910 lines
90 KiB
HTML
910 lines
90 KiB
HTML
<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1">
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<link rel="profile" href="http://gmpg.org/xfn/11">
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<title>“Human error” means they don’t understand how the system worked – Surfing Complexity</title>
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<meta name='robots' content='max-image-preview:large' />
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<!-- Async WordPress.com Remote Login -->
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<script id="wpcom_remote_login_js">
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var wpcom_remote_login_extra_auth = '';
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function wpcom_remote_login_remove_dom_node_id( element_id ) {
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var dom_node = document.getElementById( element_id );
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if ( dom_node ) { dom_node.parentNode.removeChild( dom_node ); }
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}
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function wpcom_remote_login_remove_dom_node_classes( class_name ) {
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var dom_nodes = document.querySelectorAll( '.' + class_name );
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for ( var i = 0; i < dom_nodes.length; i++ ) {
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dom_nodes[ i ].parentNode.removeChild( dom_nodes[ i ] );
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}
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}
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function wpcom_remote_login_final_cleanup() {
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wpcom_remote_login_remove_dom_node_classes( "wpcom_remote_login_msg" );
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wpcom_remote_login_remove_dom_node_id( "wpcom_remote_login_key" );
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wpcom_remote_login_remove_dom_node_id( "wpcom_remote_login_validate" );
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wpcom_remote_login_remove_dom_node_id( "wpcom_remote_login_js" );
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wpcom_remote_login_remove_dom_node_id( "wpcom_request_access_iframe" );
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wpcom_remote_login_remove_dom_node_id( "wpcom_request_access_styles" );
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}
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// Watch for messages back from the remote login
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window.addEventListener( "message", function( e ) {
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if ( e.origin === "https://r-login.wordpress.com" ) {
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var data = {};
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try {
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data = JSON.parse( e.data );
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} catch( e ) {
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wpcom_remote_login_final_cleanup();
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return;
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}
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if ( data.msg === 'LOGIN' ) {
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// Clean up the login check iframe
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wpcom_remote_login_remove_dom_node_id( "wpcom_remote_login_key" );
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var id_regex = new RegExp( /^[0-9]+$/ );
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var token_regex = new RegExp( /^.*|.*|.*$/ );
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if (
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token_regex.test( data.token )
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&& id_regex.test( data.wpcomid )
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) {
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// We have everything we need to ask for a login
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var script = document.createElement( "script" );
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script.setAttribute( "id", "wpcom_remote_login_validate" );
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script.src = '/remote-login.php?wpcom_remote_login=validate'
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+ '&wpcomid=' + data.wpcomid
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+ '&token=' + encodeURIComponent( data.token )
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+ '&host=' + window.location.protocol
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+ '//' + window.location.hostname
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+ '&postid=3383'
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+ '&is_singular=1';
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document.body.appendChild( script );
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}
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return;
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}
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// Safari ITP, not logged in, so redirect
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if ( data.msg === 'LOGIN-REDIRECT' ) {
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window.location = 'https://wordpress.com/log-in?redirect_to=' + window.location.href;
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return;
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}
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// Safari ITP, storage access failed, remove the request
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if ( data.msg === 'LOGIN-REMOVE' ) {
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var css_zap = 'html { -webkit-transition: margin-top 1s; transition: margin-top 1s; } /* 9001 */ html { margin-top: 0 !important; } * html body { margin-top: 0 !important; } @media screen and ( max-width: 782px ) { html { margin-top: 0 !important; } * html body { margin-top: 0 !important; } }';
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var style_zap = document.createElement( 'style' );
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style_zap.type = 'text/css';
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style_zap.appendChild( document.createTextNode( css_zap ) );
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document.body.appendChild( style_zap );
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var e = document.getElementById( 'wpcom_request_access_iframe' );
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e.parentNode.removeChild( e );
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document.cookie = 'wordpress_com_login_access=denied; path=/; max-age=31536000';
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return;
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}
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// Safari ITP
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if ( data.msg === 'REQUEST_ACCESS' ) {
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console.log( 'request access: safari' );
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// Check ITP iframe enable/disable knob
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if ( wpcom_remote_login_extra_auth !== 'safari_itp_iframe' ) {
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return;
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}
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// If we are in a "private window" there is no ITP.
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var private_window = false;
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try {
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var opendb = window.openDatabase( null, null, null, null );
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} catch( e ) {
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private_window = true;
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}
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if ( private_window ) {
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console.log( 'private window' );
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return;
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}
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var iframe = document.createElement( 'iframe' );
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iframe.id = 'wpcom_request_access_iframe';
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iframe.setAttribute( 'scrolling', 'no' );
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iframe.setAttribute( 'sandbox', 'allow-storage-access-by-user-activation allow-scripts allow-same-origin allow-top-navigation-by-user-activation' );
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iframe.src = 'https://r-login.wordpress.com/remote-login.php?wpcom_remote_login=request_access&origin=' + encodeURIComponent( data.origin ) + '&wpcomid=' + encodeURIComponent( data.wpcomid );
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var css = 'html { -webkit-transition: margin-top 1s; transition: margin-top 1s; } /* 9001 */ html { margin-top: 46px !important; } * html body { margin-top: 46px !important; } @media screen and ( max-width: 660px ) { html { margin-top: 71px !important; } * html body { margin-top: 71px !important; } #wpcom_request_access_iframe { display: block; height: 71px !important; } } #wpcom_request_access_iframe { border: 0px; height: 46px; position: fixed; top: 0; left: 0; width: 100%; min-width: 100%; z-index: 99999; background: #23282d; } ';
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var style = document.createElement( 'style' );
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style.type = 'text/css';
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style.id = 'wpcom_request_access_styles';
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style.appendChild( document.createTextNode( css ) );
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document.body.appendChild( style );
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document.body.appendChild( iframe );
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}
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if ( data.msg === 'DONE' ) {
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wpcom_remote_login_final_cleanup();
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}
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}
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}, false );
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// Inject the remote login iframe after the page has had a chance to load
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// more critical resources
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window.addEventListener( "DOMContentLoaded", function( e ) {
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var iframe = document.createElement( "iframe" );
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iframe.style.display = "none";
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iframe.setAttribute( "scrolling", "no" );
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iframe.setAttribute( "id", "wpcom_remote_login_key" );
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iframe.src = "https://r-login.wordpress.com/remote-login.php"
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+ "?wpcom_remote_login=key"
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+ "&origin=aHR0cHM6Ly9zdXJmaW5nY29tcGxleGl0eS5ibG9n"
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+ "&wpcomid=30291541"
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+ "&time=" + Math.floor( Date.now() / 1000 );
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document.body.appendChild( iframe );
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}, false );
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</script>
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<link rel='dns-prefetch' href='//s2.wp.com' />
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<link rel='dns-prefetch' href='//widgets.wp.com' />
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<link rel='dns-prefetch' href='//s1.wp.com' />
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<link rel='dns-prefetch' href='//s0.wp.com' />
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<link rel="alternate" type="application/rss+xml" title="Surfing Complexity » Feed" href="https://surfingcomplexity.blog/feed/" />
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<link rel="alternate" type="application/rss+xml" title="Surfing Complexity » Comments Feed" href="https://surfingcomplexity.blog/comments/feed/" />
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<link rel="alternate" type="application/rss+xml" title="Surfing Complexity » “Human error” means they don’t understand how the system worked Comments Feed" href="https://surfingcomplexity.blog/2023/12/10/human-error-means-they-dont-understand-how-the-system-worked/feed/" />
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<script type="text/javascript">
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/* <![CDATA[ */
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function addLoadEvent(func) {
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var oldonload = window.onload;
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if (typeof window.onload != 'function') {
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window.onload = func;
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} else {
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window.onload = function () {
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oldonload();
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func();
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}
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}
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}
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/* ]]> */
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</script>
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<style id="wp-img-auto-sizes-contain-inline-css">
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img:is([sizes=auto i],[sizes^="auto," i]){contain-intrinsic-size:3000px 1500px}
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/*# sourceURL=wp-img-auto-sizes-contain-inline-css */
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</style>
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<link crossorigin='anonymous' rel='stylesheet' id='all-css-2-1' href='/_static/??-eJxtjEsKgDAMBS9kjbqwuBDPUtog9o9J8fpaEQSRBw8GhoEjC50iY2QIRWRf1i0SWOSstHsYQkr1TPFIsKNXjEbkRPyhVhM18J/0m8M3fFPVlzD3UnbTtWG0J2CTNNk=&cssminify=yes' type='text/css' media='all' />
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<style id="wp-emoji-styles-inline-css">
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img.wp-smiley, img.emoji {
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display: inline !important;
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border: none !important;
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box-shadow: none !important;
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height: 1em !important;
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width: 1em !important;
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margin: 0 0.07em !important;
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vertical-align: -0.1em !important;
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background: none !important;
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padding: 0 !important;
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}
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/*# sourceURL=wp-emoji-styles-inline-css */
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</style>
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<style id="wp-block-library-inline-css">
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:root{--wp-block-synced-color:#7a00df;--wp-block-synced-color--rgb:122,0,223;--wp-bound-block-color:var(--wp-block-synced-color);--wp-editor-canvas-background:#ddd;--wp-admin-theme-color:#007cba;--wp-admin-theme-color--rgb:0,124,186;--wp-admin-theme-color-darker-10:#006ba1;--wp-admin-theme-color-darker-10--rgb:0,107,160.5;--wp-admin-theme-color-darker-20:#005a87;--wp-admin-theme-color-darker-20--rgb:0,90,135;--wp-admin-border-width-focus:2px}@media (min-resolution:192dpi){:root{--wp-admin-border-width-focus:1.5px}}.wp-element-button{cursor:pointer}:root .has-very-light-gray-background-color{background-color:#eee}:root .has-very-dark-gray-background-color{background-color:#313131}:root .has-very-light-gray-color{color:#eee}:root .has-very-dark-gray-color{color:#313131}:root .has-vivid-green-cyan-to-vivid-cyan-blue-gradient-background{background:linear-gradient(135deg,#00d084,#0693e3)}:root .has-purple-crush-gradient-background{background:linear-gradient(135deg,#34e2e4,#4721fb 50%,#ab1dfe)}:root .has-hazy-dawn-gradient-background{background:linear-gradient(135deg,#faaca8,#dad0ec)}:root .has-subdued-olive-gradient-background{background:linear-gradient(135deg,#fafae1,#67a671)}:root .has-atomic-cream-gradient-background{background:linear-gradient(135deg,#fdd79a,#004a59)}:root .has-nightshade-gradient-background{background:linear-gradient(135deg,#330968,#31cdcf)}:root .has-midnight-gradient-background{background:linear-gradient(135deg,#020381,#2874fc)}:root{--wp--preset--font-size--normal:16px;--wp--preset--font-size--huge:42px}.has-regular-font-size{font-size:1em}.has-larger-font-size{font-size:2.625em}.has-normal-font-size{font-size:var(--wp--preset--font-size--normal)}.has-huge-font-size{font-size:var(--wp--preset--font-size--huge)}:root .has-text-align-center{text-align:center}:root .has-text-align-left{text-align:left}:root .has-text-align-right{text-align:right}.has-fit-text{white-space:nowrap!important}#end-resizable-editor-section{display:none}.aligncenter{clear:both}.items-justified-left{justify-content:flex-start}.items-justified-center{justify-content:center}.items-justified-right{justify-content:flex-end}.items-justified-space-between{justify-content:space-between}.screen-reader-text{word-wrap:normal!important;border:0;clip-path:inset(50%);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;word-break:normal!important}.screen-reader-text:focus{background-color:#ddd;clip-path:none;color:#444;display:block;font-size:1em;height:auto;left:5px;line-height:normal;padding:15px 23px 14px;text-decoration:none;top:5px;width:auto;z-index:100000}html :where(.has-border-color){border-style:solid}html :where([style^=border-color],[style*=";border-color"],[style*="; border-color"]){border-style:solid}html :where([style^=border-top-color],[style*=";border-top-color"],[style*="; border-top-color"]){border-top-style:solid}html :where([style^=border-right-color],[style*=";border-right-color"],[style*="; border-right-color"]){border-right-style:solid}html :where([style^=border-bottom-color],[style*=";border-bottom-color"],[style*="; border-bottom-color"]){border-bottom-style:solid}html :where([style^=border-left-color],[style*=";border-left-color"],[style*="; border-left-color"]){border-left-style:solid}html :where([style^=border-width],[style*=";border-width"],[style*="; border-width"]){border-style:solid}html :where([style^=border-top-width],[style*=";border-top-width"],[style*="; border-top-width"]){border-top-style:solid}html :where([style^=border-right-width],[style*=";border-right-width"],[style*="; border-right-width"]){border-right-style:solid}html :where([style^=border-bottom-width],[style*=";border-bottom-width"],[style*="; border-bottom-width"]){border-bottom-style:solid}html :where([style^=border-left-width],[style*=";border-left-width"],[style*="; border-left-width"]){border-left-style:solid}html :where(img[class*=wp-image-]){height:auto;max-width:100%}:where(figure){margin:0 0 1em}html :where(.is-position-sticky){--wp-admin--admin-bar--position-offset:var(--wp-admin--admin-bar--height,0px)}@media screen and (max-width:600px){html :where(.is-position-sticky){--wp-admin--admin-bar--position-offset:0px}}
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/*# sourceURL=/wp-content/plugins/gutenberg-core/v23.9.1/build/styles/block-library/common.min.css */
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</style>
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<style id="wp-block-latest-posts-inline-css">
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.wp-block-latest-posts{box-sizing:border-box}.wp-block-latest-posts.alignleft{margin-right:2em}.wp-block-latest-posts.alignright{margin-left:2em}.wp-block-latest-posts.wp-block-latest-posts__list{list-style:none}.wp-block-latest-posts.wp-block-latest-posts__list li{clear:both;overflow-wrap:break-word}.wp-block-latest-posts.is-grid:not(.is-layout-grid){display:flex;flex-wrap:wrap}.wp-block-latest-posts.is-grid:not(.is-layout-grid) li{margin:0 1.25em 1.25em 0;width:100%}@media (min-width:600px){.wp-block-latest-posts.columns-2:not(.is-layout-grid) li{width:calc(50% - .625em)}.wp-block-latest-posts.columns-2:not(.is-layout-grid) li:nth-child(2n){margin-right:0}.wp-block-latest-posts.columns-3:not(.is-layout-grid) li{width:calc(33.33333% - .83333em)}.wp-block-latest-posts.columns-3:not(.is-layout-grid) li:nth-child(3n){margin-right:0}.wp-block-latest-posts.columns-4:not(.is-layout-grid) li{width:calc(25% - .9375em)}.wp-block-latest-posts.columns-4:not(.is-layout-grid) li:nth-child(4n){margin-right:0}.wp-block-latest-posts.columns-5:not(.is-layout-grid) li{width:calc(20% - 1em)}.wp-block-latest-posts.columns-5:not(.is-layout-grid) li:nth-child(5n){margin-right:0}.wp-block-latest-posts.columns-6:not(.is-layout-grid) li{width:calc(16.66667% - 1.04167em)}.wp-block-latest-posts.columns-6:not(.is-layout-grid) li:nth-child(6n){margin-right:0}}@media (max-width:600px){.wp-block-latest-posts-is-layout-grid[class*=columns-]:not(.has-native-responsive-grid){grid-template-columns:1fr}}:root :where(.wp-block-latest-posts.is-grid){padding:0}:root :where(.wp-block-latest-posts.wp-block-latest-posts__list){padding-left:0}.wp-block-latest-posts__post-author,.wp-block-latest-posts__post-date{display:block;font-size:.8125em}.wp-block-latest-posts__post-excerpt,.wp-block-latest-posts__post-full-content{margin-bottom:1em;margin-top:.5em}.wp-block-latest-posts__featured-image a{display:inline-block}.wp-block-latest-posts__featured-image img{height:auto;max-width:100%;width:auto}.wp-block-latest-posts__featured-image.alignleft{float:left;margin-right:1em}.wp-block-latest-posts__featured-image.alignright{float:right;margin-left:1em}.wp-block-latest-posts__featured-image.aligncenter{margin-bottom:1em;text-align:center}
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/*# sourceURL=/wp-content/plugins/gutenberg-core/v23.9.1/build/styles/block-library/latest-posts/style.min.css */
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</style>
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<style id="wp-block-list-inline-css">
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ol,ul{box-sizing:border-box}:root :where(.wp-block-list.has-background){padding:1.25em 2.375em}
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/*# sourceURL=/wp-content/plugins/gutenberg-core/v23.9.1/build/styles/block-library/list/style.min.css */
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</style>
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<style id="wp-block-paragraph-inline-css">
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.is-small-text{font-size:.875em}.is-regular-text{font-size:1em}.is-large-text{font-size:2.25em}.is-larger-text{font-size:3em}.has-drop-cap:not(:focus):first-letter{float:left;font-size:8.4em;font-style:normal;font-weight:100;line-height:.68;margin:.05em .1em 0 0;text-transform:uppercase}body.rtl .has-drop-cap:not(:focus):first-letter{float:none;margin-left:.1em}p.has-drop-cap.has-background{overflow:hidden}:root :where(p.has-background){padding:1.25em 2.375em}:where(p.has-text-color:not(.has-link-color)) a{color:inherit}p.has-text-align-left[style*="writing-mode:vertical-lr"],p.has-text-align-right[style*="writing-mode:vertical-rl"]{rotate:180deg}
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/*# sourceURL=/wp-content/plugins/gutenberg-core/v23.9.1/build/styles/block-library/paragraph/style.min.css */
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</style>
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<style id="wp-block-search-inline-css">
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.wp-block-search__button{margin-left:10px;word-break:normal}.wp-block-search__button.has-icon{line-height:0}.wp-block-search__button svg{fill:currentColor;height:1.25em;min-height:24px;min-width:24px;vertical-align:text-bottom;width:1.25em}:where(.wp-block-search__button){border:1px solid #ccc;padding:6px 10px}.wp-block-search__inside-wrapper{display:flex;flex:auto;flex-wrap:nowrap;max-width:100%}:where(.wp-block-search__label){width:100%}.wp-block-search.wp-block-search__button-only .wp-block-search__button{box-sizing:border-box;display:flex;flex-shrink:0;justify-content:center;margin-left:0;max-width:100%}.wp-block-search.wp-block-search__button-only .wp-block-search__inside-wrapper{min-width:0!important;transition-property:width}.wp-block-search.wp-block-search__button-only .wp-block-search__input{flex-basis:100%;transition-duration:.3s}.wp-block-search.wp-block-search__button-only.wp-block-search__searchfield-hidden,.wp-block-search.wp-block-search__button-only.wp-block-search__searchfield-hidden .wp-block-search__inside-wrapper{overflow:hidden}.wp-block-search.wp-block-search__button-only.wp-block-search__searchfield-hidden .wp-block-search__input{border-left-width:0!important;border-right-width:0!important;flex-basis:0;flex-grow:0;margin:0;min-width:0!important;padding-left:0!important;padding-right:0!important;width:0!important}:where(.wp-block-search__input){-webkit-appearance:initial;-moz-appearance:initial;appearance:none;border:1px solid #949494;flex-grow:1;font-family:inherit;font-size:inherit;font-style:inherit;font-weight:inherit;letter-spacing:inherit;line-height:inherit;margin-left:0;margin-right:0;min-width:3rem;padding:8px;text-decoration:unset!important;text-transform:inherit}:where(.wp-block-search__button-inside .wp-block-search__inside-wrapper){background-color:#fff;border:1px solid #949494;box-sizing:border-box;padding:4px}:where(.wp-block-search__button-inside .wp-block-search__inside-wrapper) .wp-block-search__input{border:none;border-radius:0;padding:0 4px}:where(.wp-block-search__button-inside .wp-block-search__inside-wrapper) .wp-block-search__input:focus{outline:none}:where(.wp-block-search__button-inside .wp-block-search__inside-wrapper) :where(.wp-block-search__button){padding:4px 8px}.wp-block-search.aligncenter .wp-block-search__inside-wrapper{margin:auto}.wp-block[data-align=right] .wp-block-search.wp-block-search__button-only .wp-block-search__inside-wrapper{float:right}
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/*# sourceURL=/wp-content/plugins/gutenberg-core/v23.9.1/build/styles/block-library/search/style.min.css */
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</style>
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<style id="wp-block-search-theme-inline-css">
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:where(.wp-block-search .wp-block-search__label){font-weight:700}.wp-block-search__button{border:1px solid #ccc;padding:.375em .625em}
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/*# sourceURL=/wp-content/plugins/gutenberg-core/v23.9.1/build/styles/block-library/search/theme.min.css */
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</style>
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<style id="wp-block-library-inline-css-extra">
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.has-text-align-justify {
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text-align:justify;
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}
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.has-text-align-justify{text-align:justify;}
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/*# sourceURL=wp-block-library-inline-css */
|
||
</style>
|
||
|
||
<style id="classic-theme-styles-inline-css">
|
||
.wp-block-button__link{background-color:#32373c;border-radius:9999px;box-shadow:none;color:#fff;font-size:1.125em;padding:calc(.667em + 2px) calc(1.333em + 2px);text-decoration:none}.wp-block-file__button{background:#32373c;color:#fff}.wp-block-accordion-heading{margin:0}.wp-block-accordion-heading__toggle{background-color:inherit!important;color:inherit!important}.wp-block-accordion-heading__toggle:not(:focus-visible){outline:none}.wp-block-accordion-heading__toggle:focus,.wp-block-accordion-heading__toggle:hover{background-color:inherit!important;border:none;box-shadow:none;color:inherit;padding:var(--wp--preset--spacing--20,1em) 0;text-decoration:none}.wp-block-accordion-heading__toggle:focus-visible{outline:auto;outline-offset:0}.wp-block-tab:not(.has-text-color){color:inherit!important}.wp-block-tab:not(.has-background){background-color:inherit!important}.wp-block-tab:focus,.wp-block-tab:hover{text-decoration:none}.wp-block-tab:focus-visible{outline:auto;outline-offset:0}
|
||
/*# sourceURL=/wp-content/plugins/gutenberg-core/v23.9.1/build/styles/block-library/classic.min.css */
|
||
</style>
|
||
|
||
<style id="coblocks-inline-format-inline-css">
|
||
.uppercase{text-transform:uppercase}
|
||
/*# sourceURL=coblocks-inline-format-inline-css */
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||
</style>
|
||
<link crossorigin='anonymous' rel='stylesheet' id='all-css-12-1' href='/_static/??-eJx9jEEOAiEQBD/kQECjeDC+ZWEnijIwYWA3/l72op689KFTVXplCCU3zE1z6reYRYfiUwlP0VYZpwxIJE4IFRd10HOU9iFA2iuhCiI7/ROiDt9WxfETT20jCOc4YUIa2D9t5eGA91xRBMZS7ATtPkTZvCtdzNEZt7f2fHq8Afl7R7w=&cssminify=yes' type='text/css' media='all' />
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||
<style id="global-styles-inline-css">
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<article id="post-3383" class="post-3383 post type-post status-publish format-standard hentry category-incidents category-resilience">
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<h1 class="entry-title">“Human error” means they don’t understand how the system worked</h1> </header><!-- .entry-header --> <div class="entry-meta">
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<a href="https://surfingcomplexity.blog/author/lorinh/" rel="author">Lorin Hochstein</a> </span>
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<a href="https://surfingcomplexity.blog/category/systems/incidents/" rel="category tag">incidents</a>, <a href="https://surfingcomplexity.blog/category/resilience/" rel="category tag">resilience</a> </span><!-- .cat-links -->
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<time class="entry-date published" datetime="2023-12-10T13:13:42-08:00">December 10, 2023</time><time class="updated" datetime="2023-12-12T16:59:57-08:00">December 12, 2023</time> </span>
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<span class="word-count">2 Minutes</span> </div><!-- .entry-meta -->
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<p class="wp-block-paragraph">One of the services that the Amazon cloud provides is called <a href="https://docs.aws.amazon.com/AmazonS3/latest/userguide/Welcome.html">S3</a>, which is a data storage service. Imagine a hypothetical scenario where S3 had a major outage, and Amazon’s explanation of the outage was “a hard drive failed”. </p>
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<p class="wp-block-paragraph">Engineers wouldn’t believe this explanation. It’s not that they would doubt that a hard drive failed; we know that hard drives fail all of the time. In fact, it’s precisely because hard drives are prone to failure, and S3 stays up, that they wouldn’t accept this as an explanation. S3 has been architected to function correctly even in the face of individual hard drives failing. While a failed hard drive could certainly be a contributor to an outage, it can’t be the whole story. Otherwise, S3 would constantly be going down. To say “S3 went down because a hard drive failed” is to admit “I don’t know how S3 normally works when it experiences hard drive failures”. </p>
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<p class="wp-block-paragraph">We accept “human error” as the explanation for failures of reliable systems. Now, I’m a bit of an extremist when it comes to the idea of human error, I believe <a href="/2022/05/30/imagine-theres-no-human-error/">it simply doesn’t exist</a>. But, let’s put that aside for now, and assume that human error is a real thing, and people make mistakes. The thing is, humans are <em>constantly making mistakes</em>. Every day, in every organization, there are many people that are making many mistakes. The people who work on systems that stay up most of the time are not some sort of hyper-vigilant super-humans that make fewer mistakes than the rest of us. Rather, these people are embedded within systems that have evolved over time to be resistant to these sorts of individual mistakes.</p>
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<p class="wp-block-paragraph">As the late Dr. Richard Cook (<a href="https://www.nzism.org/crm/file/store/leq62ZBzcKishAE5nGFlhYvAxNm62Uid.pdf">no fan of the concept of “human error” himself</a>) put it in <a href="https://www.adaptivecapacitylabs.com/HowComplexSystemsFail.pdf">How Complex Systems Fail</a>: <em>“<strong>Complex systems are heavily and successfully defended against failure”</strong></em><strong>.</strong> As a consequence of this, <strong><em>“Catastrophe requires multiple failures – single point failures are not enough.”</em></strong></p>
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<p class="wp-block-paragraph">Reliable systems are <em>error-tolerant</em>. There are mechanisms within such systems to guard against the kinds of mistakes that people make on a regular basis. Ironically, these mechanisms are not necessarily designed into the system: they can evolve organically and invisibly. But they are there, and they are the reason that these systems stay up day after day.</p>
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<p class="wp-block-paragraph">What this means is that when someone attributes a failure to “human error”, it means that they do not see these defenses in the system, and so they don’t actually have an understanding of how all of these defenses failed in this scenario. When you hear “human error” as an explanation for why a system failed, you should think “this person doesn’t know how the system stays up.” Because without knowing how the system stays up, it is impossible to understand the cases where it comes down.</p>
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<p class="wp-block-paragraph">(I believe Cook himself said something to the effect of “<em>human error</em> is the point where they stopped asking questions”).</p>
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Published by <span class="author-name">Lorin Hochstein</span> </h2>
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<strong>Published</strong>
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<time class="entry-date published" datetime="2023-12-10T13:13:42-08:00">December 10, 2023</time><time class="updated" datetime="2023-12-12T16:59:57-08:00">December 12, 2023</time> </div><!-- .site-posted-on -->
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