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With safety and security, more can be lessNote: this note originaly appeared in Peter Neumann's "Risk Digest," volume 23, number 63 26 Dec. 2004. I added some material afterwards.In RISKS 26.30, Peter Neumann recommended a paper by Scott Sagan entitled: "The Problem of Redundancy Problem: Why More Nuclear Security Forces May Produce Less Nuclear Security." (See references at end of this note.) I want both to second the recommendation and also to expand upon it. Many attempts by both experts and amateurs in the world of security and safety actually weaken their systems. Sagan provided three major reasons why this might be so: I add a fourth. Sagan's three reasons were:
1. Common-mode problems. (Classic example: redundant hydraulic lies in a DC-10, but an accident destroyed the part of the fuselage that held all three lines. Poof. No more hydraulics.)
2. The "shirking" problem (also known to psychologists as "bystander apathy"). Thus, NASA's Genesis spacecraft suffered an embarrassing crash, apparently due to switches being installed upside-down. One scientist pointed out that even though the spacecraft had undergone reviews by more than 100 people, "this somehow got through despite the normal reviews and the additional reviews" (N.Y. Times, Oct. 16, 2004). Well, I suspect the problem was not detected in part because so many people were involved in the checks: use less people and the chance of catching problems increases.
3. The overcompensation problem. I want to emphasize the importance of these problems, while adding an equally important fourth one:
4: The Dedicated Worker problem. Note (*) In 1992 I neamed this the "one in a million" problem. (In Norman, 1992 -- reference at end of this essay -- Chapter available here.) Low probability events are often judged to be non-existent, or at least, that happen to others. I've named it after the pilot who decided that all three of his engines could not be failing because "the chance of this happening is one in a million." My observation is, "yes, you are correct, and you are that one." Actually, with some 7 million flights a year, one in a million is not nearly good enough, but that is a different argument. Item one of these four is a technical issue: the other three are psychological ones. When attempting to increase security and safety of systems, it is essential that the psychology of the people be considered to be of equal or greater importance than the purely technical analysis. Note, the most obvious response of security and safety people is "more training is necessary." Yes, proper training is always useful, but don't count on it solving these problems. These issues happen despite training. They often are present in the best, most well motivated, most effective people in the organization. Indeed, professionals in the security and safety industry have succumbed to just these issues. ("I know my home computer isn't secure, but it was absolutely essential that I finish this report, ..."). The correct solution lies in ensuring that the security and safety measures take into account both the technical and the psychological factors. REFERENCES:Norman, D. A. (1992). It's a one in a million chance. Chapter 15 of Turn signals are the facial expressions of automobiles. Cambridge, MA: Perseus Publishing. Sagan, S. (2004). The problem of redundancy problem: Why more nuclear security forces may produce less nuclear security. Risk Analysis, 24 (4), 935-946. |
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