A doctor named Atul Gawande wrote a book named The Checklist Manifesto https://www.amazon.com/Checklist-Manifesto-How-Things-Right/...
Early in his career he did some research that showed that a simple pre-surgery checklist could reduce serious complications by more than a third. https://www.pbs.org/newshour/health/dr-atul-gawande-surgical...
I suspect we are coming at the same thing from different angles.
You can’t have a culture that tolerates accidents like this, so get some systems in place to prevent them. It’s not about one person or piece of equipment. Swiss cheese model etc.
you aren’t allowed to make mistakes of this magnitude. It really is that simple.
That does not mention prevention systems and instead put the blame squarely on the person making the mistake. They "simply should not have made the mistake, duh!"You’re right that my initial post makes it sound like I blame one person, and I sort of do. However it isn’t the guy who didn’t close the hatch. I blame the command structure and those at the top of it.
If leaving a hatch open causes one year of repairs and it contains a nuclear reactor maybe some automated sensors or checklists would be quite sensible.
Understanding and preventing human error is a basic part of design. Especially for things that cost $3B.
Really all human error that has happened before is predictable. My rule for myself is to assume any mistake I've ever made, or imagined making, is possible.
If you'd please review https://news.ycombinator.com/newsguidelines.html and stick to the rules when posting here, we'd appreciate it.
Even drive off and leave your trunk lid open? Forget a kid at the mall? Not call your Mom on Mothers' Day? Then you understand how easy it is for human error to occur.