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Why you've never been in a plane crash

asteriskmag.com

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Re: Why you've never been in a plane crash

#31

Post by kqr »

ssl232 wrote: post #12

One of the most important pieces of legislation in the UK that helped improve safety in workplaces was the Health and Safety at Work Act 1974, which placed a duty of care on organisations to look after the wellbeing of their staff. One of the tenets is to take near misses seriously. According to a health and safety engineer in a course I attended, near misses are like gifts from the heavens, as they show you exactly…

Indeed.

- An accident is a combination of the system being in a hazardous state and unfavourable environmental conditions that turn the hazard into an accident.

- A near miss is when the system was in the hazardous state but the environmental conditions were in our favour so the accident didn't happen.

We can't control environmental conditions, we can just make sure to keep the system out of the hazardous state. This means a near miss contains all we need to perform a proper post mortem. The environmental conditions are really immaterial.

Re: Why you've never been in a plane crash

#32

Post by sajforbes »

aramndrt wrote: post #9

Reminds me of the guy at GitLab, I believe it was, who accidentally and irreversibly deleted a bunch of repositories. GitLab had a fantastic approach to that whole ordeal and public embarrassment. They essentially blamed themselves for not having the proper contingencies in place instead of blaming the individual. It's worth reading up on.

Also reminds me of the Reddit thread [0] where someone accidentally used write access credentials that were on an onboarding document and wiped the production database. GitLab guy actually joined the conversation.

[0]: https://www.reddit.com/6ez8ag/

Re: Why you've never been in a plane crash

#33

Post by izacus »

josephg wrote: post #28
ssl232 wrote: post #12

One of the most important pieces of legislation in the UK that helped improve safety in workplaces was the Health and Safety at Work Act 1974, which placed a duty of care on organisations to look after the wellbeing of their staff. One of the tenets is to take near misses seriously. According to a health and safety engineer in a course I attended, near misses are like gifts from the heavens, as they show you exactly…

With the number of data breaches we see cropping up, I wonder if a similar law could be written to hold companies liable for the safe handling of personal data.

TBH having software engineer output in general be liable to some minimum safety, correctness and quality standard would be a god send for the world.

But of course the developers will revolt against that.

Re: Why you've never been in a plane crash

#34

Post by throwaway713 »

This concept of a blameless culture reminds me of one time when I was talking to a SWE at Facebook around 2010. I don’t know whether the story is actually true or just folklore, but apparently someone brought down the whole site on accident once, and it was pretty obvious who did it.

Zuckerberg was in the office and walked up to the guy and said something along the lines of “Just so you are aware, it would probably take a lifetime or more to recoup the revenue lost during that outage. But we don’t assign blame during these sorts of events, so let’s just consider it an expensive learning opportunity to redesign the system so it can’t happen again.”

Re: Why you've never been in a plane crash

#35

Post by mbork_pl »

aramndrt wrote: post #9

Reminds me of the guy at GitLab, I believe it was, who accidentally and irreversibly deleted a bunch of repositories. GitLab had a fantastic approach to that whole ordeal and public embarrassment. They essentially blamed themselves for not having the proper contingencies in place instead of blaming the individual. It's worth reading up on.

Any source would be appreciated, I'd like to read more about it.

Re: Why you've never been in a plane crash

#36

Post by izacus »

tialaramex wrote: post #23
gooddeed wrote: post #6

Earlier quoted context omitted.

The ability to drop blame from the equation is a credit to the aviation industry and would drastically improve any team, organisation, or industry to adopt it.

This very specifically works for Accidents - events nobody actually wanted to happen, where we can learn from experience and prevent it happening again. It specifically won't work for things which were not accidents at all, where blame remains a useful tool. There's some nuance, the Captain of the Titanic didn't intend to sink the ship and kill loads of people, in that sense it was an accident - but he also didn't ne…

Yes, you can even see this in aviation itself - there is still blame put on __poor decisionmaking__ and __violation of rules__.

In software I've seen "blameless" mean "people who outright broke the process and in some cases even law should not take any blame".

Re: Why you've never been in a plane crash

#37

Post by razakel »

ptaipale wrote: post #15
palad1n wrote: post #5

This is the first time I've heard of "just culture" and wish it would spread to other areas of the world and life.

It's basically the essence of aviation safety work. If one concentrates on blaming individuals, the system is not fixed.

Yep, all you've done is created a scapegoat - which in some cases does satiate the public's bloodthirst - but does not actually address the fundamental issues.

Re: Why you've never been in a plane crash

#38

Post by mulmen »

throwaway713 wrote: post #34

This concept of a blameless culture reminds me of one time when I was talking to a SWE at Facebook around 2010. I don’t know whether the story is actually true or just folklore, but apparently someone brought down the whole site on accident once, and it was pretty obvious who did it. Zuckerberg was in the office and walked up to the guy and said something along the lines of “Just so you are aware, it would probably t…

Eh, that’s a really strange way to phrase it. Singling out the engineer isn’t blameless. Sure it’s a learning opportunity but it’s a learning opportunity for everyone involved. One person shouldn’t be able to take the site down. I have always thought of those situations as “failing together.”

Re: Why you've never been in a plane crash

#39

Post by bryanrasmussen »

ptaipale wrote: post #13
moring wrote: post #8

Related: CAST analysis http://sunnyday.mit.edu/CAST-Handbook.pdf Intended to focus on maximal learning about all factors that contributed to an accident. It subsumes several approaches, including a blameless analysis and that each factor doesn't just have a single "cause" but that different factors form a network of interaction. Also nitpicking about the headline: You haven't been in a place crash because you wouldn'…

In fact about 90 % of plane crashes are survivable and people read about their own accidenyäts.

ok but 90% of plane crashes are survivable is not the same as 90% of people in plane crashes survive them.

According to this https://etsc.eu/increasing-the-survival-rate-in-aircraft-acc...

>In round and, of course, fluctuating figures it is estimated that of the 1500 who die each year in air transport accidents some 900 die in non-survivable accidents. The other 600 die in accidents which are technically survivable and crashworthiness, fire and evacuation issues are all important. Of these 600 perhaps 330 die as a direct result of the impact and 270 due to the effects of smoke, toxic fumes, heat and resulting evacuation problems.

on edit: also this https://www.psbr.law/aviation_accident_statistics.html

Re: Why you've never been in a plane crash

#40

Post by mnau »

izacus wrote: post #33
josephg wrote: post #28

Earlier quoted context omitted.

With the number of data breaches we see cropping up, I wonder if a similar law could be written to hold companies liable for the safe handling of personal data.

TBH having software engineer output in general be liable to some minimum safety, correctness and quality standard would be a god send for the world. But of course the developers will revolt against that.

How do you define "minimum safety, correctness and quality standard"?
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