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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

#62
post #38

Earlier quoted context omitted.

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.”

Strange way to describe the same situation and Zuck's thrust there in different words. Zuck is literally saying "failing together" and "learning together".

It's typically said to everyone at an all-hands meeting or similar, not to a single person.

Delivering such a message personally to an individual is also sending another message.

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

#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.

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

#64

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!”

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

#65

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…

> 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

Assuming that’s accurate, it’s a pretty shitty way to put it. “Hey man, just so you know you should owe me for life (and I pay your salary so I decide that), but instead of demanding your unending servitude, I’m going to be a chill dude and let it slide. I’m still going to point it out so you feel worse than you already do and think about it every time you see me or make even the smallest mistake, though. Take care, see you around”.

It’s the kind of response someone would give after reading the Bob Hoover fuelling incident¹ or the similar Thomas Watson quote² and trying to be as magnanimous in their forgiveness while making it a priority that everyone knows how nice they were (thus completely undermining the gesture).

But it’s just as likely (if not more so) the Zuckerberg event never happened and it’s just someone bungling the Thomas Watson story.

¹ https://www.squawkpoint.com/2014/01/criticism/

² https://blog.4psa.com/quote-day-thomas-john-watson-sr-ibm/

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

#66

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…

Someone get Zuck an above-average-manager award.

But that isn't quite what you want in a blameless culture. The right response looks something like ignoring the engineer, gathering the tech leads and having an extremely detailed walkthrough of exactly what went wrong, how they managed to put an engineer in a position where an expensive outage happened and then they explain why it is never going to happen again. And anyone talks about disciplining the responsible engineer shout at them.

Also maybe check a month later and if anything bad happened to the engineer responsible as a result of the outage, probably sack their manager. That manager is a threat to the corporate culture.

Maybe Zuck did all that too of course. What do I know. But the story emphasises inaction and inaction after a crisis is bad.

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

#67

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!”

Pretty sure the first time I heard that it was about IBM (possibly in the book "Big Blues") - here is a reference to it:

https://www.discerningreaders.com/watson-sr-we-forgive-thoug...

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

#68

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!”

> four million dollars

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

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

#69
post #56
post #27

Earlier quoted context omitted.

We don't count those that are eaten after the crash as they survived the impact and immediate aftermath. More seriously: But for those unlucky enough to be involved in the small percent of fatal air accidents, what are the odds of survival if your plane does crash? The NTSB says that despite more people flying than ever, the accident rate for commercial flights has remained the same for the last two decades, and the…

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.

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

#70
post #18
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…

Thanks for that, I really appreciated this breakdown of the accident at Three Mile Island and the concept of 'the second story' with regards systems thinking; https://www.youtube.com/watch?v=1xQeXOz0Ncs
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