Humans Error

Our central heating was on, but the normal cozying breeze from the vents had dropped to a gentle zephyr. Upon inspection, I discovered the inlet ducting had had enough of being round and sturdy and collapsed in on itself, giving our heater a big asthmatic attack.

Our gallant heating man came to the rescue. I checked in on him while he was unpackaging the replacement ducting.

“Oh shit.”

“What?”

“It’s the wrong size. Your inlet is 350mm, and this ducting is 300mm.”

He examined the ducting packaging, which stated in large letters on it was 300mm. But the wholesaler’s label said it was 350mm.

The wholesaler’s labeller had clearly not been paying attention. A human error.

Phone calls ensued. 350mm ducting secured. Disaster averted.

This got me thinking about human error and the random nature of it. A simple error can have little consequence, as in this instance, or there could be massive repercussions from something equally innocuous. Like when a software engineer at Knight Capital Trading forgot to copy new trading code to one of their eight servers. That one server kept running the old code, causing Knight Capital to accidentally buy $7 billion worth of stocks in 45 minutes! The company lost $440 million and nearly went bankrupt from a copy-paste oversight. Oops.

Then there’s the question: what does one do to prevent a recurrence of an error? The problem with people’s response to this sort of question is that they don’t tend to give much consideration to the likelihood of the error recurring. They only focus on the controls needed to prevent it.

The result is sludge. Friction. Hassle. Process. For everyone. Road cone anyone? Airport security check? And don’t get me started on how our anti-money laundering regs have turned everything it touches into a great pile of glutinous molasses.

Rules are imposed to reduce the chance of undesirable events occurring. Rather than manage by exception, the cover-arse approach is to impose rules for all to avert the chance of a low probability event occurring.

What happened to personal responsibility? Living in my parents’ and grandparents’ times, things were a little more clear-cut. You do dumb shit, you suffer the consequences. And you learn from it. Simple. That’s how we improve - learning from mistakes.

And we typically learn far more from getting something wrong than getting something right. Coz we hate pain. All Blacks only remember the games they lost.

These days, we have central and local Govt agencies trying to reduce the chance of us making a mistake. They see their role as reducing the need for us to rely on common sense. Underlying this is the quiet presumption that everyone is the village idiot and therefore needs protecting from themselves.

How did we get here? We are supposed to be evolving and improving as a society, yet to me, this nanny approach seems to be a retrograde step and at odds with natural evolution. We are dumbing ourselves down while making our computers cleverer (I’m not sure that’s a boss move).

I understand the bureaucrats’ approach comes from honorable intentions, but the willingness to ignore the consequences for the majority when trying to lower the risk of unlikely events occurring seems quite myopic.

This is probably in part due to the silos these people operate in. When the reality is we live in a system, not a silo. Stuff is connected. Nothing happens in total isolation.

The challenge is to make our regulators think about the system implications of any change as the default, rather than the occasional exception.

With a bigger picture in mind, different decisions are likely to be made because of wider consideration.

Maybe a solution is to make our rule makers do a cost-benefit analysis on the implications of all new regs. And not only do they have to account for the immediate costs, but also the second and third-order consequences and their associated costs. Which means they have no choice but to climb out of their silos. I’m sure their new view would give them a far more balanced perspective.

And when they don’t, how about a good old tar and feathering to remind them of the error of their ways? (which would be a far more effective correctional measure than creating a new process!)