I showed this to Mrs (Dr) Weasel, who asked me to email this to her at work, since she agreed with me that it was relevant as she does a lot of this sort of thing.

Can I respectfully suggest that you take your son along to your local team. The advantages are several, including

1. Increases an “attachment” to your local community
2. Although tribalism exists in the non-league game, you rarely get beaten up, spat at or abused.
3. Your son maybe surprised at the pace and skill seen at Hastings United, Northwich Victoria or elsewhere

I could go on….

I would have to go back and read the Glasgow report again, but my memory was that (a) the main person doing calculations (appointed by the supervisor)was insufficiently trained, that (b) there was an official signing-off process which should have identified this but which had been ignored by the supervisor whose responsibility it was (or more charitably was not up-to-date), that (c) one checker might have picked up the error serendipitously but was actually officially checking for something else, and that (d) the main checker (the supervisor) was specifically disallowed by the procedure from being the checker for this particular thing because he/she had been previously involved (in what capacity I forget) but ignored that bit of the procedure. All compounded by the fact that (e) the IT had been changed without a rigorous enough job being done in changing the procedures so that the IT and the procedures surrounding it made a seamless whole.

(b) and (d) were definitely the supervisor’s fault, and as a person with a lot of experience running operations, I would say that the ultimate responsibility for (e) also rested with the supervisor, even though it was also some IT project team’s responsibility. The book got thrown at the supervisor so presumably the person doing the report agreed.

There would be management responsibility too in various circs; if the department was extremely short-staffed, or the supervisor was inexperienced or ill or otherwise incapable of doing their job properly, or there weren’t any procedures at all, or even that it was consistently tacitly agreed that procedures could be ignored. The report made no suggestion that any of this pertained, apart from it was a bit busy over the Christmas period.

You might say that the supervisor didn’t pick up the error on their (unauthorised) check because of IA. But the supervisor knew that the original person doing the work, whom they had chosen, was inexperienced, and should therefore have been checking with the real expectation of picking up an error.

I reiterate that this analysis is based on memory!

I take your point. As with many things psychological the evidence is thin. I believe it is a bit more than repetition leading to sloppiness though. I do believe that one reaches a level where the system is trusted to iron out mistakes rather than the individual, and that this leads to dangerous inattention to detail. Furthermore I would not suggest (sorry for the implication to the contrary) that the practice of double checking leads to more errors. Just that the fact that both checkers are “protocolised” may mean the check has less value at detecting error.

How would you account for the Glasgow error-there was clearly a serious failure both of process and of safety checks

Also, I very much doubt that this (potential) issue was relevant to the Glasgow case (and I read every single word of the report on the latter).

I would quite like to know what Brian Toft’s PhD was about. He certainly seems to be well in with the risk management industry, which is relatively new and which contains a lot of management-speak gobbledygook which can be difficult to separate out from the genuinely useful