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I have gained such respect for the FAA and the NTSB in that every crash is followed up with a root cause analysis that all other industries should be in awe of.
by mabbo 8y ago
I have gained such respect for the FAA and the NTSB in that every crash is followed up with a root cause analysis that all other industries should be in awe of.
When this is all over, we'll know exactly what went wrong. We'll see the FAA issue guidance or rule changes that will ensure it doesn't happen again. And then we'll somehow see an even further reduction in airline crashes.
I hope that in a few more years, as more companies join the industry, we may see a similar pattern start to evolve in the space launch industry.
- technofiend 8y agoIf you enjoy reading about risk and root cause analysis in general try the venerable Usenet group comp.risks or read the digest web version at http://catless.ncl.ac.uk/risks/ http://catless.ncl.ac.uk/risks/. It's one of those internet sinkholes that can eat hours of your time.
- trikonasana 8y agoCheck out The Design of Everyday Things by Don Norman too. He talks very highly of the NTSB and their accident investigation reports. The root cause isn’t usually one single error, but a series of mistakes that collectively caused the accident.
- monkeypizza 8y agoI love this newsletter but they switched to sending out content wrapped in pre tags with baked-in newlines a few years ago and the value of fighting through wasn't worth it.
- vonseel 8y agoWhy does this matter? Screen readers or something else?
- monkeypizza 8y agoThe newlines are baked into the rss feed too, which breaks my newsreader. I've talked to the maintainer but they didn't want to change the stack they use to produce it.
- deleted 8y ago[deleted]
- meesterdude 8y agoif you're into process safety, the CSB has a number of youtube videos on disasters and their causes https://www.youtube.com/user/USCSB https://www.youtube.com/user/USCSB
- Sir_Cmpwn 8y agoThe space industry already has a long-established tradition of doing similar failure investigations.
- montenegrohugo 8y agoYeah, I really don't get his comment there. Whenever there is a crash, the launch provider usually does not launch RUD is fully investigated. The analysis is equally exhaustive (if not much more so) than in the aero industry.
- garmaine 8y agoThe space industry already does this. In fact sometimes the same people and agencies are involved. It can take years of investigation to return to flight after a serious accident of unknown cause.
- fouc 8y agoI'd be interested in hearing about it applied to totally different industries, particularly software.
- _greim_ 8y agoIncidentally, Amazon does this. Particularly, they've adopted into the culture the concept of "good intentions don't work, mechanisms do." A decent summary can be found at this link: http://nickfoy.com/blog/2018/4/7/good-intentions-dont-work http://nickfoy.com/blog/2018/4/7/good-intentions-dont-work For example, if an admin bungles a copy/paste shell command and it causes an outage, instead of punishing the admin for not wanting hard enough to do it correctly, they'll change the process so it doesn't rely on admins copy/pasting shell commands.
- jmkni 8y agoImagine if we did that with software generally. Every time there's a data breach, an agency would investigate with the same thoroughness they do in aviation. Then, National Geographic could have a spin off show called Data Breach Investigation (their aviation show is called Air Crash Investigation in the UK, I think it's called different things in different Countries.) A man can dream...
- seanmcdirmid 8y agoWe would be limited to 20 pieces of software that were very reliable. The problem with software, which makes it so unlike hardware, is that we can use so much of it, the diversity is huge.
- cryptonector 8y ago> ... software, ... unlike hardware, ... Everything is software now. So much firmware (which is software), and so much hardware that cannot run without software. Your refrigerator, your dishwasher, your car, airliners -- the trend is for everything to be software now.
- nkozyra 8y agoSure, software is everywhere, but the physical properties of hardware are fundamentally different when it comes to QA, risk analysis, general testing.
- cryptonector 8y agoBut when all your hardware has firmware, you've lost that advantage.
- danmaz74 8y agoDepends how complex the firmware is.
- 8y ago
- brians 8y agoNot root cause analysis. Complex systems fail in complex ways. If you want to read more about how this is done, try Normal Accidents (Perrow), Human Error (Reason)... but you're going to land on Engineering a Safer World (Leveson) eventually. You can get a free copy from the author's web site: http://sunnyday.mit.edu/safer-world/index.html http://sunnyday.mit.edu/safer-world/index.html There are tech shops that use these sorts of techniques for every major incident, and for collections of related near-misses. If you want to improve past 4 9s reliability, or if you're considering taking traffic that could wreck a life if it availability or secrecy fail, that only seems appropriate.
- bayindirh 8y agoIf anyone interested in the book, its webpage is moved. New MITPress web page is: https://mitpress.mit.edu/books/engineering-safer-world https://mitpress.mit.edu/books/engineering-safer-world Since the book is open access, the direct link to the book (again from MITPress webpage) is https://www.dropbox.com/s/dwl3782mc6fcjih/8179.pdf?dl=1 https://www.dropbox.com/s/dwl3782mc6fcjih/8179.pdf?dl=1
- deleted 8y ago[deleted]
- poof131 8y agoThe Navy likes to keep things simple and called it the Swiss cheese model.[1] It’s usually never a single factor, but a combination of factors. The holes line up and an accident happens. I think it’s also important to emphasize that getting to this level of safety is so much more cultural than technical. The ability to be open about failure and for people to feel safe in communicating to investigators is critical. The Navy would run two parallel investigations into an incident, one focused on Safety, where anything said was confidential and couldn’t be used in the administrative investigation (FNAEB) that could result in career ending consequences.[2] Though I worry a bit with the constant wars and punishing deployments this culture may be heading in the wrong direction. [3] One of my XOs said, “One generation of Admirals will make their names breaking the Navy, and the next will make their names putting it back together.” I have immense respect for the FAA and NTSB. They are trying to infuse this safety ethos into the fledgling drone industry. No easy task. 1. https://en.wikipedia.org/wiki/Swiss_cheese_model https://en.wikipedia.org/wiki/Swiss_cheese_model 2. https://www.airwarriors.com/community/threads/my-fnaeb-experience-or-how-i-let-my-personal-issues-get-in-the-way.38050/ https://www.airwarriors.com/community/threads/my-fnaeb-exper... 3. https://www.theatlantic.com/technology/archive/2018/10/the-navys-accident-data-is-now-hidden-from-public-view/572461/ https://www.theatlantic.com/technology/archive/2018/10/the-n...
- philipwhiuk 8y agoI wish we did it in auto investigations.
- avar 8y agoThe safety cultures of agencies like the FAA, NTSB and international counterparts such as the EU's EASA is amazing, but not without its downsides. Certification costs have been going up as a portion of overall development costs[1], this leads to more expensive planes, less competition and technological development. There's some amount of safety that's counterproductive, since people will just opt for e.g. driving which is much less safer, but the way these agencies are set up means they can't ever address that question. They're never going to declare a system as unreasonably too safe and expensive. So we really should be careful to wish that aviation safety be applied to other industries. 1. https://aviationweek.com/commercial-aviation/what-certification-tipping-point https://aviationweek.com/commercial-aviation/what-certificat...
- djsumdog 8y agoExcept for TWA 800
- WalterBright 8y agoNote that neither Fukushima nor Deepwater Horizon followed basic aircraft engineering principles: No single point of failure will cause the loss of the airplane.
- magduf 8y agoUm, I thought Fukushima was not caused by any single point of failure either: it was caused by an earthquake and a tsunami happening together (admittedly, the earthquake caused the tsunami). The earthquake caused the reactor to automatically shut down, which would have been fine, except then they got hit with a tsunami that topped their seawall and flooded the basement, shutting down the emergency generator, which disabled the pumps which cooled the reactor.
- WalterBright 8y agoThe earthquake didn't cause any damage. The single point of failure was the seawall being breached. The rest was a zipper of each failure causing the next. The tragedy is this zipper could have been halted at many places. For example, the hydgrogen overpressure in the reactor (caused by previous failures) was vented through an overpressure valve into a pipe. The pipe exited into the enclosed reactor building, which lead to an explosion. The pipe should have been vented to the exterior. The cost of that would have been insignificant, like numerous other zipper-stops. Deepwater Horizon was a big zipper, too, none of which would have been costly to prevent.
- WalterBright 8y agoAlso, the emergency generators should have been put on platforms so they wouldn't flood. Critical machinery should have been located far enough away from the reactor so they could be worked on without fear of radiation. Etc.
- magnamerc 8y agoAs someone working in the aircraft industry, I hope to see this approach with motor vehicles. I think every car should have a 'black box' as well as mandatory dash cams.
- magduf 8y agoStrangely enough, dash cams are actually illegal in many countries (namely the EU).