Communicator

In an effort to help recruit new members, I leave my copy of the Communicator laying around at work.  The Communicator is definitely giving another prospective on the fatigue rule. One of my supervisors printed out Mark Sharp's articles for OE.  It was very refreshing to read OE that was not lacking for details and OE that was not sanitized.  Everyone that has read Mark's article agrees with the question "What was I thinking", then realizes that sometime in the last day, last week, or last month, that they all may have had cloudy thinking too and could have been close to making the same mistake in judgment. 

Too often the OE from INPO is your damned if you do or damned if you don't OE.  For example you get hit for not following procedures in one paragraph and then you get hit for following an approved procedure that didn't work because you are smarter than all the people who wrote it, reviewed it, and approved it. 

Root causes are nice for boiling everything down to what exactly broke and that there was a human performance issue but you never get to learn how the operator was thinking that drove him down the wrong path.  

Fatigue is such a factor in everything we do.  When is the last night shift that you have gone all night taking a perfect set of logs?  Ever have a night where you made so many line outs that you just had to get a new copy and start over?  If I make three errors on a single set of logs, I know that its time for a break to get re-focused.  Hopefully I won’t have to be asked what I was thinking.

I hope that more of us are willing to be brave and write articles like Mark.  Because every once in a while I would like to be reminded not to think like that in a moment of weakness.