On Oct 22, 2007, at 5:41 PM, Kenny Fogarty wrote:

It’s the concept of "one strike, you're out!" that I find amazing. What constitutes a mistake serious enough to put someone's livelihood at stake? With that kind of pressure hanging over anyone, how can they be expected to
learn, and grow and enhance the company they're working for?

Kevin:
How would you handle a person that scrutinizes blood for a living and mistakes a diagnosis ? In some case an operator is just as "guilty" as the blood analyzer. If you say thats not the same, I would agree but not in all circumstances. If an operator put in a wrong date at IPL and (because of that) RACF refuses to come up and there is no backout or even worse datasets gets scratched because of the operator error which leads to a fine from say the SEC (or take you pick of agency). There are degrees of error of course some are who cares to a possible company going bankrupt there are in the last case MANY people being out of work (possibly 1000's or more) would you not fire the person? The gravity of the error is all important, of course.


I think we've all seen enough horror stories over the years, where a
command, or parameter has been entered in error, but from those horror
stories, procedures got tightened, people were educated, things got better. People learn from mistakes, and go on to pass on their findings to their colleagues, to their peers and people act on that, and learn and improve.

If you hang a sword of Damocles like that over everyone within an
organisation, nothing would get done.

Within a programming environment, has anyone ever written a 100% bug-free piece of code, that has lasted for all eternity, never once needing to be optimized or re-compiled or re-linked? Are bugs that are exposed over time by new releases of the operating system, or various subsystems classed as being serious enough to have your job and reputation absolutely caned? I
just think it’s a nonsense concept and a nonsense approach.

I think you are comparing apples and oranges. An operator can by mistake put the company out of business, a programmer can cause loss revenue and yes possibly a fine . BUT that should have been found in QA before the program goes live. In other words their work is checked by others. An operator does not have this luxury. Yes programmers can make mistakes but (in most cases) its not a shut the front doors and turn off the power whoever is the last one to leave. An operator can do so with a small "oops". That is why an operator, IMO must go through several years of training so they CAN'T make stupid mistakes. Its possible that a programmer could write a program that misdiagnoses a test (health) result and yes that could lead to the persons death, but presumably there are other fingers in the stew to catch the errors. In the case of an operator there is no way to catch all errors that could cause a major issue. Catching a Vary is a small part of any possible error. Catching a bad date at lets say early on in the IPL process is impossible by any of the suggestions mentioned as the exits (programs) are not available then.

I would suggest an incorrect VARY command might cause some amount of grief but (probably) not enough get fired over. I know some places have intercepts to catch an incorrect vary command. That is almost as bad (IMO) as saying your fired as you don't trust your operators so I am going to attempt to intercept commands and double check them. There is no guarantee that the devices were not the right devices even with an exit.

Being an operator is a lot like being an anethesiologist the skill to know how much sleeping gas to administer so the patient does not awake or die. The surgeon is one part (major) of the operation an operator is a helper. That is what an operator is a helper.

Ed

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