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by userbinator
860 days ago
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A lot of comments here are going on about process, as if humans are mindless and otherwise perfectly controllable robots... I'm going to be contrarian and say that this is exactly the sort of thing that happens when you train humans to be robots: They lose all signs of common sense and critical thinking, and what's worse is that on top of that, they'll still have their inherent imperfection. Normally the former would counteract the latter, but not if you only make them rigidly follow some process all the time. They stop thinking about what they're doing. They stop paying attention to all the other things in their environment they would've noticed, and even if they do, they won't question it because they'll just assume someone else also following a rigid process will take care of it. They won't think "this door plug should've been bolted in place now that the work that needed it opened is done, but where are the bolts?" I'm not saying to throw out all the process and make them figure everything out, but I think there has to be a balance, similar to how overautomation and reliance on that has also lead to avoidable incidents in aviation. |
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The process was there so that the people would know there was work being done on the doors despite not being there for it. If you see an unfinished work from a previous shift, it does not mean you can start messing with it - there might be context you do not know.
Which is why such things are supposed to be noted in appropriate ways. Similarly why aviation has so many procedures everywhere - because we know and understand that sometimes you miss things. For any human reason, not just mismanagement. The process is a way to have reliable place to double check with.
This is different from over reliance on automation, which is arguably less of an issue of automation itself (it's just more visible in such areas) as much as getting out of training because you do not encounter certain things so often. 96 people died because in a stream of many deviations, among other things, the crew never trained how to do IFR landing without ILS, autopilot or no autopilot.
The process is the part that says "yeah, I haven't done this in a long time, I need to train, here is documentation that provides we need to do it and can't delay".
Similarly CMES is supposed to track "work was done on this part of the ticket, now different work needs to be done, do not assume it will be done by other teams"