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[OM] Re: First CF card failure

Subject: [OM] Re: First CF card failure
From: Andrew Fildes <afildes@xxxxxxxxxxxxx>
Date: Wed, 31 Oct 2007 09:12:39 +1100
That was a classic disaster. All the safety procedures and routines  
were in place so it was assumed that everything would work. Another  
case of relying on the technology rather than the people. They  
couldn't see how it could go wrong, not really, hen they thought that  
they'd done everything possible to control the emissions. Never  
occurred to them that their people on the ground neither understood  
the procedures nor saw the necessity for them. More of an  
'undersight' than oversight.
Taleb's point is actually that reason has very little to do with  
anything - you can reason out what you cannot envisage. The engineers  
and managers who built the Bhopal plant were literally unable to see  
the real potential for catastrophe. You can't choose what you can't  
imagine.
My favorite personal example is based on Pascal's gaming theory. If  
we come to a fork in the road we assume that we have two choices -  
left or right. We actually have four choices - left, right, stay put  
or go back. But the last two are not even on the agenda. It is  
amazing how well that analysis works for a simple two variable  
situation and how blind we are to the real range of choices,  
especially when there are more than just two variables. Especially  
when we are addicted to change, growth and 'progress.'

Andrew Fildes
afildes@xxxxxxxxxxxxx



On 31/10/2007, at 7:21 AM, Doug wrote:

> I remember a conversation I had with the project manager on the  
> project that I
> was working on. We were talking about the Union Carbide disaster in  
> bhopal
> India. His contention was that we didn't really know how to manage  
> large
> projects. He believed that we didn't have too many problem, not  
> because we
> were good but that it took several things going wrong at the same  
> time for
> someone to get in trouble. In other words we are lucky.
>
> In response to Moose, The real idiots are the managers that  
> support, promote
> or otherwise encourage luck choices over well reasoned choices. The  
> person
> who preaches caution very seldom has as much influence as the  
> person who says
> lets just do it. I'll get off my soap box know.



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