Errors LO12195

David Nelson (
Sat, 25 Jan 1997 15:47:24 -0400

[Arbitrarily linked to Normal Accidents LO12048 by your host...]

I've been intrigued by the couple of notes about failures. Our operaton is
team based, with low supervisory coverage. Recently we've been disturbed by
a pattern of errors. The characteristics are:

- Simple, repetitive jobs
- Done by experienced, competant people who know how to do them right
- After, the person's self-analysis "I was was on automatic."

We had been working to raise consciousness of this exact sort of risk. In
spite of that the pattern goes on. Typically we deal with these events as
a learning experience unless there's evidence of willful disregard, in
which case disciplinary action may be taken.

Any thoughts on how, without departing from a team based approach, we
could either reduce erros or increase the energy of people to anticipate &
prevent them?

When an idea is wanting, a word can always be found to take it's place-Goethe


David Nelson <>

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