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Why you've never been in a plane crash

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

#121

Post by polynomial »

ricardobeat wrote: post #64
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…

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!”

This is the version I've always heard.

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

#122

Post by growingkittens »

kqr wrote: post #18
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'…

Whoever got curious enough to enter this comment section: carve out some time to read the CAST handbook. It changed how I look at accidents but also how I look at organisations and the rest of the world. Should be mandatory reading for anyone in any position of responsibility. I have long wanted to write a review/summary of it on my blog but it's so dense in useful content it's hard to compress further. (There's a re…

Thank you for posting your summary! I appreciate summaries because each individual finds something different to emphasize about the text.

Have you looked at the book "Handbook of Systems Thinking Methods" (2023, Salmon, Stanton, et al)? It's all about applying systems thinking to safety and talks about the STAMP-CAST model.

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

#123

Post by cainxinth »

sgjohnson wrote: post #88
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 happe…

> 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.

Of course it is. Customers always ask for the impossible. Responsible firms say no to unreasonable requests.

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

#124

Post by izacus »

m_fayer wrote: post #105
izacus wrote: post #33

Earlier quoted context omitted.

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.

The agile-peddling consultants and managers would certainly be the first to the barricades.

As long as they're first to the stocks too, we're fine with it ;)

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

#125

Post by mathstuf »

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…

> 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.

I've not been following closely, but I suspect the Post Office did not follow this. Are there ramifications happening along these lines for the Post Office fiasco? Or is it already a big enough thing that this would just be "oh, and also that too I guess" kind of thing?

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

#126

Post by jroseattle »

Well-executed RCAs are just so satisfying to me. Blameless culture is absolutely critical to getting to the "right answers".

Across the teams in my company, I hit nirvana when reviewing something like a major/impactful outage and the involved members in discussion are drilling down to the the essential state and sequence of events that caused said outage. Focus on actions and outcomes, including both those central/peripheral to the outage and those with zero knowledge prior to the event. It takes a high degree of trust in yourself, your peers, and your organization to get to nirvana.

Go through a few of these in a proper way, and a simple principle tends to emerge: if your mechanism is dependent on the perfection of humans, it will eventually fail. The only real discussion beyond that is basically what to do next -- do we need a mechanism that protects against human imperfections? Is the cost of implementing a solution worth the mechanism it would be designed to protect? Can we live with the infallibility of humans in this scenario?

Organizations that can achieve this level of discourse have a distinct advantage in execution.

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

#127

Post by mnau »

josephg wrote: post #118
mnau wrote: post #110

Earlier quoted context omitted.

So you propose no idea of "minimal set". If a liability is proposed, it has to be reasonably binary state: compliant/non-compliant. Just like every time, there is no concrete proposal what constitute "minimal set". That's like "make education better", with no concrete plan. We can agree on goal, but on on the method.

There are several ways we could write a list of best practices. But the simplest would be to simply attach a financial cost to leaking any personal data to the open internet. This is essentially how every other industry already works: If my building falls down, the company which made it is financially liable. If I get sick from food poisoning, I can sue the companies responsible for giving me that food. And so on. We…

Software is in a very unique position. It can be attacked all the time with completely impunity.

Buildings are completely vulnerable even to simple hammer breaking windows, locks have been basically broken for decades

Food processor is easily vulnerable to poisoned potato.

Only the software has to take all attacks humans can come up with and withstand it.

What other industry has to deal with that? Maybe military, army camp in middle of enemy territory?

We have improved massively and will and should continue to do, but it's very different from other industries.

That's the core reason for breaches.

Some security checklist will help to filter most egregious idiots (especially upgrades from vulnerable versions).

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

#128

Post by jroseattle »

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…

> let’s just consider it an expensive learning opportunity to redesign the system so it can’t happen again.

Also, Zuck: but hey everyone, keep on moving fast and breaking things!

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

#129

Post by red-iron-pine »

devjab wrote: post #75
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…

When I was only a few years into my career I accidentally deleted all the Cisco phones in the municipality where I was a sowtware developer. I did it following the instructions of the IT operations guy in charge of them, but it was still my fault. My reaction was to go directly to the IT (who wasn’t my) boss and tell him about it. He told me he wasn’t happy about the clean up they now needed to do, but that he was ve…

I'd much rather hear about a problem from a team member than hear about it from the alert system, or an angry customer.

plus when the big fuckup happens and the person causing it is there, there is an immediate root cause, and I can save cycles on diagnosis; straight into troubleshooting and remedy.

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

#130

Post by filleduchaos »

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.

...it's the same aviation industry with the same approach to investigations outlined in the article that did, in fact, expose everything that you know about the 737 MAX's MCAS issues and led to their ultimate mitigation.

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