The question was "Do we really have to pay so high price to learn the lesson?"
My response is in two parts. The first one is, as I assume you believe since you ask the question in the context you did, no -- not really. The second one is yes, look at history. I was in the US Air Force for 23 year, the last 9 in System Safety for various development and test programs. There are two things that will continue to keep us at the "blood threshold" *. The first is economics. Both time and money. The second is human attitude, which is partially driven by the first, but is also driven by the attitude that it won't happen to me. On the first point, how much can you afford spend to prevent mishaps and still make a profit or stay within budget? How long can you delay a product delivery and still satisfy the customer, or even have one if your competitor beats you to it? (In the military this is seen as meeting a threat before it overcomes you.) On the second point, budgets and schedules impact our decision making. If we don't meet the deadline we might be replaced. The news history is replete with stories of people who have tried to get safety issues corrected before a project was finished. They are called "whistle blowers". They usually pay a high price for their integrity. Additionally, just like adolescents but in a different way, we think we are invincible. Problems only happen to others that are not as good as we are. We will do it better and avoid the same problems. But we never seem to attempt to learn the lessons being taught by another's failures. How do these play into the standards and regulation development. The same way as it does in product development. It is often driven by economics and time. We hesitate to impose a requirement on ourselves that might cost us profit or schedule. We aren't intentionally trying to hurt anyone and if we knew if one of our decisions to limit the scope of a standard was the direct result of an injury or death, we would be regretful. It is just that since we don't see the immediate payoff of a stricter standard and we do see the immediate cost, we tend to not impose the more strict requirement. I realize that this is a rather jaded view. Most of the safety professionals that I have met are truly concerned and dedicated to their work in minimizing risk. I think the bigger problem is not the safety professionals but the profit (budget), promotion, ego, stockholder, and customer driven environment in which we are working. There are so many engineers and managers on programs that the responsibility is now diluted to the point where no one is responsible. "The Company" is as fault and the insurance will take care of any losses. I know that insurance is necessary, but like every other protective system we develop, we start relying on it for primary protection instead of back up. Another element in the problem is individuals that are into product (system) safety because of reasons other than that is what they wanted to do. I have met several people that were doing safety work because the company "needed" some safety people and picked someone that was expendable from another department. Or a department was being eliminated or downsized and a position was offered in product safety instead of letting that person go. That is not to demean those who have been "chosen" (I have met some really good safety people from that situation), but to show the attitude of management toward what it takes to be a safety engineer, manager, whatever you want to call the position. When I first got into system safety, a co-worker ask me who I ticked off to get stuck in that job. I had to inform him that I had worked hard and risked much to take that safety job. But it illustrates the perception that many have of product safety. To get back to the point of regulation. As long as engineers/accounting/marketing/management/customers see regulations as a hindrance and a cost, we will continue to see mishaps such as the Concord, Arian, Challenger, Hyatt Regency, Pinto, ad infinitum. Gentlemen and Ladies, we have job security because without us there would be no one to blame for missing all the errors that cause mishaps. Please don't get me wrong -- I love my job and have been doing it for over 15 years now and intend to do it for at least another 15 years. As the famous philosopher, Clint Eastwood, has said, "A man's gotta know his limitations." We do what we can, we tilt at windmills, and know that without us; it would be a lot worse. We try to use the examples of the failures of the past to convince the engineers and managers that the future doesn't have to be the same. * The "blood threshold" is the point where action is delayed until a mishap is serious enough that an serious injury or death occurs, at which time vigorous action ensues. "Minor" mishaps that do not result in any significant action, even though they are indicative of a pending "Major" mishap. **** The views expressed do not represent any person place or thing but myself. They are mine and mine alone. Any entity to which I am associated disavows any knowledge of knowing me. This email will self-destruct in 5 seconds. **** barry_ma%altavista....@interlock.lexmark.com on 07/31/2000 08:43:13 PM Please respond to barry_ma%altavista....@interlock.lexmark.com To: emc-pstc%ieee....@interlock.lexmark.com cc: (bcc: Oscar Overton/Lex/Lexmark) Subject: What safety lesson we may learn from Concord crash? Hi, "What safety lesson we may learn from Concord crash?" When having read recent reports on Concord crash the question occurred. ----- http://www.washingtonpost.com/wp-dyn/articles/A2191-2000Jul29.html reads "A preliminary report on Tuesday's crash is due to be published at the end of August, but just three days after the tragedy, a sketchy image of the sequence of events has surfaced. "At least one tire exploded, which could have triggered a chain of events, structural damages, a fire and an engine breakdown," the Transport Ministry said Friday. ...... In 1981, the U.S. National Transportation Safety Board reported five "potentially catastrophic" incidents resulting from blown-out tires during Concorde takeoffs between June 1979 and February 1981." ------ There are lot of Safety standards in Electronic and Electrical industries. If we strictly follow them we can avoid fatal accidents. Is there any previous example showing that accident still happens although all relevant Safety regulations have been followed and maintained, and then resulting in revision of some safety standard? It looks weird if the maintenance was not required to exclude possibility of tire blown-out, due to what the above article said: "FIVE 'potentially catastrophic' incidents resulting from blown-out tires during Concorde takeoffs between June 1979 and February 1981." I have no knowledge of aviation safety aall. It was really sad to the world that the "potentially catastrophic" danger finally became a real catastrophe. Do we really have to pay so high price to learn the lesson? Barry Ma ANRITSU company _______________________________________________________________________ Free Unlimited Internet Access! 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