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HUMAN_ERROR


                                             May 20, 2008


   A common error people make is
   to distrust the very idea of                 It's a well-recognized
   automatic safety systems.                    cognitive bias: people
                                                like to feel like they're
   For example, they worry about whether        in control, hence they
   a nuclear power plant will really            virtually ignore the
   shut down automatically in the case          risks of errors in car
   of trouble.                                  driving, but panic
                                                about every reported
      But getting that kind of                  airline crash.
      failsafe behavior to
      work is really pretty
      trivial as engineering
      problems go.

      I was working at the Nuclear
      Research Facility at the INEL when
      a small earth quake hit: all of the
      reactors that were running shut
      down automatically, as they were
      supposed to.

         It was also not the problem at
         Three Mile Island: the automatic
         systems saw rising temperatures and
         shut the plant down multiple times.

             The trouble was that
             the human operators
             continually did
             manual overrides of
             the safety systems.
                                        And interestingly enough, once you
             They looked at the         point this out to people they tend to
             low pressure gauge         feel better about the TMI accident.
             readings and assumed
             the high temperature                      They *like* the fact
             readings must be bogus.                   that there were
                                                       screwups by the
             They were in the process                  human operators.
             of switching to fancy new
             computerized temperature                     But this hardly
             measurements, and trusted                    let's the nuclear
             the lower tech pressure                      industry off the
             gauges more.                                 hook: if human
                                                          beings are part
                And the operators had been                of the control
                trained that pressure and                 loop, then the
                temperature would always go               reliability of
                up together: but that's                   the whole system
                *only* true if there's no gas             depends on those
                bubble in the system.  Gas is             humans, and you'd
                springy and compressible, and             better have some
                it makes it possible for the              way of making
                pressure in the water to stay             sure they *don't*
                low when temperature goes up.             screw up.

                                                 So we need social systems
                                                 (training and management) that
                                                 create an institutionalized
                                                 commitment to safety and
                                                 ensures that the operators are
                                                 well-informed and competent.

                                                 As is often the case:
                                                 the social component
                                                 is the hard part of
                                                 technical problems.
                             TECHIES_FALLACY
                                                   But then, in the
                                                   case of TMI the
                                                   problem was largely
                                                   self-healing.

                                                      Afterwards no one would
                                                      would dare shrug "oh,
                                                      it's probably a false
                                                      alarm."

                                                                 Nothing like
                                                                 trashing a
                                                                 plant to
                                                                 convince
                                                                 that it's a
                                                                 good idea to
                                                                 take every
                                                                 warning
                                                                 seriously.


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