Tag: human factors

I am almost certain that I learned more from popular culture than the classics (whatever the classics may be).

 

For example, the TV series M*A*S*H provided me with two philosophical bits that I still recycle on a regular basis. The first warns me to never drink when I need a drink, and the other restricts the need for tattoos by noting that it makes no sense to permanently inscribe something on your body if the art is not worthy of hanging on your wall.

 

These two bits came up during separate M*A*S*H episodes that I had only seen once many years ago when they originally aired. I had a very distinct memory of the scenes, but when I recently replayed the episodes on the internet, I found that the actual scenes were different from my memory.

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Life is complicated, and designing to deal with life’s complications is difficult. Unfortunately bad design unnecessarily punishes humanity by increasing inefficiencies and frustrations. Design mistakes get made, and sometimes the mistakes cannot be easily corrected. However, it is difficult to imagine anything more destructive to humanity than bad design that affects many people that can be easily corrected, but is not, due to mental laziness by those in charge. This story is about a sign.

 

 

 

On Easter I visited Hoover Dam. Earlier that week we had visited some of the great National Parks in the area and marveled at the skill of the National Park Service in designing and redesigning access to some of the most striking places in the world. Knowing that the Hoover Dam, like the National Parks, falls under the Department of the Interior, I was disappointed to note that the Bureau of Reclamation does not lean into the problem like the NPS.

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Accident analysis is a strange and complex task. Often blame is considered to be the motivator for an accident analysis, but the most interesting and useful purpose of an accident analysis is to tease the universally useful gems out of the huge pile of information that tends to get generated during an accident analysis.

I recently read the accident report on the January 2013 grounding of the USS Guardian, a US Navy minesweeper that ran aground and was ultimately lost on a reef that was mislocated on an ECDIS  type chart.

 

The report makes interesting reading, mostly because it is a US Navy version of the work Martin & Ottaway engages in on an almost daily basis. It is interesting to compare the Navy approach to the civilian approach and learn from it. read more »

The weak English translation of the MIT Costa Concordia report made me wonder about the use of English as a more universal communication system. While driving to a project, I was listening to National Public Radio, and there was a bit about Voice of America broadcasts. I never realized that Voice of America programs cannot be broadcast within the United States, since, in essence, they are government propaganda. However, if there is a specific request for VOA information, a recent law change has now made it possible to broadcast VOA segments in the United States.

Oddly, the factual quality of VOA is not bad, and probably much better than some of the commercial networks we all are subjected to. Actually, VOA’s efforts at truth during WWII had a major beneficial impact on the whole scope of the war. Regardless, the most interesting point in the NPR broadcast was their reference to Special English, which may be a path to better communications in international shipping.

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A while ago Wayne Thomas forwarded the “Costa Concordia Report on the Safety Technical Investigation” to everybody in the office and only just now did I have a chance to read it.

 

While the report is not dated or specifically identified as “final” it appears this is an English language version of the last word by the Italian Ministry of Infrastructure and Transports on the Costa Concordia and closely resembles an NTSB final report in its technical thoroughness.

There have been various press and web discussions regarding the recommendations in the report, but a few less obvious paragraphs struck me as particularly interesting with regard to emergency human factors issues as have been discussed in the women and children first and OODA Loop blogs and in some of our papers such as the QESTH paper.

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A disaster like the Costa Concordia opens a wide variety of investigations and undoubtedly many people are very busy in analyzing what caused the vessel to strike the reef and to capsize, but striking reefs and capsizing actually is nothing new and, on a technical level, actually is pretty well understood.

 

What is much more interesting is to place oneself in the Master’s mind immediately after the Costa Concordia struck the rock. From a technical point of view, this is the interesting part of a disaster, and where proper analysis and training can make a real difference.

 

Undoubtedly, it is necessary to avoid disasters. But since disasters will always happen, an even more important goal is to figure out what to do once you are in the middle of the disaster.

 

What really is a disaster? A disaster is an undesirable condition, but maybe it is better to define a disaster as a condition where the manager can no longer figure out what to do to get control of the condition.

 

This is an important consideration, because this definition shows that one person’s disaster is not necessarily another person’s disaster.

Which brings us to John Boyd. John Boys is one of the most amazing characters of the second half of the 20th century that nobody has heard off. Here I will only discuss one aspect of his accomplishments. John Boyd was an amazing fighter pilot, but instead of riding the mystique of the right stuff, John Boyd managed to figure out what the right stuff is and developed a fighter pilot training method to teach the right stuff. He called it the OODA loop.

 

It stands for Observe, Orientate, Decide and Act, and then do it all over again right away.

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Our first blog on "Women and Children First" elicited a fair amount of comment on various discussion sites. 

 

A major part of the discussion centered on the Birkenhead disaster. The Birkenhead disaster is considered to be the first application, or even the invention, of the "Women and Children First" concept.

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Mikael Elinder and Oscar Erixson of Uppsala University recently performed an interesting analysis of survival rates in a large number of major ship disasters ranging over a period of over 150 years. They were interested in determining whether the old adage "Woman and Children First" actually occurred in such disasters.

 

While many of their conclusions are statistically very dubious, their data indicates that women and children survival rates actually are substantially lower than men and crew in major shipping disasters.

 

The most significant exception is the Titanic where a much higher percentage of women and children did survive. This study was a statistical analysis, and while the numbers do support their findings, each disaster is unique and there may have been factors that would have resulted in lower women and children survival rates even if there was an intent to allow the women and children to enter the life boat first. Some of these disasters may have been so confusing that the order was never heard, others may have developed too quickly for any type of abandonment order to have taken place. And when panic develops, "Woman and Children First" (or any other type of group objective) is simply abandoned in the quest for individual survival.

 

However, quite possibly, Messrs. Elinder and Erixson's analysis just sheds light read more »