On Saturday, September 13, 2003, at 04:14 AM, Randall Clague wrote:
On Fri, 12 Sep 2003 18:44:08 -0400 (EDT), Henry Spencer <[EMAIL PROTECTED]> wrote:The "documentation" is mostly part of the problem, not part of the solution. Its presence, in overwhelming profusion, should lead you to expect more of this, not less.
We were talking about this at work today. One person expressed the opinion that it's human nature not to check something you know was fine last week. I got my back up: "That's WHY you FOLLOW the CHECKLIST."
This is also why it's incumbent on the checklist writer to make an easy-to-follow checklist, and on whoever designs the procedure to make an easy to follow procedure, and on whoever designs the equipment to design in such a way as to make it easy to do the right thing and hard to do the wrong things, etc. etc. This is a little hard to do in an R&D environment where flexibility is important, but even there the people doing the checklists and procedures have choices about how to set them up. It's tempting to say "just do it right" but reality is that humans tend to make certain kinds of errors more easily than others, and taking that into account reduces the chances of mistakes like this one. I get the impression that NASA in particular has a Superman complex about people's ability to follow complex, poorly written, jargon heavy documentation and checklists.
The details of this particular incident make me wonder what kind of magic bolts they were using that they didn't have plenty of them lying around. Perhaps the bolt requisition paperwork was just too complicated and it was much easier just to steal them from someone else's stand :-)
......Andrew
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