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huhnmonster | 5 years ago

While I agree with the gist of this, the ones to finally call the shots on such projects are always in a bad spot.

They underprovision and an anomaly happens. Now they are the ones who did everything wrong and should be blamed. The overprovision and nothing ever comes close to the theoretical limit of the structure. Now they have wasted huge amounts of money and again, should obviously be blamed. The easiest way out: Plan exactly to what is considered standard. No one will blame you in either case, even if you know that it is insufficient or stupid.

This is something that will probably hold true in many different industries, the consequences for dams are just a little worse..

discuss

order

gumby|5 years ago

> Now they are the ones who did everything wrong and should be blamed.

Is it possible to develop a blame-free (or at least blame-avoiding) culture that also can still look for root cause problems? I'd like to think so but have never seen such a thing at scale.

huhnmonster|5 years ago

This is the question that has been going through my head after I wrote the parent comment.

I have never been in such a situation (at least not one where the stakes were relevant), so take this with a grain of salt. Blaming under these kind of circumstances might arise because the people who do it:

* Either do not have access to the information necessary in order to develop a sufficient understanding of the problem at hand

* Or are incapable of understanding the problem at hand to a sufficient degree (because the project is too big for a single person to grasp or whatever)

So, they resort to assuming some simplifications in order to make everything understandable to them, but these simplifications are likely to be wrong. Consequently, they start blaming people they think to be at fault under their own flawed model of the situation.

A blame-free culture? Explain the situation to such a degree that the decision making around the root cause is easily understandable for everyone. For example, if a bridge fails, there will likely be experts that identify what has caused the failure. If the decision makers for the bridge now say that due to circumstances they disregarded a certain load situation, because x and y and this is an acceptable argumentation (to whoever is judging the situation), there will be less/no blaming as it is now understandable why things have been done that way.

But at a cultural level? I think that this would require everyone to ultimately only judge situations once they have understood the problem at hand. At that point, why do we even talk to each other? Everything we say is based on incomplete information anyways..

pdfernhout|5 years ago

https://en.wikipedia.org/wiki/Just_culture "Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, “What went wrong?” rather than “Who caused the problem?”. A just culture is the opposite of a blame culture."

Also "Just Culture: Restoring Trust and Accountability in Your Organization" by Sidney Dekker

krona|5 years ago

I believe you're talking about Human Factors which is an entire field of study in complex systems and psychology. The book The Field Guide to Understanding Human Error might be of interest.

runarberg|5 years ago

I think that single person electorates and direct voting for the executive branch are not exactly helping this situation.

I wonder if it would be batter if the primary power was in the hands of a multi-party, proportionally elected assembly with representation greater the 1 assembly member per a population of 20.000 residents (for both national and local governments) and no executive branch (or perhaps executive branch being experts hired by the assembly). There would certainly be less room to blame here (or at least the blame would be on the entire governing body; which could be voted out proportionally rather then individual representatives).

sokoloff|5 years ago

In general, I want to understand what happened and since most issues have a human component, that often means understanding which human under-performed, how and, ideally, why.

In that sense, I want us to understand where the responsibility for the failure (aka the blame) lies. That’s different from punishing based on any single incident.

You absolutely can have blame without punishment.

dTal|5 years ago

Yes. The NTSB is such a culture.

vkou|5 years ago

Yes, it's possible, as long as you are willing to give up democracy. I'm not sure you want to make that trade-off.

Edit: This seems to be negative karma bait, so let me express in clear terms - in a democratic system, all else being equal, a challenger who does play the blame game will prevail over an incumbent, who let a disaster take place on their watch.

nine_k|5 years ago

I think this is similar to what happened in Fukushima, where the original architects of the Daiichi plant suggested building a much higher protective wall against tsunamis, but were forced to build a lower wall because such a catastrophic tsunami was deemed too improbable. (Then it came, of course.)

gerdesj|5 years ago

That may or may not be true but as per the article, building standards like that are defined in terms of 1 in 100 or 1 in 1000 year events etc. The years bit in Japan will be defined already in their standard for designing a protection for tsunami events. Now, I don't know what 1 in n years is used but I suspect that it would be 1 in 500 or 1000 years. If a 1 in 10000 years event turns up then the inevitable happens.

So all we have to look up is the standard and the event and compare. Even then you have to design to account for what to do and what happens in the event of your wall's failure and that is probably where things went really wrong.

You could always read things like this: https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-Repor...

huhnmonster|5 years ago

Yeah, exactly. The thing is, where do you draw the line of what is statistically so unlikely that you can deem it improbable?

If we run multiple different climate models through some sort of Monte Carlo simulation, I suppose each model would output a different probability of such an event occuring. In the case where all models predict a very low probability, it may be easy to say that it is unlikely. But what if two predict a very low and one predicts a low probability? Is this now applicable and should we build to be able to sustain such an event?

These are hard questions and I currently do not see any way to get better data for the future as the different models still do not agree in many points

the-dude|5 years ago

I am sorry to bring it up, but this is about the same as the way I view the response to COVID by our (Western) leaders.