Why do things go right?
web.archive.org
web.archive.org
EDIT: a TL;DR:
Topic is failures/successes in complex projects/operations, like construction, surgery, or manufacturing.
The article first proposes that the usual way of evaluating safety - by focusing on failure cases - is insufficient, and a more productive approach would be to focus on the success cases.
The article then observes that the following is found in both the failure and success cases:
Workarounds
Shortcuts
Violations
Guidelines not followed
Errors and miscalculations
Unfindable people or medical instruments
Unreliable measurements
User-unfriendly technologies
Organizational frustrations
Supervisory shortcomings
Diversity of opinion and the possibility to voice dissent.
Keeping a discussion on risk alive and not taking past success as a guarantee for safety.
Deference to expertise.
Ability to say stop.
Broken down barriers between hierarchies and departments.
Don’t wait for audits or inspections to improve.
Pride of workmanship
The norms and procedures - even if followed to the letter[1] as much as possible - are not enough to avoid serious accidents, and as a matter of fact they might even be the source of problems[2].
What really counts in my experience is professionality, communication between workers and management, continuous attention and "common sense" (something that is not very common, unfortunately).
[1] In theory safety in the design is one of the main points of the Law, but in practice it is never or very rarely properly implemented. In theory a safety engineer should have the powers, besides advising, to alter the design and construction method proposing alternate, safer designs or construction methods, in practice these end up as being slower or much costlier and they are discarded.
[2] As an example relatively recent norms make obligatory to use a safety harness hooked to the basket of lifting platforms. This is a good thing, as it prevents the worker in the basket to fall out of it if there is a sudden bump when the platform moves or however the arm gets hit by something, BUT, on the other hand, if for any reason the platform collapses or tips over, the worker secured to the basket by the harness is more likely to be more severely injured.
> Keeping a discussion on risk alive and not taking past success as a guarantee for safety.
> Deference to expertise.
> Ability to say stop.
> Broken down barriers between hierarchies and departments.
> Don’t wait for audits or inspections to improve.
> Pride of workmanship
I love your list, and would like to see how well it would hold up when you compare start-up failures and successes against these criteria. Will definitely use this, thank you very much!
[1] https://www.nytimes.com/2016/02/28/magazine/what-google-lear...
It reminds me a bit of a story I heard years ago about a power utility company in the mid west that wanted to reduce accidents among its line workers. They looked at all their line crews, and found one team with a significantly better safety record than the others. They sent out a consultant to see what was going on and found that this particular crew was composed entirely of smokers. Before each job, they'd park their truck and have a cigarette while talking it through.
Said consultant came back with this information and the company instituted a detailed pre-job planning worksheet that each crew had to complete. From what I remember (I can't find the link anywhere - I read this 15 years ago and Google is no use here at all) the net effect was to worsen safety across all crews, while reducing the standard deviation between crews a bit.
But checklists were the hot new thing in 2012. They were going to save everyone from iatrogenic harm. This article doesn't explain how all the previous research supporting checklists got it so wrong. I'm updating my beliefs significantly away from checklist effectiveness, but I'm also really confused.
Did checklists just stop working in 2015, or something?
Atul Gawande’s “The Checklist Manifesto” comes to mind, where he argues that even experts need checklists to walk them through the key steps in any complex procedure. These complexities are such that it is easy to forget a key step or two. Following such checklists or written procedures minimize errors. He then shows how using checklists improves successful outcomes significantly.
I've always liked that mentality and this articles echoes that sentiment IMO.
For example, in competitive games in general focus on minimizing mistakes rather than focusing on capitalizing on your opponent's mistakes.
Particularly in combo-based fighting games, worry about your ability to execute rather than when to execute. Without fail you should always be able to 100% execute a combo without dropping it, even if you don't always go for the best combo for the scenario. Always going for the best combo but unreliably executing it and dropping it will lose you more games on average.
And for most games, most of the time, playing to not lose is a more reliable way to win, because it is more consistently rewarding to practice, even though it can result in a boring risk-assessed playstyle. Playing to win is an emotionally-driven way to do things and good technique will usually counter it, but every once in a while, late in a match, the mask slips and there's an opportunity to make a play on an overwhelmed opponent.
This said, when you get a 500 there isn't much which can go right.
To take it further, some things will just fail without any good outcome and they are too trivial to even learn from them.