When Systems Fail

Ape happened to stumble across this blog.

The author recounted the incident on Bt Panjang LRT when the train door was opened while moving. For the benefit of readers who may not be aware of the background and cjain of event, LRT is a driverless, short distance train. On that fateful day, due to certain issues, it failed to operate. Procedures call for a driver to take over and drive it manually. Although the driver ensured the doors were closed prior to moving off, he failed to check that it is locked. As a result, the door opened and the fail safe mechanism automatically applied brakes forcing the train to a stop. Following that, the driver checked a second time and ensured that the door was closed and locked before moving off. Fortunately, no one got injured as a result of this chain of events.
What caught ape’s attention is that disciplinary action was taken against the driver. Key word here is ‘disciplinary’. Ape is in the line of safety and whenever the words ‘disciplinary actions taken on operator’ pops up, like the failsafe brakes, ape automatically raises his eyebrows.

Back in the dark ages of safety management, or rather the lack of, whenever an incident or accident occurs, blame was almost always apportioned to the operator. It could be the driver, ship/plane captain, engineer etc. Since it’s the human operator to be blamed, well, disciplinary actions were taken on the operator. However, to err is human, as the cliché goes. To prevent the mistakes of an operator causing harm to productivity or human lives, machines were built and designed to have as much automation as possible, thus removing the human element and human errors. No human, no error. Perfect world, right? Things are not so simple. Machines can fail and sometimes with disastrous result. Complex ‘machines’ designed, built and managed by experts do fail as in the case of Space Shuttle Challenger, Chenobyl Nuclear Power plant or in more recent years, Fukushima nuclear power plant. Failure of Fukushima plant was attributed to natural disaster but humans were involved to recover and contain the further failure as much as possible. Furthermore, complex systems are designed and built by humans. An error introduced at the design and building stages can be dormant until that fateful day. The point ape want to make is that we can never remove the human element and with it, potential human errors. The question is whenever human error is involved, is it just or fair to impose disciplinary action on the ‘erring’ human? To err is human. If we accept that every one who has erred and ought to be punished, including possibility of job termination and criminal charges, rightfully, when such people is removed, there should not be any more of these problems, right? Accidents still continue to occur and often, involves human who ‘erred’. Take a moment to pause and think. In spite of disciplinary actions and even threats of criminal charges in some profession, who do people continue to ‘take short cuts’ or ‘take the easy way out’ or ‘forget’?
Remember, to err is human. Those in the line of psychology or human factors will tell you that the very nature of humans that make succeed and rise above animals, traits such as adaptability, are also the very reason how human can err. Yes. Humans adapt if you’ve not realised yet. Humans adapt under stress. Humans adapt when needed tools are not available. Humans adapt when they race against time. Humans adapt when there are conflicting priorities such as ‘get the train moving’ vs ‘check and double check’. Humans adapt when procedures were not clear. Humans adapt… you get the point yet?
Well, fortunately in current safety management, operator error is not the end stage of investigations but the beginning. We are never satisfied with the simple answer of operator action / inaction. We delve deeper. What could have caused the operator not checking the doors are closed and locked. Are the procedures clear? Was the driver receiving instructions that caused him to overlook? Was he trained properly? Were there other alarms or signs that could’ve warned him that the doors are not locked? Could the system be built that the train could not move in the first place until doors are closed and locked . Simply put, what caused the operator to commit the error. To be fair to SMRT who manages the LRT, at least they are looking into redesigning the system to address human errors. However, what if procedures were not clear or the driver wasn’t trained properly. Does he deserve to be ‘disciplined’? The question of culpability has to be addressed. How then should management decide when disciplinary actions be taken?
Ape will just end this post here with this last question for readers to think about.
Also, here’s an interesting chart for readers to refer. The chart is developed by a psychologist dealing with human errors and promoting just culture. It is meant to help people like ape to determine when should disciplinary actions be taken when an operator commits an error or violation (of prescribed SOPs)
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Parliament Debates

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Of late, much has been spoken on mainstream media, online or print, social media, local blogs and websites etc about the AGO’s report on AHPETC. Clarifications, feedbacks, comments, accusations and what not were all over the place. Ape shall not repeat what has been said, especially who’s right, who’s wrong, was the audit politically motivated, did AHPETC conduct their business with due diligence and all the blah blah blah…

Instead, ape wonders, how often do our parliament file a motion to debate on the conduct of a ministry, statutory board or any organs of state. When was the last time a ministry requested AGO to conduct a special audit, out of the usual scheduled, periodic ones, on any other TC, statutory board etc.

Ape remains unconvinced that the AGO findings is so critical that a motion has to be filed to support the AGO report in parliament. Is that a norm? If that is so serious, what about AGO report on other ministries and statutory boards whose function affect not just residents of Aljunied, Hougang and Punggol East constituencies but the whole of Singapore. When was the last time AGO report is debated in parliament? Or is Minister Khaw setting a precedence, perhaps to warn all public service officers that corporate governance will be the highlight henceforth and any unsatisfactory findings will be flagged, highlighted in parliament and debated?

Another related issue got ape confused, that is with holding the 7 or 6 million SCC grant to AHPETC. Does the Minister has unfettered powers to withhold such grants? Or such authority has to be guided by certain principles and processes?

Ape is not an ardent follower of parliament or Singapore statutes but if any of you do know, please share.

Last but not least, ape wishes everyone a Happy Chinese New Year… And for those of you who do not celebrate CNY, enjoy the super long weekend!

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Thaipusam – Celebrations Or Noise?

P/s Ape spoke to a Hindu friend. Apparently, ape’s suggestion won’t work. According to friend, devotees normally put on their kavadi outside the temple. During this moment, the devotee may have engaged performers to play music. After which, as the kavadi bearer begins his procession in the streets, the performers will continue playing their music. Thus, if each kavadi bearer has his own performers, then the suggestion of having two groups performing at any one time would not work. However, ape still remain unanswered as to the basis for musical instruments not allowed.

Thaipusam is a festival celebrated by Hindus. Being a multi-racial, multi-religious country, Singapore is not short of Hindus celebrating this event. Unfortunately, the otherwise celebrative and vibrant Thaipusam is marred by one rule – no musical instruments or sound systems.

Ape was perplexed like many others when the Hindu Endowments Board (HEB) restrictions on Thaipusam surfaced to general public a few years back. In particular was the rule forbidding the use of musical instruments and sound systems. What’s a celebration without music. How is kavadi attam (dance) performed without naiyandi melam (music ensemble)? Ape, although not an Indian nor Hindu, likes the music played by them. There’s something in the rhythm that makes ape feel like clapping its hands and hopping with joy. Also, it seemed such rule is discriminating Hindus. While it can be seen that Chinese has their gu or Malays has their kompangs, why Hindus can’t have their urumee? To the allegations of discrimination, Law Minister, Mr Shanmugam explained in his Facebook post.

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Ape sincerely appreciates the Law Minister’s explanation. His explanation seemed fair and dispelled the element of discrimination, as far as ape is concerned. However, ape is still unconvinced of the need to forbid the playing of music during the procession.

What exactly is the basis that musical instruments are not allowed? It appears to ape that the reason seemed to be that because Hindus are ‘privileged’ to hold foot procession over a long distance, therefore something else must be restricted. Surely this is not the case and shouldn’t be as simple as that.

If it’s an issue of noise, well, many have wrote that the procession occurs during the day. It’s once a year event. The route is not in residential area. Ape will also add that the sound from urumee and other drums is more pleasing and joyous than screeching MRT tracks, roar of F1 Race or some community events blasting their sound system at maximum volume.

Ape hopes the good minister can discuss this matter in depth with HEB. Ape really don’t understand the basis for forbidding musical instruments.

Here’s a proposal though. Ease the restriction on musical instruments. Perhaps allow only two groups of performers. One at the head of procession and another at the end. Or multiple groups but on rotation basis. That is, at any one time, only two groups get to perform. No amplifier system. Perhaps restrict the number of performers. (Ape imagines one group made up of a hundred urumee players :p ) Will this achieve a win win situation?

Side note: Ape happened to be in the vicinity in this year’s Thaipusam. Without the music, ape thought the road blocks were for some road repair works.

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Blood Bank In Singapore

For more details, please visit the following link
http://www.hsa.gov.sg/content/hsa/en/Blood_Services.html

Ape was away for quite sometime. The last 3 months had been so exciting. What started out as a simple photo of a school, ended up with ape reconnecting with friends of his primary school. Schoolmates of his cohort, the P6s of 3 classes. That’s considering we were in primary 6 almost 3 decades ago!
What happened over all these years is anyone’s guess but ape noted one’s primary school academic performance has no relevance to what we eventually are now. Perhaps ape will write about this bunch of fun loving, down to earth people, including a doctor whom ape affectionately call Dr Mai Coon (meaning “don’t sleep” in Hokkien)

Anyway, this post is really about Blood Bank in Singapore. Ape was told that every time someone posted a call on FB or other social media requesting for certain blood type because a friend, relative, family member, acquaintance etc is in need of blood transfusion, staff in Blood Bank scrambled to do stock take. Why? Some ‘concerned’ people will ask the staff if they’re short of blood. It can happen anytime of the day including post mid night. We, as members of public, who didn’t know better and tried our part to share and forward such posts to help in the appeal are actually disrupting Blood Bank more than we know.

Here’s some insider info to help us understand better how Blood Bank operates. So the next time, do think twice before we forward or share posts appealing for blood donation.

Stock Keeping And Distribution
Blood Bank keeps stock of all blood types. No blood type is allowed to deplete below a certain level. When it does come close to the ‘low level’, the official channel is Singapore Red Cross. SRC will call up the specific blood group donors to come forth or specific public channels such as SRC Facebook. Only when such targeted or specific channels failed to get enough donors, a nation wide appeal thru official media like radio or TV will be done. Fortunately, ape don’t recall Blood Bank had to resort to nation wide appeal other than the occasional blood donation campaign and promotion.

Since Singapore is relatively small in size, Blood Bank keep most of the stocks and a certain level is maintained in each hospital for emergency cases. Therefore, when a particular hospital falls short, the hospital will obtain from Blood Bank to top up their stock. This can happen when there’s major accidents with many casualties warded to a particular hospital. The stock in that hospital can deplete fast. This is also where confusion arises and individual appeal for blood donation cause a small panic.

Sometimes, hospital staff who don’t know the process would tell the patient that they are short of blood. What they actually meant was that particular hospital was short of that particular blood type. The staff either didn’t know or perhaps with intent of encouraging blood donation, told family members to donate. So when family members post appeal in FB, Blood Bank staff saw it, they’ll be like huh?!? They’ll scramble to stock take, check the case, identify source etc all in interest of ensuring that there’s no lapse. However, such scrambling take away their time from their work.

So We Don’t Appeal, Don’t Donate?
We can still appeal but in the least, tag a date in the message body. What happened was the post may get circulated, forwarded, shared and re-forwarded, re-shared for years. The patient might have recovered or (sadly) died but the post still circulating and that is creating a lot of confusion.

Also, do donate as and when you can. Don’t wait for last minute or urgent cases. Ape’s friend said they do have regular donors but age group getting older. Most of these regulars started several years back and continue to do so. However, new and young donors are getting less. When the current cohort gets old and no longer suitable for donation, the regular donors pool will dwindle.

Also, don’t wait for last minute for reasons of ‘saving blood for own family’. As far as blood donation is concerned, your blood may not go direct to your family members. Imagine someone you know and love needs blood transfusion urgently. You step forward to donate. Your blood will still need to be tested for suitability and processed. By then, the patient who needs blood might have died if waiting for this process to go through. What we saw in movies where the donor and recipient lay side by side for transfusion is really bull faeces. Maybe that scenario can happen when situation is so dire where everyone can’t be bothered with checking blood for virus etc.

The process of checking and testing is also quite complex and not merely checking blood type. Ape’s doctor friend described the process with jargons and ape simply… Lost in lallang. In a nutshell, if your love ones needed blood now, your last minute donation is unlikely to reach your love ones but you can do your part now before anyone you know needs blood.

Surely, Immediate Family Members Should Not Have Problems? Why The Tests?
This question was raised when we talked about this. The good doctor explained ethics and confidentiality in layman terms for us. Imagine a daughter needs blood transfusion urgently. Healthy parents who are not on any medication shouldn’t be any problem right? What if the father visited prostitute recently? If he says no, the family will be suspicious right? Worse if he lied and he had in fact contracted HIV? To save the family from further anguish, all must go through tests, not only for blood types, but check for HIV, STDs, Hep A B C and do re mi… OK OK, no do re mi. The point is all donated blood must be tested and processed. So if any anomalies found, the donor will be contacted privately. Family members won’t know whose blood is used since hospital is likely to use existing stock which is not from any of the family members.

If you’re keen to do your part, do read up the official link above and start donating now. Have a great weekend ahead

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Doing The Right Thing

Ape read the following news from Straits Times and it simply pissed ape.

http://www.straitstimes.com/news/singapore/more-singapore-stories/story/just-smile-dont-talk-rookie-security-guard-learns-be-see#xtor=CS1-10

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Pic from Straits Times

Undercover rookie security guard gets to experience first hand what is wrong in our society… Simple disregard for professionalism. Just because he is salaried and salaried at the lower end, he can get reprimanded for doing the right thing. It appears not only the rich mighty trod down on security, even work site supervisor gave a dressing down for reporting and logging an event that appears abnormal.

Just imagine, if he didn’t do what he was trained and supposed to do. If he didn’t check the visitors or rich home owners failed to register their car and he allowed an unregistered ‘visitor’ to pass through resulting in crime being committed. Who’s to be blamed? Management Committee?

Or he didn’t evacuate the workers or alert the fire control centre and turned out there was a real fire. Who’s to be blamed? The site supervisor or the developer?

One may argue false alarm can be unreported and he should have at least check first. Perhaps. However, if false alarm is recurring problem at the worksite, shouldn’t some actions be taken to address it? If he didn’t log it down, would management know how frequent false alarm were? Or would you argue the same (check first before activating) when SPF turn out to the Little India Riot was slower than expected? Maybe the relatively slow response could have been because the call centre wanted to confirm if it was a riot or traffic accident or a handful of drunkards engaging in a brawl.

The saddest part is those who see themselves as mightier than him failed to register his actions was for their benefit. Ape thinks the high end condominium owners deserve it should their estate turned out to be a crime scene.

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National Day 2014

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Singapore reaches it’s 49th year of independence. Flags and banners dot our landscape. Parade rehearsals and occasional jet engines shooting across our sky is familiar in the month of July, leading to our National Day on 9 August.

Ape started this post, with the knowledge of the Isreal/Palestine armed conflict. Further north from there, Ukraine is fighting a civil war with their pro-Russia separatists. If you’re thinking these events have nothing to do with us, an unconfirmed (at time of writing) collateral damage suffered by Malaysian Airlines MH17 as it was allegedly shot down, killing all civilians on board. It could’ve been our national carrier Singapore Airlines for all we know.

We may grouse about certain things in our country but can anyone deny we have peace for the past 49 years? The recent Little India Riot may be a wake up call to us but to others, it might be a weekly affair.

Such peace are achieved not only by the good measures the government put in place. A lot also depends on ourselves, citizens of Singapore to be wanting to and making constant efforts to maintain peace. For these years of peace and harmony, ape is very thankful to everyone making this effort, especially our pioneer generation who are willing and able to set aside differences in opinion, culture, religion and native backgrounds to make and maintain peace and harmony our objective.

Ape is being very candid to express his scepticism of the younger generation, the post 65s, on their ability to see peace an objective that needs constant maintenance and not something to be taken for granted. It’s like our public transport and other public amenities. In spite of the best, latest, state of art and whatever ‘tok chiang’ (publicity) made, they will breakdown sooner than you think if we don’t invest in upkeeping and maintenance. Sadly, ape is seeing more and more people becoming self centred. People who worked with the objectives of meeting targets, getting promotions, hoping for pay increment, without a single thought about their actions if what they do will benefit society as a whole.

Ape hope for this year’s National Day celebrations, his readers will spare a moment to think if next next year, as Singapore, reaches its 50 year of independence, will there still be parades and celebrations as we did? Or we have to be constantly reminding ourselves not to take peace for granted so as to make sure we’ll still be enjoying peace and harmony.

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RE: 400 gather outside National Library for reading event in response to NLB’s removal of three books

http://www.straitstimes.com/news/singapore/more-singapore-stories/story/250-gather-outside-national-library-reading-event-respon

Ms Ong set up a Facebook page, Singapore’s Parents Against Library Censorship, to express her disapproval of NLB’s decision to remove the children’s titles. – See more at: http://www.straitstimes.com/news/singapore/more-singapore-stories/story/250-gather-outside-national-library-reading-event-respon#sthash.WZz2xNd8.dpuf

If you’re following this news, it started with a “concerned parent” writing to National Library Board claiming 2 books in rhe children section are unsuitable for the young because these books ‘promoted’ an alternative family unit, that is, homosexual ‘lifestyles’. In response, NLB destroyed the books.
The LGBT community is disappointed by NLB’s decision. Perhaps what many people didn’t expect were the reactions from several book writers, playwrights and others in the field of literature, many of whom had been working closely with NLB to promote literacy, to boycott NLB. Judges for the Singapore Literature Prize and writers for the Singapore Writers’ Festival also also distanced themselves from these two events organised by NLB.
An incidental ‘alliance’ of sorts between the LGBT and people in the field of literature, along the lines of freedom of information and human rights. Parents of atypical family, single parent, divorcee, parent of children with special needs also stood up to object NLB’s pulping of the books. These people stood up for one deserving cause, they wanted to remove ignorance and discrimination.

Perhaps some people don’t see it and continue to insist on family values and morality to have all materials/events/activities that doesn’t seem to conform to mainstream views removed. This is a myopic view and leads to ignorance.

Good or bad, we have to face realities. By pretending something that’s abnormal doesn’t exist, by hiding what we perceived as ‘wrong’ in the name of protecting our children, is to impart ignorance to them. Such actions do a disservice to our children. To get government to ban the books totally borders on being irresponsible parents.

Fortunately, good sense eventually prevail and under the instructions of the minister, NLB restored the books and placed them under adult section. The books are still accessible by responsible adults who are prepared to guide their young in due time.

One of ape’s pet peeves living in Singapore is to have to come across ‘concerned’ and self proclaimed ‘responsible’ parents, writing to the government claiming certain shows or books shouldn’t be shown for whatever reasons. Ape is fine if the suggestions lead to a more restrictive broadcast such as after 10pm or to have the book with ‘objectionable’ materials sealed such that access to children and young people are not easy. A responsible parent will choose to guide the children and reveal the realities of life to their children in due time. An irresponsible parent will ask for someone else to do the ‘dirty’ job and demand for an outright ban… by the government of course. How much do we really want our government to nanny our children and us? If we sheltered our children too much, imagine what happens when they become adults and got a ‘cultural’ shock? Ape had that once when he came across schoolmates who came from broken families. One is from divorced parent and the other is raised by his father and grandmother because the mother left them. It was awkward interacting with them initially because prior to that experience, ape was only exposed to the ‘traditional’ family unit. Fortunately, ape’s parents are quite liberal and allowed ape to ‘explore the world’ when he hit teenage. In those years, ape got into a ‘crash course’ interacting not only with peers from ‘broken’ families, ape was acquainted with illegal money lenders, glue sniffers, gangsters and all sorts of misfits in society. Everyone has a tale to tell and ape was able to see their side of their life. Maybe because ape was young (and lucky), these people gave ape good advice – don’t be like them, study well, do your parents proud. Ape was a lot wiser since although ape denies he is wise.

Avoid the acts if it doesn’t fit into goodness but don’t avoid knowledge.

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