I've certainly seen this when in the hospital with family; new doctors would frequently ask me for historical information, including about what other doctors had said or done. I was fine giving it, but what if I hadn't been there?
Checklists are an easily observable symptom of an team drive for improvement of outcomes. But you can't reverse that and plop down checklists that are used under threat.
I'm going to try to find it. But, if I don't, you got the gist of it:
Have a checklist, and stick to it. Don't expect one person, or even multiple people, to remember all of the steps off the top of their head.
It's an -excellent- book about the application of checklists to error reduction etc.
I'm worried it might have been .NET Rocks![1] They have a great podcast, but their episodes aren't indexed by Google because of their website structure.
I'm gonna keep looking, and even check my home computer's history when I get home tonight, but I wouldn't hold your breath. Someone a bit above linked to a book that I'm pretty sure was the impetus behind the podcast I listened to, so it might be worth giving that a read.
EDIT: HA! I found it! It was actually in the press section on the book's web page.
http://www.npr.org/templates/story/story.php?storyId=1222261...
As someone else said, there's a lot of ego involved too. Given that a lot of it is "brainwork", it's the only physical way they might be able to feel they're testing themselves against something.
Most of it in those jobs is just production-churn and an attempt by the higher-ups to save money on things that a) were bid low and b) have shitty margins.
And most importantly, know that this is not necessary. American doctor supply is restricted by the AMA. America could suck the best doctors out of many other nations if it so desired and its healthcare practitioners would be better rested, more mentally well, and far less error prone.
Seems pretty well researched by a quick google. Maybe they're eliding the support not because it's an assumption, but because it's so thoroughly established they take it for granted?
http://www.nejm.org/doi/full/10.1056/NEJMsa1405556#t=article...
https://psnet.ahrq.gov/primers/primer/9/handoffs-and-signout...
...
> But there is a wealth of evidence that says that doctor performance drops significantly with motor performance being harmed
That's true too, but I worry you're trying to rebut (X & Y) with evidence for Y.
If we find ourselves slipping into a battle of emphasis, maybe we face a problem of optimization?
It probably varies by specialty and even individuals, probably a monster of a problem.
Second half has been at a company with a very pro-family-time CEO, and as a bachelor that just means a lot of time to explore this awesome new city :) So I haven't yet experienced the "utter madness startup" I guess?
A battle in 1942 was lost, badly, because the USN crews were zonked from a routine that gave them almost no chance for sleep.
The Luftwaffe was more "professional" and worked their crews much harder and didn't take time to relax and had a culture of focusing 24 hours a day on the job.
I read - years ago - that the most active combat was in the area around London. Not a small area, but it allowed RAF to move squadrons to lower threat areas for reconstitution and rebuilding before rotating them back to a hot area.
The culture is risk-averse to a fault, but at the same time have nearly zero capability to accurately asses risk or fix problems beyond punishing people when things inevitably go wrong.
Official "risk assessments" are performed before every dangerous undertaking, with numbers that are pulled out of someone's ass, along with additional "risk mitigation" numbers that are also pulled out of someone's ass so that leaders have cover when an accident happens. "We performed all the necessary risk assessments and were still a go."
Let me give you an example. Underway replenishment is when one ship will pull alongside a supply ship and transfer fuel and supplies from the supply ship. It's very dangerous because the ships are within 300 feet of each other for hours on end.
A risk-assessment is done and briefed the night before. Those are a PowerPoint presentation with a grid of things that can go wrong on the Y-axis. There are two columns, "risk" and "mitigation," and in line with each disaster are the probability conflated with the severity of that happening. Not actual numbers, just words like, "severe," "marginal," "likely," etc. Those are color-coded between red and green.
One of those things is always "crew preparedness" or similar. The risk of having an unprepared crew that didn't get a lot of sleep is shown as, for example, "severe" and colored red. The briefer will say, "well this is a severe risk, so we're making an announcement that everyone needs to get plenty of sleep tonight and that mitigates that risk down to "tolerable."
Actually this is more technical than what actually happens most of the time, which is that you'll hear things like, "we've mitigated the yellow risk down to a green." The entire ship's company of NCO's and officers will watch that presentation and nod their heads along. There is never one of these that results in a decision not to do something.
And there you have it. I've taken you through the entire risk mitigation strategy for the Navy, that happens nearly every day.
Does anyone know the actual probabilities of disaster? If so, they're not saying. Are they changing existing procedures or spending additional money to fix problems based on actual numbers? Hell no.
Really severe problems are dealt with in the following manner; a "zero tolerance" policy for that problem existing will be created, and when disaster strikes, it's a career-ending event for whatever scapegoat is standing there. Problem solved!
By the way, don't join the Navy.
EDIT: Also, the "too much technology" portion of the article is laughable. Part of the problem is that technology that the rest of the world uses to avoid these sorts of things is seen as anathema to the luddite SWO community, and rather than embrace anything that could help automate error-prone tasks, they pay lip service to it and continue doing extraordinarily stupid things for tradition's sake.
Aircraft carriers are driven by issuing voice commands to (mostly undertrained) helmsman in an environment where any additional noise could result in a misunderstood command and disaster. Or the helmsman gets tired of standing for a five hour watch every day and accidentally turns left instead of right like she's told. Imagine driving a car by telling the driver what to do from the passenger seat. Not just a "turn left up there," but "turn the wheel 15 degrees to the left, ok, now turn the wheel back to center, ok, now turn it back three degrees to the right because you oversteered..." It's insane.
Former aircraft carrier OOD (and nuke SWO) here. I agree with your comment about fatigue, but did you get much bridge time? At least back in the day, the conning officer's voice commands weren't so micro-managey. They were along the lines of, "Right 15 degrees rudder [0], steady on course 090," which the helmsman would repeat back to make sure the command was correctly understood. The helmsman would then turn the wheel as needed to make the turn and steady up on the ordered course.
[0] The conning officer would specify the rudder angle in part to control how much the ship would heel in the turn. That can be important when you have armed jet aircraft driving around on the flight deck.
In many cases those helmsmen were undertrained or tired, as a direct result of cuts in manning/funding and additional requirements.
The "old" people in the navy, including many of the admirals at the time (ten years ago) had many of the same opinions as those expressed in the article (they need to stop looking at radar!!!)
What those people didn't seem to realize is that we were doing the same things they were doing 20 years prior with about half the crew they had.
That is the best-case, textbook way to run the model. Still very subjective pseudo-science, masquerading as objective risk management, but at least has something of a method to it.
In practice, the repetitiveness of the GAR model results in many crews blowing it off, and giving a vague, arbitrary cumulative score without any discussion around how they got there. This sounds bad, and by policy it is bad, but in practice I have observed no discernible difference in how crews approach risky missions and operations when they conduct a full GAR brief or just give a somewhat random score and move on. In other words, the GAR model does not seem to provide any tangible risk management benefit, and largely seems to serve as a bureaucratic CYA solution.
GAR was introduced in an attempt to reduce the number of mishaps occurring due to what was deemed to be excessive risk-taking. The statistics may demonstrate that it had that effect, though I would argue from my perspective that other training programs introduced to address problems related to risk assessment have far more deckplate-level impact and effectiveness. The problem with GAR is that it tries to objectively standardize something which is, by its very nature, dynamic and subjective. No two people, in the exact same situation and having the exact same capabilities and experience, assess the risk the same way. Assigning numbers to a series of broad categories and giving a color-coded risk level to the situation does not inform anyone of anything very useful. Discussion of risk factors is more helpful, but due to the way the system is structured, is a step frequently skipped.
What matters far more is focusing on continuous, dynamic training and education of those in billets for whom risk management is a critical part of the safe completion of their mission, and emphasizing clear communication unfettered by rank or positional authority to ensure that everyone has full situational awareness. Be respectful, but make sure that information can move freely between all involved.
[0] https://www.uscg.mil/hq/nsfweb/foscr/ASTFOSCRSeminar/Present...
I think what I learned from my superiors is that it doesnt matter so much what system is used for risk assessment, but whether a conversation about risk was had in a meaningful way. Sometimes quantification helps this, where complex systems can be analyzed and the consequences assessed. Usually if you are going to do that it has to happen well in advance of an operation. Othertimes the desire to get a number leads to a real ham fisted attempt to "quantify" things like how fatigued the crew is on a scale of 1-10, or to rate the environmental conditions. When the GAR model, which stands for Green - Amber - Red, was used to facilitate an honest conversation about how people felt about an operation as opposed to just checking a box so that it could be put in the logs. When I saw it being used as the former it absolutely made things safer, but that was very dependent on the attitude of those participating.
Semper P
Do you know the people who studied for and aced all exams through brute force memorization, promptly forgot all the material or never understood how it would be applied, but now have the certificate that says they know X? That was 90-95% of Naval officers.
I had a one week class in digital communication, as part of a nine-week introductory class for new officers. They go over basic information theory as it applies to naval communication systems and encryption. The valedictorian of that class, who had just aced the test on digital communications the week before, raised her hand the following week to ask a clarifying question about a follow-on topic: "When you say everything is just ones and zeros...what does that even mean?"
That sums up naval training. I realized then that this person, despite all appearances of knowing the material and being an excellent student, had NO clue what anyone was talking about and hadn't for the entire class despite having the highest grade of anyone.
So you'd have an aircraft carrier CO with a Master's degree in chemistry who didn't really understand the concept of vector addition as it applied to calculating relative wind. He'd be yelling at subordinates for not being able to calculate (improperly) wind vectors and distances. All subordinates were clearly confused by this, felt like the CO, being highly educated and the CO of the ship, must know what he's talking about. If you'd ask the CO to explain what he meant he'd become irate and tell you you were stupid.
The nuclear officers/enlisted knew their shit, and those were some of the smartest and best people I've ever worked with. They'd nod their heads at the aforementioned CO and then ask, "he really doesn't understand vector math, does he?" when he was out of earshot. The rest of the crew would assure the nuclear guys that they must be wrong.
That sums up a big chunk of computer science. What answer did she get from the instructor?
It's a good question, coming from a non-technical person, and I'd definitely give a dirty look to anyone who laughed at it.
Perhaps that would be appropriate before said person had taken a digital communications class and aced a test on it. After that, however, I think a wry chuckle is very much appropriate.
He just unpacked the black boxes in a different order.
1)...at what? Many of them are very bright and well trained, but seriously, at what? People who go into leadership are often strong managers but that doesn't make them good captains or good seaman. They are incredibly skilled, just at the wrong thing. You gotta remember that at the end of the day it is likely someone under the age of 22 with their hands on the wheel and people of similar age running all the major systems. The promotion path to captain is not exactly hands on.
2)...oh yeah. They have been serving on ships for a long time. But in the Navy, serving on ships does not in any ways equate to seamanship. The Navy (and obviously IMHO) has a little bit of a chip on its shoulder about 'blowing shit up' that likely comes from feeling underutilized in our last to endless wars, and this is especially prevalent in the surface fleet. They tend to prioritize things like warfare officers and sometimes even ex-pilots for promotion up towards captain ranks. Those people are absolutely deployed but doing things totally unrelated to navigation and seamanship as a core mission. They should, but often don't have the time or space, have impeccable seamanship skills.