Monday, September 02, 2002

A textbook example of a bunch of people more interested in placing blame than in fixing the problem: "What does this switch do?" the trainee asked plaintively. Wouldn't it have been simpler and/or safer to have designed either a single switch that controls both buses, or at least a safety interlock that prevents them from being throw in the unsafe order? How in the world could a system that allows a two-week trainee to destroy half a million dollars worth of equipment possibly be the trainee's fault? I also enjoyed this bit of "knowledge transfer":
Stephenson said Coady had no clue what had happened. "He was completely unaware," Stephenson wrote in a memo to Baker. "With his lack of knowledge of the plant electrical controls, it was not even possible to explain to him what he did. He would not have understood. His training did not include these advanced concepts."

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