Thanks for sharing the animation.

The animation suggested that the accidents came from many accumulated
layers of human errors interacting with multiple, complex factors. And
finally, it crossed the edge of tolerance.
Sadly, I have to agree a similar accident will come again. I also agree a
punishment on people who were in charge may not help prevent a future
disaster in future.

However, I think the animation is missing an important possibility and
concerns.
The root cause of the accident may not be coming from many layers of small
human errors.
The disaster may be a result of profound system defects in Korea.
It means any efforts of systemic Kaisen or elaborated designs cannot solve
the whole problem.
Because the trouble has deep roots, it is a wicked problem that is much
larger social issue than a design issue.

The Sewol-ferry disaster has three side stories.
The animation is focusing on the first side; Why it happened?
The second story has much bigger question. Why rescue system is failed?
The third story is; why everything are so unclear?

Evidences of the accidents shows those human errors were not just small
reckless selfish behaviors.
I think it shows the existence of human evil intentions, which exploit the
system for selfish reasons. Within an edge, it is OK. However, it shall
make a disaster eventually.

As designers, we may learn from the disasters.
I believe most of people is good but I cannot deny there is no evil mind as
well.
Hence, we should prepare the case of it. Public system design should not be
based on such an assumption, which believe all stakeholders will behave
good.
Extremely, small possibility of systemic failure can be real over long
time. We learned it from the Fukushima.

As citizen, we should support justice.
If it fails root out the person in charge, the root of evil will grow back.
In a social system, punishments and reinforcements are an effective
yin-yang strategy to operate things in a good condition.

In worst case, we fail to fix the system and to remove defects. All things
can hide behind multiple and complex factors.

I am sure that a disaster will come again (hope not). So in my opinion,
healthy social system need to push them to back in safe places. Never let
them playing business around edges.
If a business cannot make a business with a proper safety, society need to
kill that business. I am sure we don't need that.

Regards,

D.H. Alf Bae.




On Mon, Jul 13, 2015 at 3:34 PM, Ken Friedman <[log in to unmask]
> wrote:

> Dear Thomas,
>
> The problem of knowledge silos and the nature of disciplines has always
> made it difficult to address these kinds of issues. There is a second
> problem involved. This is inherent in the nature of what we label wicked
> problems, in that many of these issues remain unsolvable due to political
> choices and desired outcomes.
>
> Your last reply suggests a challenging problem: “Some additional
> references would be very helpful for future, but I really hope to think
> that it is time for action, not for further discussion.”
>
> While the attribution of blame is a mistaken, the call to action is
> equally problematic.
>
> What action is it time for?
>
> What precisely are we to do?
>
> The value of your video is that is offers a clear, concise analysis of a
> relatively well-understood problem. The fact that some of us understand the
> nature of the problem doesn’t mean that we have an answer.
>
> The fact that nations and organisations continue to blame these incidents
> on individuals without addressing systemic failure or its root causes
> suggest that many key actors in the chain of causation do not yet
> understand the nature of the problem.
>
> Societies and cultures determine the larger context within which these
> issues take shape. This involves ethics, and this involves phronesis: wise
> choice for practical action.
>
> One interesting voice on these issues in the news is Pope Francis. His
> talks on catastrophic climate change, global capitalism, and social justice
> address these kinds of problems. Essentially, Francis says that we cannot
> solve many of our global problems because some groups of people benefit
> from the world financial system today.
>
>
> http://www.nytimes.com/2015/07/12/world/americas/in-fiery-speeches-francis-excoriates-global-capitalism.html?hpw&rref=world&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well
>
> To change this requires social action and political decisions. It is often
> impossible even to discuss these issues in public because those who benefit
> from the systems in place control the governmental mechanisms through which
> systemic issues find public discussion.
>
> Some of these same issues came up over a century ago when Pope Leo XIII
> issued an encyclical in 1891 on the rights and duties of capital and labor,
> Rerum Novarum
>
>
> http://w2.vatican.va/content/leo-xiii/en/encyclicals/documents/hf_l-xiii_enc_15051891_rerum-novarum.html
>
> This was at the height of the Gilded Age, and few of the key
> decision-makers of the time paid proper attention.
>
> Yesterday’s edition of "The Strip" in the New York Times captured the
> issue of systemic failures on Wall Street in a more humorous way than
> Thomas’s video — but the humorous statement of facts is equally significant:
>
>
> http://www.nytimes.com/slideshow/2012/07/08/opinion/sunday/the-strip.html?action=click&pgtype=Homepage&version=Moth-Visible&module=inside-nyt-region&region=inside-nyt-region&WT.nav=inside-nyt-region#1
>
> In most times and cultures, there have been many systemic rewards for
> doing the wrong thing, and few for doing the right thing. Even those who
> wish to do the right thing find themselves circumscribed by the inertia of
> culture and the slow grind of organisations in daily life. After reading
> Thomas’s note and watching the video, I read your comments.
>
> Don wrote, “Your animation makes the point brilliantly. Next step: Getting
> people to view it, digest it, and change behavior. I disagree with Richard
> in that this is a “new look.” This look is at least 40 years old: Reason,
> Rasmussen, Woods, (and Norman and Cook) have been preaching this for
> decades. We need to get this animation out to more people.
>
> “Alas, each industry thinks they are different. So industrialists will
> look at the animation and say, yes, that is Korea, or Ferries, or Korean
> Ferries. But we are different. No they aren’t.”
>
> This is not merely the case for special industries or Korean Ferries. The
> “we” who is not different is nearly any group of human beings who live and
> work within a society, a culture, or an organisation.
>
> Cartoonist Walt Kelly created a character known as Pogo. Pogo was an
> opossum who lived in the Okefenokee Swamp. Kelly created a poster for the
> first Earth Day in 1970, showing Pogo looking about at a damaged,
> garbage-laden landscape, saying, “We have met the enemy and he is us.”
>
> We are all embedded within these systems. Even though we do not wish to do
> so, we keep the systems alive through the mechanisms of social and cultural
> engagement, and through the organisations in which we participate.
>
> The nature of knowledge silos and disciplines is only part of the problem.
>
> I have followed this thread with real interest — I should very much be
> interested in knowing just how it is that we are to act to solve these
> kinds of problems, and I’d like to know what action it is that we should
> take.
>
> I’ll agree that it is time for action, but I am not sure that anyone can
> actually prescribe useful action that solves the real problem that your
> video discloses.
>
> Yours,
>
> Ken
>
> Ken Friedman, PhD, DSc (hc), FDRS | Editor-in-Chief | 设计 She Ji. The
> Journal of Design, Economics, and Innovation | Published by Elsevier in
> Cooperation with Tongji University | URL:
> http://www.journals.elsevier.com/she-ji-the-journal-of-design-economics-and-innovation/
>
> Chair Professor of Design Innovation Studies | College of Design and
> Innovation | Tongji University | Shanghai, China ||| University
> Distinguished Professor | Centre for Design Innovation | Swinburne
> University of Technology | Melbourne, Australia
>
> --
>
> Thomas Jun wrote:
>
> —snip—
>
> In a sense, I think knowledge silo is inevitable given the vast growth of
> knowledge production in recent years (hard to catch up). We can be better,
> but I understand challenges we face.
>
> My intention of making this animation was to communicate the important
> knowledge to wider audience. As Don pointed out, I did not produce new
> knowledge, but tried my best to communicate it better. I am very glad to
> hear that I did not misrepresent some of important knowledge.
>
> I had the privilege of reading, listening, discussing with many great
> system safety thinkers; Jens Rasmussen, James Reason, Erik Hollnagel,
> Richard Cook, Sidney Dekker, of course Don's work as well.
>
> —snip—
>
> Some additional references would be very helpful for future, but I really
> hope to think that it is time for action, not for further discussion.
>
> —snip—
>
>
> Don Norman wrote:
>
> —snip—
>
> But the responses seem to indicate a lack of awareness of the huge amount
> of work on the complexity of accidents and analyses (and hindsight bias).
> And the tendency to blame someone and think the problem is thereby solved.
>
> But the design community doesn't seem to realize that many excellent
> people have been making this argument for years. The American Academies of
> science has a group on "Human System Integration" that has long been an
> effective leader in this enterprise, and decades ago I took part in a
> similar seminar held at the Royal Society in London.
>
> --
>
> it works the other way too: other disciplines do not know what work the
> designers have been doing.
>
> I myself am equally guilty, as I recently discovered that one group of
> designers (which included me) was unaware of what other design groups were
> doing.
>
> Ah, the research solos we find ourselves within.
>
> —snip—
>
>
>
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