The following tale demonstrates what can happen if you don't allow people to make mistakes:
In a large consumer electronics factory a trainee design engineer, straight from school and keen as mustard, had an idea for a new gadget. He did the obvious thing and asked his boss "Do you think we could make this here?"
"It sounds promising." his boss replied. "Leave me some details and I'll think about it." Over the next two weeks he thought about it. Did he dare commit design time to something that might not work? What would he put down on the time sheets? Could he fiddle them and hide it just in case?
There was only one thing for it. He went to see the R&D manager. "Do you think we could make this here?" "Leave it with me and I'll think about it" was the reply.
The R&D manager thought about it then shoved it to the far corner of his desk where it lay for some time. Whenever he saw it he thought a bit more. Yes, it was feasible but what if it didn't work? What if nobody bought it? As R&D manager it would be his responsibility; his fault!
The months went by.
There was only one thing for it. He went to see the chief engineer. "Do you think we could make this here?" The chief engineer looked at it and cringed.
"Leave it with me and I'll think about it." It looked good but there was no way to be sure. No amount of calculation or statistical analysis would give him an answer - and if he got it wrong those money grubbing g*ts at Head Office would surely have his job.
Months passed by. In desperation he gritted his teeth and went to see the managing director - who threw the question straight back! "You're the chief engineer. What do I pay you for? You tell me if it'll work!"
He slunk out of the office wishing he'd given that answer to the R&D manager - and then he had a brainwave.
He would form a committee of all the engineering department managers to advise him. Then if it didn't work he could pass the blame downwards; brilliant! It took a while to get everybody organized but after that he just sat back and waited.
The R&D manager looked once more at the idea. He was none the wiser but at least he was only one committee member. "Collective responsibility. That's more like it" he thought to himself.
But he was still the R&D manager. The others would surely all turn on him anyway.
There was only one thing for it. He would form a committee to advise him. Then if it didn't work he could pass the blame downwards. The others were doing the same thing already.
And so it was that, more than a year after he first had his big idea, the young design engineer found himself on a committee discussing its pros and cons. Most of the factory seemed to be in on it and it was encouraging that the comments were mostly good. Some were even complaining that none of the shops had any!
Then, one day, one of his workmates came in pleased as punch. "I got one" he said "and it's great!"
It's inventor gave it a quick look and noted that it didn't look anything like his original doodle. "Never mind" he thought. "The production department must have made a few changes." But he was wrong! Somebody just like him in a factory down the road had got wind of his idea. "We can make that" he had thought and told his boss. "Why not? It's worth a try." was the immediate answer. So they did - and they cornered the market.
I know I'm not comparing like for like here. There were no lives at stake in that fictitious factory; it was only money, (cringes as a million accountants scream "ONLY MONEY!!!") but I think it demonstrates a point. If you don't allow people to make mistakes they will never make anything at all.
In an environment where mistakes CAN cost lives (I work in a hospital) you get round this by a process of check and check again and, whenever possible, two different people do the checking. (In our department we also have a general rule that you always check one more detail than is really necessary.) This approach would surely have avoided that train crash where the contractors left a whole rail out!
I couldn't believe that anybody could be that stupid. Do they have warning signs on their toilet seats that say "lift before use"?
But that's engineering and I recognize incompetance when I see it. I know very little about law enforcement so I can only go by what I read. It seems to me that no single event lead to the death of an innocent man. Put yourself in the place of any one of those who pulled the trigger. All your information says that you are face to face with a terrorist on a crowded train. We know that's not true but you don't. He makes a movement typical of a nutter about to detonate his bomb. You have a split second to act. What would you do? In that situation I think I would have shot him straight through the brain stem. I thank my lucky stars that it wasn't my job!
Should Ian Blair resign over this? I'm not sure. I can think of a few things that could lose me my job. Sabotage is too obvious. Knowingly leaving a machine in a dangerous state would, I think, get me kicked out of the department if not right out of the NHS. A Spanish engineer who bodged a job then disguised it ended up in prison - and quite right too. Several patients were overdosed and some died. But what about the software engineer who unwittingly left a bug in his program? Despite rigorous testing the machine subsequently threw a wobbly and all but cooked a hole through a patient!
Some disasters are just not foreseeable and so, for the moment, I'll give Ian Blair the benefit of the doubt. If somebody tells me that the shortcomings in the Met were as obvious as a missing piece of railway line - and that he knew it but did nothing - then he should go.
