I'm interested in confirming or refuting (edit)

the idea that this is a collective responsibility, not an individual one.

I have seen a lot of industrial accidents in my line of work over the years. Sometimes there was someone fucking around, or not following instructions, or drunk, or willfully negligent (despite proper training and solid procedures). Those people usually hang, if not injure or kill themselves or others.

In one case, a guy just ignored his pre-op checklist and activated a flow without checking to see if there were any stop-work alerts. Turns out there were two welders inside the pipe at the time. They were lucky to live. Another case involved a guy so lazy he didn't bother to double-check his paper work, and ending up sending five tons of hazardous waste to a public landfill. That guy went to jail.

In both those cases the procedures were crystal clear and the training was completed and certified. In both cases an individual truly fucked up.

Most of the time, however, the point of failure is more nebulous, and can't be tracked down to a single person. The operators were doing everything according to their procedures, but the procedures were outdated. Or there was a situation not covered in the procedures, and nobody knew how to react. Or there was equipment failure. Or poor or muddled communication resulting in some kind of mishap, despite a commitment to safety on the ground. Despite sometimes grave (and mortal) consequences, the cause cannot be traced to a single point of failure. This is much more common. And it is not to absolve the organization of responsibility, but to reflect the truth of the matter: yes, oftentimes things were preventable, and will absolutely require an organizational review, response, practical changes, and depending on the outcome, compensation. But pinning the blame on one person would not only be not truthful, but also not helpful to the rest of the organization in assessing the cause and preventing the next accident.

It can be dangerous for the organization to simplify it. If people think it's because of one person's actions, they're less liable to check themselves. "Well, the reason that happened is because Joe is a screwup -- that would never happen to me." That's a horrible dynamic to occur, for the entire organization.

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It's really fascinating, because it's the very nature of such accidents that the blame is diffuse. Nearly every air disaster has had multiple points of failure, any one of which, if properly corrected, would have prevented the crash. It takes a whole suite of screw-ups to make a plane fall out of the sky, and the majority of them come from simple miscommunication.

Gladwell talks about why Korean Air had the worst safety record of all the airlines. It had to do with institutional/cultural power relationships in the cockpit. Captains would screw something up, and the others would just go along with it, even though they knew they and every one aboard would be killed. Their record improved after they identified the problem and trained the crews to behave as equals.

The bottom line is that unequal power relationships can make people behave totally irrationally. I don't doubt that there is a similar dynamic in college football programs.

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And it creates the potential for a serious accident when the people in your operation who are at the greatest risk of bodily harm are also the ones on the lowest rung of the food chain. It should be explicitly spelled out to everyone in that position that they have the authority to come out of that lift if they feel that the conditions are unsafe for whatever reason. Such rights may have been implicitly understood as part of ND's operational procedures, but that's not enough. A lot of kids in that situation might be inclined to feel that coming out of the lift not only represents a failure to do the job required but that they're letting the football team down, as well. And that's not fair at all, although I doubt that ND is alone in the lack of clear communication on that front.

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The whole point of that part of the book is to show the banality of the types of communication errors that, when uncorrected, can claim the lives of hundreds. Those errors are ubiquitous.

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Every employee and contractor has a laminated card they carry which states they have the authority to stop any work they feel is unsafe. Everybody in the company, from management on down, goes through the same training, and anyone, regardless of rank, can "pull the card" and effectively halt things without any fear of repercussion, no questions asked.

Of course this grows out of a high-risk industry where accidents are an everyday threat. It would probably be overkill for a place like ND, but maybe not.

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because Brian Kelly is hardly the chief safety officer. The guys who should be serving that role likely deferred to him on matters he wasn't equipped to and didn't intend to handle. I doubt the lifts occurred to the coaches much before Elston yelled to bring them down. That's not an accusation -- the coaches have 50 different things to manage in practices. The people they thought were handling discrete peripheral issues may not have been.

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It's easier (and somehow, in a perverse way, more comfortable) to know that some evil person in the chain of command ordered Declan Sullivan to his death.

Obviously it's a lot messier than that.

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from essentially saying that Kelly did just that. Of note have been With Leather, a myriad of Bleacher Report types , and(to a lesser extent) Deadspin. Sometimes I really hate this generation of "news media".

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Here's all With Leather posts that are tagged with Brian Kelly. The article from yesterday is rather brief, but in the context of the other articles the pattern is hardly subtle. That Punte guy hates Brian Kelly:

http://withleather.uproxx.com/tag/brian-kelly

Here's the specific post from yesterday which only has a sentence mentioning Kelly.

http://withleather.uproxx.com/2011/04/notre-dame-collectively-responsible-in-student-death

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It doesn't specifically address single points of failure vs breakdowns in the system. But, it does address how well-written checklists can drastically reduce the frequency of these failures. Gawande uses the airline and construction industries as the best practitioners of checklists, and is pushing for their use in medicine.

I think the biggest problem with preventing as incident like this is that no one saw it as a hazardous situation until this tragedy occurred. By their nature, accidents are generally rare, and we are often lulled into a false sense of security when something things go well a hundred times in a row.

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and the example in my top post is in a heavy industry where accidents are fairly common despite a long history and strong culture of safety and compliance. It's the nature of that business.

I'm going to go out on a limb and say some kind of electric lift has been used at ND for 40+ years. However, this is obviously the first fatality to occur. It is sad, but not surprising for a place with comparatively few workplace accidents, that ND was lax on procedures and training protocols.

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I'll refute that "anyone" should have known that the 27th was a day when they "should have known" it was a horrible day to have kids out on lifts simply by virtue of some sort of osmosis of national headlines.

The 26th was, for anyone not paying attention to the ND football program, the day of note. The 27th was actually relatively "unremarkable" after the 26th came to pass.

http://www.kktv.com/news/headlines/Windpocalypse_Wreaks_Havoc_On_Midwest_105857158.html

http://www.pbs.org/newshour/rundown/2010/10/windpocalypse-bears-down-on-illinois.html

http://blog.cleveland.com/metro/2010/10/windpocalyspe_maybe_but_first.html

http://www.myfoxtampabay.com/dpp/news/national/windpocalypse-hits-midwest-10262010

http://www.aolnews.com/2010/10/26/chiclone-wreaks-havoc-on-chicago-and-midwest/

Also note the trends on google between 26th and 27th October...

26th: http://www.google.com/trends/hottrends?sa=X&date=2010-10-26#

27th: http://www.google.com/trends/hottrends?sa=X&date=2010-10-27#

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Sometimes I rhyme slow sometimes I rhyme quick.

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(posted the morning of the 27th) concludes with this:

"Eleven states are still under a high wind warning: Illinois, Wisconsin, Indiana, Iowa, Michigan, North Dakota, South Dakota, Nebraska, Minnesota, Ohio and parts of Kentucky."

It was a windy day. Everyone knew it was windy. Even though everyone knew it was windy, apparently, no one who considered the idea (anyone?) thought the lift would fall, whether because they thought it wasn't windy "enough" or otherwise.

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according to the report, the wind warning had been lifted prior to practice.

"Although reported wind speeds and gusts increased after the staff last checked the
weather, prior to practice, the National Weather Service Forecast Office ("NWSFO")
downgraded a previously-issued wind warning to a wind advisory. Meteorological data shows
that, at approximately 4:00 a.m. on October 27, the NWSFO issued a high wind warning valid
from 8:00 a.m. until 9:00 p.m. for northern Indiana. However, at 2:44 p.m., before outdoor
practice began, the NWSFO canceled the wind warning, downgrading to a wind advisory which
was valid until 9:00 p.m. on October 27. "

We need some primary sources.

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Sometimes I rhyme slow sometimes I rhyme quick.

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I don't buy any contention that the 2:44 downgrade was determinative

1. It still suggests winds over the 35mph benchmark and

2. Nothing changed that I can tell. It's not like there's evidence ND was planning on relying on taping from the ground or something and then changed their mind at 2:44.

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the kids on the lifts. They should have every right to lower the lift and get off if they're uncomfortable, but I'm not particularly fond of the current/old procedure apparently being, "send them up there, ask if they're uncomfortable."

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Sometimes I rhyme slow sometimes I rhyme quick.

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that might've would've worked.

It's not like they said: if the winds get over 35mph we're getting down, b/c Declan already knew gusts were expected at 60mph.

Getting back to that 2:44 downgrade, what's the evidence that the 2:44 wind advisory (as opposed to inertia) was the basis for the decision to tape from a lift?

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I doubt decision makers knew of the downgrade. Doubt they knew of an existing warning too.

The procedures should have existed to make sure the decision makers weren't left up to their own, probably very brief scans of weather.com to make decisions like this.

I really only bring up the downgrade because people are arguing that "anyone" should have "known" that it was a dangerous situation. Why? What if they had been actively looking at weather.com and had seen that the warning had been downgraded. Let's say it had been downgraded, and the predictions were for sustained winds of 20mph and gusts up to 25. Is that where the line of "should have known it's too dangerous" is crossed? Why?

Folksy common knowledge of the weather makes for crap indictments.

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Sometimes I rhyme slow sometimes I rhyme quick.

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...I think it was pretty obvious that the wind was intense and dangerous. Everywhere. In the entire midwest. For the whole day. And I feel fairly secure from my perch in Kenosha, Wisconsin, condemning the decisions that were made or not made by people hundreds of miles away in South Bend, Indiana.

Yes, it was a tragedy and probably a preventable one at that, but I have little interest in listening to the wailing wallers who simply want to use this incident as their emotional fulcrum to vent their spleens in the general direction of the University and get their fix of righteous indignation.

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that around the time of the accident, he went for a run about 2 miles away from the scene. And it was really windy.

http://twitter.com/jdubs88/status/60006862128553984

"FWIW: On day Declan died, I went for run 2 miles from practice b/w 3:45-4:30. Windy, w/some ridiculously powerful gusts. Intermittent, tho."

But he still went for a run.

And I'm not trying to compare running on the ground to being in a lift 40 feet up. I'm just wondering, if it's so "obviously extraordinarily windy" at that time, why go for a run? Is Walters nutty?

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Sometimes I rhyme slow sometimes I rhyme quick.

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multiple times leading up to practice. Nobody put the brakes on practicing outdoors. What are the possible reasons why? Their data was incorrect; they did not check it at the right times; they didn't know what the proper threshold was; they lacked the power or clout to put on the brakes; they knew the threshold, had the clout to stop things but were too lazy or incompetent to act. The report chalks it up to some of these reasons.

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For instance...

http://www.weather.com/weather/today/Rockville+MD+20851

I'm currently under a "High Pollen Warning" and a "River Flood Warning."

They include a freaking high pollen count with a river flooding warning.

I ignore them all the time.

I was caught in the middle of a weather disaster without an ark on Saturday night because of it.

So if we're looking at breaks in the system, the usability design of weather.com is also partly to blame, maybe.

For me, it's not about "do I buy this report?" It's "can I prove they're lying?" And for 1, I don't think they'd lie to protect anyone involved. And for another, no, I can't prove that they're lying, but I can spend all day digging up reason for doubt of any "obvious proofs" I see getting thrown around on the internet. And I'm not much interested in any burden of proof being laid on the "defendants."

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Sometimes I rhyme slow sometimes I rhyme quick.

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If you were about to go up in one of those lifts? If your kid was?

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I think it's clear Collins et al failed to appreciate the risk the lift would fall. They probably hadn't ever seen one fall. For all I know, it's possible the concern in their mind regarding the wind was on the risk of a kid falling out of the lift, as opposed to the whole lift toppling over.

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But I'm particularly prone to being aloof when busy. Particularly prone to driving right into the middle of a hellstorm when the rest of the world is apparently talking about the weather, so I can sort of relate to people who said they just didn't realize.

The biggest problem I'm certain existed was that precautions didn't exist to protect against people being aloof/unaware.

And like I've said elsewhere, what I'm really surprised by is that the program is left to using weather.com, like I am, to know what's going on with the winds.

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Sometimes I rhyme slow sometimes I rhyme quick.

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This dumbass is never driving his piddly Honda Civic during a snow storm for the ages on unplowed Northern Indiana highways.

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Turned out it wasn't an issue with my alignment. It was the "worst wheel bearings" the mechanic had seen in 25+ years. He explained that in a normal case, my driver's side wheel -- rim and all -- would have flown off while I was at 70+ miles per hour and there would be fatalities. He had no idea how that hadn't already happened. And this was the mechanic who didn't have the part to fix my car so referred me to a competitor. He had nothing to gain from this scare story.

The previous weekend, I had taken two of my kids to Chicago. Does that mean I wouldn't have deserved to answer for a terrible accident? No. Nor is this completely analogous to the organizational failures that occurred at ND. But I can't pretend I would have acted with hindsight's wisdom, because I often don't.

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Chiclone? Windpocalypse? Give me an f'ing break, I hate the media sometimes.

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Where each layer represents a level of defense or organization against something terrible happening, with small, potentially insignificant holes in each. Normally anything that got through one hole would just run into the defenses of a different level, but on rare occasions, the holes align and the entire system collapses.

Or is checking the weather from two hours before practice just such a grievous oversight you blame that?

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I guess the ultimate question is whether we buy the report or not. Was there a single point of failure? Or was it a collective failure, as Jenkins said?

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...it was the weather reports Collins was accessing, correct? After reading the report, the reports accessed by Collins seem to contradict the "conventional wisdom" of the day, that it was very, very gusty.

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the Polo Grounds

I'm interested in confirming or refuting (edit)

Read the section in "Outliers" about airplane crashes

That's an interesting point re: unequal power relationships.

Oh, ND is not at all unique in that regard

But, I mean, they're still going to fire someone, right?

some companies use "Stop Work" cards

And it could have been even more out-of-whack in football

I guess it's simpler to believe someone ordered a Code Red

That hasn't stopped certain blogs

do you have a link to the With Leather post?

Here ya go

Check out The Checklist Manifesto

yep

There's one thing I'll definitely refute...

Your first linked article

Sure, but...

Carrying this over from another front.

I think a real issue is that a decision was left up to...

It wasn't an informed delegation.

I'm not arguing that it was.

Well, if you were anywhere in the upper midwest that day...

John Walters tweeted earlier...

Collins, Russ, and Klunder all checked the wind

I check weather.com, and find their "alerts" easily ignored

Would you ignore a high wind warning

Now, no.

If I'm aware of it, probably not.

I've made the same mistakes, too

I had an issue with my alignment a few months ago.

Have I ever mentioned how much I hate headline writers?

Would this qualify as the Swiss Cheese Model?

could be

if there was a single point of failure...