[AR] Re: Damascus AR Incident
- From: Derek Lyons <fairwater@xxxxxxxxx>
- To: arocket@xxxxxxxxxxxxx
- Date: Wed, 18 Jan 2017 11:53:41 -0800
On Wed, Jan 18, 2017 at 3:20 AM, James Padfield
<james.padfield@xxxxxxxxx> wrote:
If perhaps the valve (or whatever) had been designed so that it
required a special, particular tool, not "any old
spanner/wrench/socket", could the accident have been prevented? i.e.
engineering in safety, rather than relying on training and operators
following correct procedure. Relying on training and procedures
should always come _after_ engineering in safety (IMO).
Maybe, maybe not. The real problem wasn't that that they didn't use
the special tool - it's that they'd gotten in the habit of using the
wrong tool. (Which can and has happened even if when the tool is
common one.) You simply can't engineer away stupid. And that's where
the next layers of defenses comes in, training, supervision, and
discipline. Having BTDT, it's my experience that professionalism and
professional discipline underlies everything else.
One thing Schlosser doesn't bring out that I've long suspect was a
contributing factor is that the Damascus accident occurred on or near
a nadir of morale, material readiness, and professionalism in the US
armed services. The Pentagon did not handle the transition to the all
volunteer force very well, and the chain of command was still stuck in
essentially WWII mode. The (largely local and small scale at that
point) efforts to transition to a professional cadre based force were
only beginning to gain traction.
D.
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