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Comment by Telemakhos | Hacker News Reader

That sounds a lot like industrial safety culture: blame the process, not the worker, so we can iterate on the safety built into the process if there is a failure, because doing so lessens the chance of future failures. It’s a great way to build airplanes.

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Theoretically ... in practice, Boeing's most rigorous days in the 80s and 90s were directed by empowered individuals in the manufacturing org, and when it went full "strict process only" in the 2000s and 2010s the quality fell.

I don't think that's due to following the process but rather systemic cultural issues. The process doesn't exist in a vacuum. There's a good faith meta process that needs to be followed to incrementally fix issues as they arise.

Bad faith actors and cultural dysfunction can break pretty much anything no matter how well thought out it might be.

McDonnell Douglas merged with Boeing in 1997. Timeline checks out.

> Bad faith actors and cultural dysfunction can break pretty much anything no matter how well thought out it might be.

U.S. politics today in a nutshell.

It's also leaving out that system only works (worked) for building airplanes because it happens (happened) to be an industry with a hugely passionate workforce. Switch it to contracted out wage slaves and 'the system' doesn't work. Because the system never 'worked', many passionate people worked via sheer force of will/desire/care/investment into the final product. It was about the people all along.

The idea in the aerospace industry is that you should not blame the pilot, since pilot error became a all-catch rule no matter if there was design or system errors. The classical example is the button for the landing gear, where pilots continued to accidentally press it and crashing the plane. The engineers added guardrails to the button and the pilot error rate went down.

That's my dad who worked at NaSA doing aeronautics stuff said.

Pilots fuck up all the time so blaming them doesn't excuse anything.

And I find myself butting heads with people over that all the time. Coworker (smug satisfied voice) well if the end user fucks up it's not our fault. Me (trying not to sound really annoyed) yeah it's still our problem.

Although it has far from mainstreamed yet, I like how the software industry has the notion of a “UX bug”: if the user failed at anything, the software is at fault, because it wasn’t easy enough to use.

The lever for the landing gear and the lever for the flaps were easily confused. After landing the pilots intended to retract flaps but accidentally retracted the landing gear instead.

At first they assumed their recruitment process accidentally favoured stupid people so they made sure to only recruit smart pilots. But it kept happening. Then they put a little flap on the end of the flap lever and a small wheel on the end of the gear lever and the problem went away.

I simplify. Read the full story. It is cool!

Sort of, but the difference here is that it's really "blame the person who created the process, not the person following it". The people with the authority to alter faulty processes don't want to change it, even if it's clearly bad, because then they become "the person who created the process".

Industrial safety must (if it is to be effective) recognise that people are an important part of the process! They're so often forgotten, with disastrous results.

People need to be given timely information, communication channels, and authority to straighten things out when they go awry. That's good for safety!

It's also a crap way to run a culture when you scale it.

You need to make the people best positioned to notice something is stupid responsible enough to make them say no fuck you because otherwise every oversight and edge case will be substantially more likely to cause harm because they have less skin in the game.

See also: Cops getting "paid vacations" for bad stuff.

Except a lot of the safety in any given process comes from the people: if technicians, pilots, and air traffic controllers were not empowered to assess the situation and make decisions then there would a heck of a lot more accidents.

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