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by hughesjj 847 days ago
Well certainly not after the first time at least

Imo it's a function of time, company and team culture, severity, and role guidelines.

If an employee makes a mistake but followed process, and no process change occured, that's just acknowledging the cost of doing business imo and would be a unbounded number of times so long as it's good faith from the employee
2 comments
s1artibartfast 847 days ago
My point is that good faith and sufficient competence are crucial. If the employee didn't care if the plane crashed, they are a bad fit.

If they cant read the refueling checklist, they are a bad fit.

Ideally you have system controls to screen and weed these people out too.

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roenxi 847 days ago
> a function of ... severity

Not severity; that sort of thinking is actually part of low-safety cultures. A highly safe culture requires the insight that people don't behave differently based on outcome. In fact, most people can't assess the severity of their work (this is by design; for example someone with access to the full picture makes the decisions so that technicians don't have to). So they couldn't behave differently even if they did somehow make better decisions when it matters.

But, and I'll reiterate the point for emphasis, people make all their decisions using the same brain. It is like bugs; any code can be buggy. Code doesn't get less buggy because it is important code. It gets less buggy because it is tested, formally verified, battle scarred, well specified and doesn't change often.

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hughesjj 847 days ago
Would s/severity/impact/g also be counterproductive of safety culture? Genuinely trying to learn here, gotta be responsible/accountable and all.

Maybe impact relative to carelessness/aloof-ity?

I agree that an engineer/person will not behavior differently based on outcomes, but if they know in advance something can have a wide, destructive blast radius if some procedure is not followed, I feel there's a bit more culpability on the part of the engineer. Regardless I don't think I feel I have a sufficient grasp on this concept I'm trying to define so definitely agreed I shouldn't have included 'severity' in the function definition nor any alternative candidate

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