Date: Thu, 21 Apr 2011 10:53:22 -0400
Reply-To: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
Sender: DCHAS-L Discussion List <DCHAS-L**At_Symbol_Here**LIST.UVM.EDU>
From: Ralph Stuart <rstuartcih**At_Symbol_Here**ME.COM>
Subject: Re: Nature News Article: Fatality adds further momentum to calls
From: LaRosa, Rob 

A different perspective.

A discussion about "common sense" for this and nearly all other incidents
has little value.  To me, "common sense" as a finding in an incident
investigation is biased, suggests blame, and provides no basis for effective
and sustainable solutions.  The same is true for: "human error", "poor
judgment", or "inattention".

Sidney Dekker's said it best in "The Field Guide to Understanding Human
Error" :
"Explaining one error (e.g. operator error) by pointing to another
(inadequate supervision, deficient management, bad design) does not explain
anything.  It only judges other people for not doing what you, in hindsight,
think they should have done."

In the same book, he later states:
"Problems result from your organization's real complexity - not some
apparent simplicity (e.g. somebody's inattention)."

One suggestion would be to critically evaluate severe injury/fatality risks
and mitigations in open and honest discussions.  It takes individuals from
many areas/departments to conduct meaningful assessments and sustain the

Rob LaRosa
Lennox International Inc.

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