craig Nova