Errors LO12291

William J. Hobler, Jr (
Thu, 30 Jan 1997 19:08:29 -0500

Replying to LO12251 --

Malcolm Jones asked

>Excellent Point Andrew - the interesting question would be if anyone had
>done any research on what type of problems, or even proportion, can be
>dealt with using linear thinking (surely there must be some, or even many)
>and what type of problems require systems thinking.

After some 16 years making nuclear power plants run safely I can attest to
the problem of human errors while doing simple repetitive tasks. I think
we tried every way possible to prevent reoccurance. Linear thinking got
us having the person record a meter reading that indicates the previous
problem. Sometime after recording the value the umpteenth time the person
records the normal value when the meter shows an abnormal value -- error!

System thinking has operators calculating a value from three or four
values so that they become aware of a systematic error. With the same
results. In the tedium of doing the calculation again the results ar
normal from abnormal input.

I think the most effective tactic was to rotate people quickly. That is
to not allow the situation to become repetitive. The best rotation was
one in which the operators moved from one part of the system to another,
it seems that they would have a better feel for the state of the whole
system. Moreover, we encouraged them to take the broader view.



"William J. Hobler, Jr" <>

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