systemic flaw Archives

Close Calls and Human Biases

Close Calls and Human Biases, Near misses receive different interpretations in different countries, cultural backgrounds. Some societies consider them glorified achievements of intuitive semi-gods. In others they are just plain indicators of near failure. When near misses become repetitive, it can be assumed they are the result of a systemic flaw. Systemic flaws only require a small “twist of fate” to turn into an accident, possibly a disaster. In an industrial operation we know of, people became accustomed to a…