Design Error I’m in the doghouse. Mrs Lawther asked me to do the washing whilst she was out. As I am a modern man and expect to do my bit, I was happy to comply with the request. Unfortunately, there was a complication. The washing included my wife’s very chic and expensive dress. Ordinarily, this […]
Risk Compensation
Understanding Risk Compensation — Because Error Proofing Isn’t Enough Road safety is an excellent example of a system where many have tried to change the public’s behaviour and stop things from going wrong. Error proofing is a common approach, making things easy to get right and difficult to get wrong, but it isn’t without its […]
Operational Controls
Operational Controls are Worthless if They Aren’t Maintained At approximately 5 pm on Monday 22nd June 2009, a Washington Metro train heading towards Shady Grove smashed into the rear of the train ahead of it. The Automatic Train Control system had instructed the train to travel at full speed (55 mph). When the driver of […]
Reducing Complexity
Avoiding Overwhelm In their book Meltdown, Clearfield and Tilcsik show how complicated systems fail. They discuss nuclear accidents, financial disasters and medical mishaps and show how we can avoid disasters by reducing complexity. The more complex our systems become, the less easy they are to understand. So they become harder to fix when they break. Add […]
Preventing Human Error
A Problem with the envelope On February 26th 2017, The Academy of Motion Picture Arts and Sciences held its 89th award ceremony, celebrating the best films of 2016. The ceremony was a case study in preventing human error (or not depending on your perspective). It went swimmingly until the very last award for best picture. Faye Dunaway […]
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