I'm halfway through the article right now (thanks to Zealotux's cache link). Don't be discouraged by that 500 error - it seems to be a really solid piece of writing.
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
Therefore, it is suggested that focusing on those issues isn't going to reduce failures further. The article then follows with a list and description of things the authors observed to be more frequent in successful than failed projects:
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
Overall, a pretty interesting article. I await comments from people in the field :).
The article perfectly reflects my experience (building/construction sites).
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.
> 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
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!
It's not my list, it's the authors' :). Don't forget to review the original document, as each of those points has some commentary attached to it, explaining what exactly they mean by those phrases.
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.
This article is a strong volley aimed directly at checklist culture. It has a lot of citations.
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?
This article seemed inconclusive. They identified some differences of factors between things going right vs wrong but didn’t follow through with a scientific study.
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 think you have that backwards? In competitive gaming I was always of the mentality, and taught the mentality, that you shouldn't play to win. You should play to not lose. The best players I've spoken and played with also share this mentality.
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.
I think this one is mostly reflective of the risk/reward payoffs of aggressive and unusual play in any particular game. Play to win means - force the confrontation, take gambles, push your way into a surprise advantage. Play to not lose means - lean on your techniques, stay in control of the situation, build an advantage gradually.
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.
Speaking specifically about fighting games, there are multiple levels of progression, and thus different mentalities. At the lower levels of competitive play your best options are in fact, "playing not to lose" and letting your opponent make mistakes, then punishing them. At higher levels, execution is assumed for 90% optimal combos and situations, and dropped combos are uncommon. In those situations you need to force your opponent to make mistakes that they wouldn't make normally, and thus you "play to win". I can make a similar analogy in tennis, where low-level matches have a low ratio of unforced errors to passing shots, whereas professionals have a higher ratio. Professionals in competitive fields are working on a different level where consistency is expected.
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:
Therefore, it is suggested that focusing on those issues isn't going to reduce failures further. The article then follows with a list and description of things the authors observed to be more frequent in successful than failed projects: Overall, a pretty interesting article. I await comments from people in the field :).