sábado, setembro 25, 2021

"is a system issue (a what), not an individual issue (a who)"


 "A final connotation of failure is that it can have moral overtones. To be alert to failures could imply that someone is to blame for the failure, not that a system is at fault or that something can be learned. Before getting caught up in these associations, keep in mind that the dictionary defines reliability as “what one can count on not to fail while doing what is expected of it.” This definition suggests three questions:

  1. What do people count on?
  2. What do people expect from the things they count on?
  3. In what ways can the things people count on fail?

The answers to these three questions provide clues about what it is that could go wrong and what it is that you don’t want to go wrong. The key word in all three questions is what one can count on, not whom. A preoccupation with failure is a preoccupation with maintaining reliable performance. And reliable performance is a system issue (a what), not an individual issue (a who)."

Isto ainda a propósito da treta do erro humano.

Trecho retirado de "Managing the Unexpected - Resilient Performance in an Age of Uncertainty" de Karl E. Weick e Kathleen M. Sutcliffe. 

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