4 ms·
Not 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 (Re
by brians 8y ago
Not 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...
- yesenadam 8y ago>Though I worry a bit with the constant wars and punishing deployments this culture may be heading in the wrong direction. Maybe 'constant wars' is already the wrong direction.
- ACow_Adonis 8y agoI just wanted to reiterate that I've found the Swiss cheese model one of the simplest and most effective communication tools for thinking about and communicating to laypeople how various events happen where they want to attribute 'cause' to a single factor, decision, etc. In my experience it can be doubly difficult to get people to think in this way once culture has got them thinking differently (I despise regression analysis now, because it breeds a layperson culture of both an illusion of understanding, and that individual variables really have individual coefficients that can be simply manipulated). My first introduction to it was watching a documentary on air crash investigation as a child, and I've never forgotten it since. I don't even work in 'safety' per se(currently I do analytical and data work for banks and financial regulation, so one could argue that is a kind of safety), but it just keeps coming up again and again because in the real world, most big human disasters are multi-causal chains, because evolution (in a social sense) will breed out those disasters that are both big in their detriments and simple in their causes.
- neurotech1 8y agoThe JAGMAN investigation is the legal/administrative investigation. The Safety Investigation Board is separate, and privileged. FNAEB investigates the crew, and usually follows a Class A mishap ($2m damage or hull loss, or death/permanent disabling injury) but can be triggered by near-miss or pilot flathatting etc. A friend is a retired Naval aviator, said the #1 reason aviators get permanently grounded from the fleet, is refusal to accept responsibility for mistakes that they were clearly responsible for. Things like forgetting to set the altimeter correctly before takeoff, causing a serious near-miss or pilot deviation. Honestly and fully admitting their mistakes, is more likely to result in a FNAEB returning them to the fleet. Asoh Defense comes to mind.[0] [0] https://en.wikipedia.org/wiki/Japan_Airlines_Flight_2#The_%22Asoh_defense%22 https://en.wikipedia.org/wiki/Japan_Airlines_Flight_2#The_%2...
- hlieberman 8y agoEngineering a Safer World was a truly career changing book for me, and I am so thankful for bts and mstone for introducing it to me.