[IP] 2 more on Brainwave fault explains slip-ups
Delivered-To: dfarber+@xxxxxxxxxxxxxxxxxx
Date: Sat, 20 Dec 2003 17:18:33 -0500
From: Russell Nelson <nelson@xxxxxxxxxx>
Subject: Re: [IP] more on Brainwave fault explains slip-ups
To: dave@xxxxxxxxxx
Cc: Don Norman <norman@xxxxxxxxxxx>
> Shame on all who propagated this nonsense. More shame on the fact that now
> this will only reinforce the notion that human error is the culprit behind
> accidents, when it fact it is almost always poor design plus business
> conditions and a profit-driven culture that force people to violate
> procedures in order to get the work done. (How many of you paste the
> password on the front of your monitor, or use the same password on multiple
> accounts, or ... ?)
Someone who is going to accuse other people of promulgating silly
nonsense should refrain from it himself. "A profit-driven culture" is
the cause of accidents? What is the alternative? A loss-driven
culture? "Honey, good news at work -- we didn't make a profit this
quarter, so not only do we get to fire another hundred workers, I'm
losing my job too! And they say that if another quarter goes by
without a profit, we'll be able to shut down the whole company!"
Would that be safer? Really, Don, you sound like an intelligent
person, why do you maunder so?
--
--My blog is at angry-economist.russnelson.com |
Crynwr sells support for free software | PGPok | You can't spell Fiasco
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Date: Sat, 20 Dec 2003 16:55:34 -0600
From: Don Norman <norman@xxxxxxxxxxx>
Subject: RE: [IP] more on Brainwave fault explains slip-ups
To: 'Russell Nelson' <nelson@xxxxxxxxxx>, dave@xxxxxxxxxx
Organization: Nielsen Norman group
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"angry-economist" (his self-description) Russell Nelson takes me to task for
my rhetoric -- I argued that many so-called "human errors" are really the
result of a misguided corporate culture that pushes immediate profits over
safety (and therefore, over long-term profits and stability). Nelson chides
me by stating:
> Someone who is going to accuse other people of promulgating
> silly nonsense should refrain from it himself. "A
> profit-driven culture" is the cause of accidents? What is
> the alternative? A loss-driven culture?
So let me be very clear about what I mean. First, there is nothing the
matter with making a profit. Indeed, companies that fail to make a profit no
longer exist, so any altruistic tendencies they might have had disappear.
I'm in favor of making money.
The concern, therefore, is not with profit-making, it is with addressing the
proper balance between maintaining operations, keeping costs appropriately
low, and also maintaining safety. There are many (documented) instances of
situations where the balance is all towards production and cost-reduction,
to the detriment of safety. As a result, workers are forced to violate good
practices, else the production suffers -- and they will be punished or even
fired. Most of the time, these violations do not result in problems, in part
because complex systems require multiple things to go wrong before an
accident occurs. (Some safety experts call this the Swiss Cheese theory of
accidents: line up twenty slices of Swiss cheese -- you only get an accident
of they line up so that there is a whole all the way through.) Indeed, the
violators are often promoted -- after all, they improved efficiency. But
every so often, the multiple factors line up and an accident takes palace --
and then, hurrah, we find the culprit who violated procedures, fire the poor
guy (or prosecute), and go back to the same unsafe practices.
That's what I was writing about. Note how incompatible the Swiss Cheese
theory of accidents is with the simple test of measuring someone's brain
wave to see if they are going to make a mistake. In a well-designed system,
no single mistake should ever cause trouble. And even most badly designed
systems have this property.
OK?
Donald A. Norman
Nielsen Norman Group AND Prof. Computer Science and Psychology
norman@xxxxxxxxxxx http://www.jnd.org
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