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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

#81

Post by ourmandave »

defrost wrote: post #69
mrjin wrote: post #56

Earlier quoted context omitted.

I guess it counts in minor accident that managed to land successfully and those more serious but crash landed with little or no casualties at all? As far as I know, there were no survivors in recent Boeing crashes. Correct me if I was wrong.

You're correct that there were no survivors of crashes that killed everbody. Of all the aircraft crashes that were counted as crashes by the NTB, many survived.

Unless you live in the Final Destination universe.

Where the death-by-implausible-circumstances clock starts ticking.

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

#82

Post by hayst4ck »

That was a well written article. I think my favorite thing about it, is how it showcases the power of long term thinking over short term thinking. It also showcases an organization that was not using hope as a strategy.

I think the focus on "blameless" is incorrect. It is a culture of responsibility that results in better outcomes and it starts with engaged responsible leaders. Blame is in many ways the opposite of taking responsibility, but you can have a blameless culture without having a culture of responsibility. A culture of blame is always a culture of irresponsibility.

Blamelessness was a function of a leader actively choosing to take responsibility for the problem. They said "it is our organization that is responsible for this tragedy, not the individual." "We caused this through institutional negligence, not the ATCer."

Boeing still has problems because Boeing leadership has not taken responsibility. Boeing leaders have not said "I have created a system of incentives and punishments that have resulted in unsafe airplanes," which is why they are still having safety problems.

The paradox of leadership is that "while a leader is responsible for the actions of the organization, the actions occur from the individual decisions of those who follow."

If the air traffic controller was not consciously making an error, it is a clear problem for leadership to solve. Leadership has a responsibility to make a change. Blame would have prevented that change.

Admiral Rickover brought this culture, a culture of responsibility, to the nuclear navy which has quite a good record of safety. This article echos a good amount of what I have read about Americas Naval engineerng tradition. These are quick short reads to give a taste of Admiral Rickover:

https://www.ans.org/news/article-1592/caught-in-the-leadersh... https://govleaders.org/rickover.htm

I am very confident that the author would enjoy reading about Admiral Rickover and his philosophy if they have not already.

I also think anyone who enjoyed this article would also enjoy reading Extreme Ownership, which is a much much much better book than the cover and subtitle implies and is applicable to every job in silicon valley.

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

#83

Post by brazzy »

rob74 wrote: post #24
dotancohen wrote: post #16

Earlier quoted context omitted.

The USAir 1493 crash happened in 1991, a decade after the PATCO controllers were fired. I have a hard time believing that there is any connection - by 1986 or 87 the controller position has already been fully properly staffed with trained controllers. Throwing the mention of PATCO in a discussion of a 1991 incident would just further a political agenda and add nothing to the discussion.

Yeah, that's probably why she didn't do it. But if you imagine having to suddenly hire 10,000+ people in conditions which made the previous occupants of those positions so frustrated that they went on strike despite not being allowed to, I guess you can't be too picky with who you hire...

The article makes it pretty clear that Washer was not incompetent at her job, and that the role of the PATCO aftermath hiring spree was not to allow her to get hired when she otherwise couldn't, but to push her to apply when she otherwise might not have for specific personal reasons.

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

#85

Post by sgjohnson »

arethuza wrote: post #84

Over the last week or so I've become very fond of the "Pilot Debrief" channel on YouTube - basically an ex-military and current commercial pilot talking through the analysis of various incidents - I find it completely fascinating.

I can also recommend Green Dot Aviation and Mentour Pilot

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

#86

Post by dudul »

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…

First of all, the "expensive training now you'll be the guy we trust the most blabla" story has been around for decades.

Second, if this one is true it's a terrible way to phrase/present it.

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

#87

Post by ricardobeat »

latexr wrote: post #68
ricardobeat wrote: post #64

Earlier quoted context omitted.

I don’t know when this was turned into a Facebook trope, but I’ve heard it before as an engineer asking “Am I being fired?”, to which the director responds “We just invested four million dollars in your education. You are now one of our most valuable employees!”

> four million dollars That looks like a value inflated by retellings of the popular Thomas Watson quote (see sibling comments).

Probably, though when your business is making billions this is still just a few hours outage, or one long-running experiment dragging your conversion down by a few percentage points.

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

#88

Post by sgjohnson »

phkahler wrote: post #74

Boeing management should read this so they can maybe understand the nature of their quality problems is systemic and not the result of a few little oopses.

Boeing fucking up with the 737 Max so much is merely a symptom.

They so desperately needed it to remain a 737 so it wouldn’t be a new type and therefore wouldn’t need a new type rating was mostly because the airlines demanded a better 737.

Yes, Boeing is at fault for the MCAS disaster (no redundancies, holy fucking hell), but in reality it was the entire industry.

My point is, had nothing changed, it would have happened anyway, and perhaps with Airbus and not Boeing.

The one big oopsie is “we want a better plane and we also don’t want to retrain our pilots”, which is an oopsie that absolutely was not Boeing’s fault.

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

#89

Post by sgjohnson »

siva7 wrote: post #63

>> It’s often much more productive to ask why than to ask who. In some industries, this is called a “blameless postmortem,” and in aviation, it’s a long-standing, internationally formalized tradition. If people die in an accident, blameless postmortem shouldn't be the answer but accountability. Otherwise events like the MCAS disaster would be just an "happy accident" with no one to blame.

> Otherwise events like the MCAS disaster would be just an "happy accident" with no one to blame.

But it was. Boeing being allowed to self-certify their own aircraft was ultimately what allowed it to happen.

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

#90

Post by varjag »

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…

(This is a harmonized EU legislation)
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