September 20, 2014 at 12:14PM
"One solution is to insist on thoroughness in places where there is a transition between subsystems..." #readingToday

_It is unrealistic in practice to require everyone to be thorough rather than efficient, even though this often seems to be a direct or indirect outcome of accident investigations when the recommendation is that people should 'follow procedures.' If everyone really tried to be thorough it would be devastating to productivity without necessarily improving safety, as illustrated by 'work-to-rule' situations. It is equally inadvisable to allow everyone to be efficient rather than thorough, since that definitely will put the system at risk, perhaps even in the short run. One solution is to insist on thoroughness – or TETO – in places where there is a transition between subsystems or sets of functions, and where this transition is known to be critical to both productivity and safety. Such solutions must be based on a different approach to system analysis, one that focuses on couplings and dependencies rather than on failures and malfunctions.

The ETTO Principle, Erik Hollnagel