We can find fault among those directly involved - and we probably need to. But if our purpose is to attack the roots of such an accident, we may find them so entwined with the system that they are impossible to extract without toppling the whole structure…Beyond the question of blame, it requires us to consider that our solutions, by adding to the complexity and obscurity of the airline business, may actually increase the risks of accidents. … The ValuJet case…fits the most basic definitions of an accident caused by the very functioning of the system or industry within which it occurred… The two unfortunate mechanics who signed off on the nonexistent safety caps just happened to be the slowest to slip away when the supervisors needed signatures. Other mechanics almost certainly would have signed too, as did the inspectors… The falsification they committed was part of a larger deception - the creation of an entire pretend reality that includes unworkable chains of command, unlearnable training programs, unreadable manuals, and the fiction of regulations, checks and controls. Such pretend realities extend even into the most self-consciously progressive large organizations, with their attempts to formalize informality, to deregulate the workplace, to share profits and responsibilities, to respect the integrity and initiative of the individual. The systems work in principle, and usually in practice as well, but the two may have little to do with each other. Paperwork floats free of the ground and obscures the murky workplaces where, in the confusion of real life, system accidents are born.
In social psychology the term fundamental attribution error describes a cognitive bias in which an individual interprets another person’s actions as driven primarily by intent while deemphasizing or disregarding any external or environmental conditions which may have influenced their actions.
Point here is that the entire Valuejet crash could be blamed on the mechanics in a narrow sense even though there were just doing what they always did every day.
A sort of malevolent but illustrative example is the Hillsborough Croud Disaster. The disaster itself was fairly uncomplicated, but the story that was spun from it by way of an “investigation” is an awful example of these principles at work. BBC did a stellar documentary about it: [video]https://m.youtube.com/watch?v=XaBnY-SnwxA[/video]
Yestereday I finished a novel which also does a dramatic job of exploring this idea. The City & The City, by China Mìeville, if you like police procedurals and speculative fiction. I can’t recommend Mìeville strongly enough. I may or may not carry his picture around in a locket even though we’ve never been introduced.
Today I read that prior to Marconi’s great brain wave, a spark produced from static electricity was called a “disruptive discharge.” Not knowing what they were describing exactly, they couldn’t know how misleading the term was (it results from an equalization, not a disruption; and Marconi found a way to transmit something as ordered as language thought it.) By calling it a disruptive discharge, they gave each other the idea that they knew what it was and gave each other the feeling that it wasn’t useful. Turns out that being very clear about what is understood and to what degree of certainty can be a fairly important, if not a very common element of communication.
[QUOTE=Emrobu;189339]
Today I read that prior to Marconi’s great brain wave, a spark produced from static electricity was called a “disruptive discharge.” Not knowing what they were describing exactly, they couldn’t know how misleading the term was (it results from an equalization, not a disruption; and Marconi found a way to transmit something as ordered as language thought it.) By calling it a disruptive discharge, they gave each other the idea that they knew what it was and gave each other the feeling that it wasn’t useful. Turns out that being very clear about what is understood and to what degree of certainty can be a fairly important, if not a very common element of communication.[/QUOTE]
On of the examples used in The Structure of Scientific Revolutions by Thomas Khun is the development of Leyden Jars. A good read about the history of science. Took me a while to get through but I enjoyed it.