The Plant That Forgot The Fix The sentence that keeps bothering me is not dramatic. It is the opposite of dramatic. Maintenance adjusted. Monitor next shift. That is the kind of note that can pass through a plant without setting off any alarm. It sounds responsible. It says someone responded. It says the line was running again. It says the next crew should keep an eye on it. Nobody reading it would think the plant had failed....
For about fifty years, the United States has run a system that the rest of the safety-critical world looks at, agrees is excellent, and quietly fails to copy. The Aviation Safety Reporting System, NASA-administered since 1976, is non-punitive: a pilot, controller, mechanic, or flight attendant can report a near-miss, a procedure violation, or an unsafe condition with the implicit guarantee that — except in cases of criminal intent or willful misconduct — the report will not be used as the basis for FAA enforcement....
Every System Has a Wolf Interval There’s a phrase that’s been rattling around in my head lately: tuning the world. Not in the self-help sense. Not “finding your frequency” or “raising your vibration” or whatever the wellness influencers are selling this week. I mean it literally. The act of taking a system that is mathematically incapable of being perfect and making deliberate, strategic compromises so it works anyway. That act — that craft — turns out to be everywhere....