15 ms·

Why you've never been in a plane crash

325 points by throwup238 3y ago

rob74 3y ago
...by Kyra Dempsey, a.k.a. Admiral Cloudberg, who has a long series of in-depth airplane crash investigation articles on Medium: https://admiralcloudberg.medium.com/ https://admiralcloudberg.medium.com/ This is her Medium article on the LAX runway collision: https://admiralcloudberg.medium.com/cleared-to-collide-the-crash-of-usair-flight-1493-and-skywest-flight-5569-or-the-los-angeles-5d24ab5fec46 https://admiralcloudberg.medium.com/cleared-to-collide-the-c... - with further details that would probably have distracted from the point she's trying to make in the Asterisk article (e.g. that the controller who made the fatal mistake was originally hired after Ronald Reagan fired and banned from rehiring 11,345 air traffic controllers in 1981 - https://en.wikipedia.org/wiki/Professional_Air_Traffic_Controllers_Organization_(1968)#August_1981_strike https://en.wikipedia.org/wiki/Professional_Air_Traffic_Contr...)
- kubanczyk 3y ago
  This is however not her usual writing style as used for the blog.
  - mbork_pl 3y ago
    It is, it's just a slightly more formal variant of it.
- dotancohen 3y ago
  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.
  - rob74 3y ago
    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...
    - brazzy 3y ago
      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.
      - swells34 3y ago
        A different, and likely more productive, way of looking at a possible connection between PATCO firings and USAir 1493 is in the form of institutional knowledge lost. I think a decent argument here is that the mass firing of a large portion of existing ATC personnel damaged the institutional knowledge and rigor of the ATC profession as a whole. What highly technical profession wouldn't be damaged by that? And this damage just increased the risk of serious mishap across the board; it suddenly became much more likely an ATC would make a mistake, and this one is one of those mistakes
- OJFord 3y ago
  And if you like this sort of thing, you might also enjoy the various people that do reconstructions on YouTube - the real audio played over animations/flight sim of what the planes are doing. The most interesting/lively ones are those with a 'possible pilot deviation' or 'number to call' IMO if you want a search term to narrow them down. I'm not a pilot or planespotter or particularly interested in planes generally, I've just fallen down that rabbit hole a couple of times for some reason, can be quite interesting. It has made me wish the in-flight entertainment included a 'listen to pilot/tower comms' option.
  - psunavy03 3y ago
    There's a reason it doesn't. The last thing any pilot or controller would want is to have something sensationalized or misconstrued and then spewed all over social media.
    - mazugrin2 3y ago
      United Airlines used to have this back in the days where your seat had an audio jack and a few channels of music to listen to. Channel 9 was the audio from the cockpit. Nowadays you can listen to ATC from nearly anywhere by visiting https://liveatc.net/ https://liveatc.net/
      - Sohcahtoa82 3y ago
        I've listened to liveatc.net, and then took a flight in an Extra 330LS stunt plane and got to listen to ATC from an actual headset... ...and I can't understand hardly a word they say. Even having a slight idea of the phraseology from countless hours in MSFS and watching VATSIM streams on Twitch, when it comes to the real thing, they talk so fast and there's so much static that it blows my mind that anybody can understand them at all.
        histriosum 3y ago
        Commercial rated pilot here. It's definitely a bit of a learned skill, but it doesn't honestly take that long to learn, and it works better than any other alternative might. The most important thing is for everyone in the system to be willing to speak up if they don't clearly understand what's been said to them. "Say again slower" is a perfectly acceptable response, and is a required one of a pilot or controller who did not understand what was said. Controller cadence is a bit geographical - the busier the airspace the faster the tempo, and the more important it is to speak up. AM simplex radio works amazingly well overall for this purpose, and none of the potential technology that could replace it would be as safe or reliable..
- justusthane 3y ago
  Thank you for pointing that out! I’m a big fan of Admiral Cloudberg, and was in fact even thinking of her while reading this article, but I did not make the connection. She’s such a fantastic writer. Does anyone know how she became so good at writing about airline disasters? She doesn’t seem to have any sort of aviation background.
deleted 3y ago
[deleted]
palad1n 3y ago
This is the first time I've heard of "just culture" and wish it would spread to other areas of the world and life.
- gooddeed 3y ago
  The ability to drop blame from the equation is a credit to the aviation industry and would drastically improve any team, organisation, or industry to adopt it.
  - bertil 3y ago
    When the conference LeadDev happens in London, they often have Nickolas Means give a talk about an aeronautic topic. It’s usually 45 minutes of nail-biting in-depth analysis of a very complicated problem, and ends with a 5 minute rotation to how the lessons from that incident apply to engineering management in general. (You also feel like you could engineer an airplane, but no you can’t: that’s just Nickolas’ talent for explanation that is fooling you. Airplanes are very hard to make.) This is all done in such a smart, seamless, obvious way to deliver a lesson that would make the Brothers Grimm feel cheated. Strongly recommend. https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=4rOPAYoR80M https://www.youtube.com/watch?v=4rOPAYoR80M
  - sokoloff 3y ago
    Exactly. When we have an incident, I want us to be very clear about who did what, what they were thinking that led them to that course of action, and the other facts about the incident. Knowing which individual took which action and when is very, very different from holding an individual responsible (in terms of suffering repercussions) from it. If team members trust they won't suffer from it, you get much clearer data, often without even asking for it. Related, I recommend that teams subject to SOX-404 controls consider adopting a variant of FAR 91.3*. Our SOX docs explicitly permit our incident managers (and two additional high-level tech employee roles) to authorize any action they deem justified during a production emergency. * - https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F/part-91/subpart-A/section-91.3 https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F...
isolli 3y ago
"Cutting straight to the case, Wascher was not punished in any way." Have to appreciate a writer who doesn't force you to read until the very end of their piece in order to get the ending of the story.
- karmakaze 3y ago
  This is where I stopped reading the story. I couldn't tell that we were getting to the point of answering the titled question. I'm guessing it's the blameless culture/process that keeps information flowing and improvements made. 'Blameless' doesn't work for corporations though.
- charles_f 3y ago
  Yes I think it even flows better to know that and then focus on discovering why.
moring 3y ago
Related: CAST analysis http://sunnyday.mit.edu/CAST-Handbook.pdf 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't be reading this if you were :)
- Vecr 3y ago
  Yeah, probably, and the counterfactual where airlines were worse at preventing crashes would probably have worse crash survival rates as well. Maybe planes bumping into each other at very low speeds on the ground would skew the stats in that case, but you know what I mean by "plane crash".
- ptaipale 3y ago
  In fact about 90 % of plane crashes are survivable and people read about their own accidenyäts.
  - bryanrasmussen 3y ago
    ok but 90% of plane crashes are survivable is not the same as 90% of people in plane crashes survive them. According to this https://etsc.eu/increasing-the-survival-rate-in-aircraft-accidents-impact-protection-fire-survivability-and-evacuation/ https://etsc.eu/increasing-the-survival-rate-in-aircraft-acc... >In round and, of course, fluctuating figures it is estimated that of the 1500 who die each year in air transport accidents some 900 die in non-survivable accidents. The other 600 die in accidents which are technically survivable and crashworthiness, fire and evacuation issues are all important. Of these 600 perhaps 330 die as a direct result of the impact and 270 due to the effects of smoke, toxic fumes, heat and resulting evacuation problems. on edit: also this https://www.psbr.law/aviation_accident_statistics.html https://www.psbr.law/aviation_accident_statistics.html
- jasonkester 3y ago
  I don't know... I once met a guy who had survived two of them: https://news.ycombinator.com/item?id=7370320 https://news.ycombinator.com/item?id=7370320
aramndrt 3y ago
Reminds me of the guy at GitLab, I believe it was, who accidentally and irreversibly deleted a bunch of repositories. GitLab had a fantastic approach to that whole ordeal and public embarrassment. They essentially blamed themselves for not having the proper contingencies in place instead of blaming the individual. It's worth reading up on.
- sajforbes 3y ago
  Also reminds me of the Reddit thread [0] where someone accidentally used write access credentials that were on an onboarding document and wiped the production database. GitLab guy actually joined the conversation. [0]: https://www.reddit.com/6ez8ag/ https://www.reddit.com/6ez8ag/
- mbork_pl 3y ago
  Any source would be appreciated, I'd like to read more about it.
  - lfkdev 3y ago
    https://www.youtube.com/watch?v=tLdRBsuvVKc https://www.youtube.com/watch?v=tLdRBsuvVKc
  - latexr 3y ago
    https://about.gitlab.com/blog/2017/02/01/gitlab-dot-com-database-incident/ https://about.gitlab.com/blog/2017/02/01/gitlab-dot-com-data... From that link you should also be able to find conversations on Hacker News and the like. It was talked in a lot of places at the time. If I’m remembering correctly (take this paragraph as imperfect memory), at the time a lot of people on the outside were looking to assign blame but the team tweeted something to the effect of “yes, we know who did it, and no, they won’t be fired” and didn’t even reveal who it was. Then they live-streamed the process of trying to recover as much as they could. They got a ton of community encouragement and it was widely viewed as the right way to handle things.
- xtracto 3y ago
  It happened to me and my team like 10 years ago or so: An engineer deleted the production database. We were able to recover it. But the postmortem basically focused on why the he heck did we let that happen. The guy stayed in the company for 8 years more IIRC. We fixed our systemic issue as well. I've read about blameless postmortems from Medical professionals and I always tell my teams: if those guys (doctors) can do blameless PMs after someone has died, we can do them.
ssl232 3y ago
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 how something could go wrong despite no one getting hurt, giving organisations a chance to improve their processes. If a workplace accident does occur, the Health and Safety Executive (who enforce the act in large organisations) can levy enormous fines for preventable accidents especially where there is evidence of a near miss beforehand.
- bertil 3y ago
  Very true. In general, I think that piece has a bit of a European blind side when starting by “The United States leads the world in airline safety.”
  - deleted 3y ago
    [deleted]
- josephg 3y ago
  With the number of data breaches we see cropping up, I wonder if a similar law could be written to hold companies liable for the safe handling of personal data.
  - izacus 3y ago
    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.
    - mnau 3y ago
      How do you define "minimum safety, correctness and quality standard"?
nsoonhui 3y ago
>> Why you have never been in a plane crash? Because those who are in a plan crash are mostly dead?
- defrost 3y ago
  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 survivability rate is a high 95.7 percent. -- The European Transport Safety Council (ETSC) has also examined the survivability of aircraft accidents worldwide, estimating that 90 percent are survivable (no passengers died) or “technically survivable," where at least one occupant survives. Most of those fatalities were a result of impact and fire-related factors including smoke inhalation after impact. ~ https://abcnews.go.com/International/odds-surviving-plane-crash/story?id=22886654 https://abcnews.go.com/International/odds-surviving-plane-cr...
  - mrjin 3y ago
    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.
    - defrost 3y ago
      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.
      - ourmandave 3y ago
        Unless you live in the Final Destination universe. Where the death-by-implausible-circumstances clock starts ticking.
bArray 3y ago
> The United States leads the world in airline safety. That’s because of the way we assign blame when accidents do happen. The communists were great at assigning blame, just usually not to the right person. If I remember correctly during the VW emissions scandal [1] they tried to pin it all on one engineer. The UK Post Office similarly tried to blame Fujitsu for a systemic failure [2]. > In the aftermath of a disaster, our immediate reaction is often to search for some person to blame. Authorities frequently vow to “find those responsible” and “hold them to account,” as though disasters happen only when some grinning mischief-maker slams a big red button labeled “press for catastrophe.” With Health and Safety (H&S) in the UK, every person is each themselves responsible for raising concerns as they see them. If something were to happen in our work place for example, I think questions would rightfully be asked of all employees 'if you saw it and agree it was dangerous, why didn't you say anything?'. To foster this all you need is a work culture that accepts criticism and is open to discussion about it. > 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. It's all good and well, but the blame is then just assigned to a system with no real accountability - any accident can be explained away with tighter control measures. I remember a story about nuclear lab technicians taking photos of radioactive materials and almost causing a serious incident. I couldn't find an article on it, but it happens regularly enough at nuclear facilities [3]. You can't use a system to entirely automate your way out of negligence. If you hire people that have no drive to improve their work place, you will inevitably have issues. Just a few days ago I was at a theme park type event and noticed that a structure that was fully on the ground (easily accessible) had been allowed to rust. Most paints for this use have a 10 year rating, but the employees were young and had no interest in the future of this place. An accident will at some point occur and some rules will be changed, but the company itself will continue to hire people with no incentive for the company's future. [1] https://en.wikipedia.org/wiki/Volkswagen_emissions_scandal https://en.wikipedia.org/wiki/Volkswagen_emissions_scandal [2] https://en.wikipedia.org/wiki/British_Post_Office_scandal https://en.wikipedia.org/wiki/British_Post_Office_scandal [3] https://www.science.org/content/article/safety-problems-los-alamos-laboratory-delay-us-nuclear-warhead-testing-and-production https://www.science.org/content/article/safety-problems-los-...
scosman 3y ago
Survivorship bias?
- bmacho 3y ago
  Anthropic principle or observation selection effect [0]. If you are observing something, then you are in a position that you can observe it. [0] : https://en.wikipedia.org/wiki/Anthropic_principle https://en.wikipedia.org/wiki/Anthropic_principle
- throw1234651234 3y ago
  Title is iffy. Tantamount to writing "Why you have never died."
throwaway713 3y ago
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 take a lifetime or more to recoup the revenue lost during that outage. But we don’t assign blame during these sorts of events, so let’s just consider it an expensive learning opportunity to redesign the system so it can’t happen again.”
- mulmen 3y ago
  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.”
  - bheadmaster 3y ago
    > Singling out the engineer isn't blameless. Considering that everyone already knew who was responsible, I think saying "you won't be held accountable for this mistake" is the most blameless thing you can do. > 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. The way I read the comment, it sounds to me exactly like what Zuckerberg said.
    - jacquesm 3y ago
      Not really. If you single someone out as CEO that's a punishment. Even if your words are superficially nice what he really did was blame the engineer and told him not to do it again. He should have left it with the engineer's line manager to make that comment, if at all because essentially he's telling the employee nothing that he didn't know already. You did something well, but we made mistakes.
cgio 3y ago
Because I am reading this?
- jagged-chisel 3y ago
  No, I don’t think reading this (now) has prevented you being in a plane crash (in the past.)
dbrgn 3y ago
Just this month, there was a court case in Switzerland where an ATC was charged and convicted because he gave wrong instructions to a military jet, which then crashed into a rock wall. The case was quite interesting to follow, due to the various implications of a conviction or acquittal. It had quite some media coverage. https://www.swissinfo.ch/eng/swiss-military-jet-crash--public-prosecutor-seeks-suspended-prison-sentences/49100956 https://www.swissinfo.ch/eng/swiss-military-jet-crash--publi... https://www.swissinfo.ch/eng/air-traffic-controller-blamed-for-fatal-military-crash/49112604 https://www.swissinfo.ch/eng/air-traffic-controller-blamed-f... (Note that this was a military court, not a civil court. Proceedings might be different in these cases, even though both civil and military ATCs work for the same company - Skyguide.)
siva7 3y ago
>> 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.
- 010101010101 3y ago
  I don’t think that’s what’s implied here at all - the focus on blamelessness is to get to the root cause of failure and prevent future occurrences rather than to punish existing failures without affecting any actual change.
- sgjohnson 3y ago
  > 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.
- brazzy 3y ago
  No, accountability is a very insufficient answer, because it helps very little in identifying and fixing broken systems. In a lot of cases, this one being a particularly good example, nobody was particularly incompetent, negligent, malicious, or greedy. But the system as a whole lacked safeguards so that a single person's inconspicous mistake could cause a disaster, and overloaded that person's attention. Sure, there's other cases where you can clearly identify negligence, malice, or greed of specific people as causes of the disaster. But there as well, holding those people accountable doesn't fix the system than incentivised the greed, doesn't prevent incompetent, malicious or negligent people from getting into positions where actions based on those traits cause disasters, and doesn't provide safeguards against such actions. The deterrence value of holding individuals accountable for extremely rare events is approximately zero.
- rob74 3y ago
  The thing with the two MCAS accidents is that you don't have too few people to blame, but too many: - the airlines who wanted a more fuel-efficient plane that should still have the same type certificate as the (at that time) 40+ year old Boeing 737 - Boeing management, who wanted to keep those airlines as customers - Boeing engineering, who did what they did at the management's request - the FAA, who failed to spot the issue - the mechanics of the involved airlines, who dispatched the planes without working angle-of-attack sensors - the airlines who ordered planes without the (optional) "angle-of-attack disagree" alert - the pilots (just for the sake of completeness), who failed to notice the issue and either refuse to fly the plane or correct it in time to avoid the crash Who do you want to single out here?
phkahler 3y ago
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.
- sgjohnson 3y ago
  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.
  - petesergeant 3y ago
    > in reality it was the entire industry Do you have further reading on this? First time I’ve seen someone suggest that Airbus has similar structural issues to Boeing when it comes to safety
    - sgjohnson 3y ago
      I didn’t suggest that Airbus has similar issues. What I meant by the “entire industry” also includes the airlines. I suggested that had nothing changed, it might have been Airbus that was low-key blackmailed into making a new plane that’s of the same type, with similar issues that would become evident only after a couple of crashes. The very root cause of the issue was that Boeing was simply allowed to say “trust me bro, this is just a 737, it’s like any other 737, no retraining of any kind needed”, when, in fact, it wasn’t just the same old 737. Now this can’t happen anymore.
  - cainxinth 3y ago
    > 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.
hayst4ck 3y ago
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-leadership-paradox/ https://www.ans.org/news/article-1592/caught-in-the-leadersh... https://govleaders.org/rickover.htm 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.
- class3shock 3y ago
  Rickover is an intriguing figure to read about in general. I've heard different versions of his "rules", one set located here: https://www.linkedin.com/posts/kelly-robinson-phd-92842b6_rickover-created-a-culture-of-operational-activity-7080868879614308352-cQQ9/?trk=public_profile_like_view https://www.linkedin.com/posts/kelly-robinson-phd-92842b6_ri... Another I'll include at the bottom of this post. I also just wanted to highlight two things. Not only did he create a highly safety conscious organization but an incredibly technologically innovative one that was born despite huge resistance from the US Navy. Think about trying not only to build a small nuclear reactor, something that had never been done before, but one that could be put on a submarine. Not an easy technical goal. And on top of that, aiming to complete this task in the face of resistance from the highest levels of the organization he made his life, including efforts to get rid of him entirely. He wasn't perfect but what he achieved quite alot. Definitely worth reading more up on particularly if you work more in the mechanical engineering world. Second set of Rickover Rules: Rule 1: You must have a rising standard of quality over time, and well beyond what is required by any minimum standard. Rule 2: People running complex systems should be highly capable. Rule 3: Supervisors have to face bad news when it comes and take problems to a level high enough to fix those problems. Rule 4: You must have a healthy respect for the dangers and risks of your particular job. Rule 5: Training must be constant and rigorous. Rule 6: All the functions of repair, quality control, and technical support must fit together. Rule 7: The organization and members thereof must have the ability and willingness to learn from mistakes of the past.
arethuza 3y ago
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.
- sgjohnson 3y ago
  I can also recommend Green Dot Aviation and Mentour Pilot
petesergeant 3y ago
Feel like this boils down to “if an average person can make an average mistake and people die, the system is culpable”
bradfa 3y ago
Why don't we as a society apply similar safety culture to driving cars and trucks as we do to aviation? MANY more people are harmed or killed by automobiles than by aircraft per person-mile traveled. A small improvement in automobile safety could make a large impact on society. Many of the types of improvements implemented by aviation mentioned in this article, when applied to the automotive world, would look like improvements or changes to road design. Obviously, if you're a pilot and flying drunk who harms others or a driver who drives drunk and harms others, YOU are clearly to blame. But for the other kinds of crashes, it feels like the automotive world learning from aviation would have a lot of value.
- SoftTalker 3y ago
  Well we do. That's why automobiles have seatbelts and airbags, rear-view cameras, antilock brakes, traction control, and have to pass crash safety tests.
  - bradfa 3y ago
    Sure but we still have tens of thousands of traffic fatalities every year in the USA and the stats are not decreasing in any meaningful way. What we have done is not working to actually reduce automobile deaths.
- r_klancer 3y ago
  Strong Towns is attempting to change that with the "Crash Analysis Studio": https://www.strongtowns.org/crash-studio https://www.strongtowns.org/crash-studio I can think of many reasons it's difficult, though: * The fact that accident investigations are designed to figure out which driver was at fault, for insurance purposes * The fact that road designers are shielded from liability (good, right?), but only if they can show they followed the standard design handbooks, which not only fail to prioritize safety over traffic flow but also don't require or even contemplate performing a thorough case-by-case investigation into how to prevent a certain type of accident from happening again. (Crash Analysis Studio tries to demonstrate how to do this.) * The sheer scale of the changes to roads that would be needed. In the States, access of hundreds of thousands of businesses and probably millions of homes depend on roads that are supposed to get people from A to B fast but also have lots of access points for businesses on them, which is like just like mixing taxiing and holding with takeoff and landing, but without the air traffic controllers. And don't get me started about unprotected lefts across multiple lanes of traffic. * The lack of buy-in from the citizenry for enforcing professional-like standards on drivers. Despite the blameless culture that helps identify flaws in the system, air traffic controllers, pilots, maintenance crews, train engineers, etc also know that their job depends on making a sincere effort to follow the rules that are written, and in most cases their professional identity is tied up with following the rules. (I've heard that to be a pilot you really have to be comfortable with doing what you're told, all day long.) There's really no obvious way to get the masses of drivers to think and feel that way about their driving, and of course we can't just sanction our way to compliance because people need their licenses to go about their lives. And of course usually there is no reasonably alternative to driving yourself where you need to go.
deleted 3y ago
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braunjohnson 3y ago
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jroseattle 3y ago
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.
xyzelement 3y ago
Something that appealed to me during my years at Bridgewater is the willingness to attribute failure to individuals without making those individuals suffer. In "blameless" there's no personalities mentioned at all but in reality personality and individuals matter. EG if we had an outage because I put code into production w/o review, yes it's a systemic failure but it's also something about me, something about my manager, etc. By talking about those things as well, you make it easier for both the system and the individuals to evolve.
- 16bytes 3y ago
  The issue with attributing failure, no matter how little suffering there is, is that it provides a huge incentive to not self report and/or downplay incidents. Unless you are acting with malice, your actions are a product of the system and procedures in place. Those should be the focus of improvement, not individuals. E.g. preventing prod pushes that contain unreviewed code. Of course we need to talk about individuals, but that's performance management and not incident management.
- filleduchaos 3y ago
  It's interesting how people carry their preconceived notions into articles like this, especially when those articles are about entirely different industries and/or contexts than they're used to. For example, reading any NTSB report would make it quite clear that the actions of specific individuals - from pilots to controllers to maintenance techs and more - are very much mentioned and dissected under the "blameless" style of investigation that international aviation adheres to. But people already have their own ideas of what "blameless" means that inevitably colours their reading - in some cases, colours it so strongly that not even the evidence of success is enough to budge the conclusion that there must be something wrong with the way "blameless" culture is implemented.
gadders 3y ago
I think it's a fairly safe assumption that if you are alive to read the article, you are unlikely to have been in a plane crash (yes, I agree some plane crashes are survivable). Next article: Why you've never been struck by lightning.
- charles_f 3y ago
  It sounds like you didn't read the post. It's not an assumption, it's the explanation of why.
  - gadders 3y ago
    No, but I read the clickbait title.
    - add-sub-mul-div 3y ago
      This is far more insufferable than clickbait titles.
jonnycat 3y ago
This should be required reading for every software engineering team (and the business & product teams they interact with).
fortran77 3y ago
But I have been in a plane crash! An overshoot of the runway at Burbank airport that narrowly missed hitting a gas station. https://en.wikipedia.org/wiki/Southwest_Airlines_Flight_1455 https://en.wikipedia.org/wiki/Southwest_Airlines_Flight_1455
- ibcj 3y ago
  Wow, I remember this! Glad you were a-ok. Would love to hear more about your story and your method of egress from that bird. For those that don't know, LAS to BUR is the best way to get from LA to Vegas (save private) and always has been. I've been on that Sunday afternoon flight from LAS->BUR many times; with the afternoon flight informally known as the Hangover Express and the morning flight known as the Stripper Express. Good times. And FWIW, I still prefer FORTRAN over Perl any day...
  - fortran77 3y ago
    The slide inflated inside the airplane! Rescue workers laddered uninjured passengers out. I signed an NDA to get my modest settlement. I still fly Southwest. The pilots were fired.
leesec 3y ago
Except my sister and her husband died in a plane crash 2 years ago. A lot of these ultra cautious safety requirements apply a lot more to bigger commercial airlines and less to small private chartered planes.
- leetrout 3y ago
  Sorry for your loss. I hope something was learned by others so it will not happen again.
  - leesec 3y ago
    Thanks, unfortunately it was primarily pilot error so I doubt it. The pilot also passed
    - hanche 3y ago
      Pilot errors also have underlying causes. Was the pilot properly trained for the particular situation that arose? How is the safety culture of the airline? Did some aspect of the airplane design make that mistake more likely, or hinder the possibility of recovery? Was the pilot tired or not well and should not be flying in the first place? There’s a thousand questions like that which can and should be asked in a proper investigation. Hopefully, they were. (I have been binge reading my way through Admiral Cloudberg’s blog on medium lately. Perhaps not to be recommended for you, as reading about a hundred fatal plane crashes may be too emotionally painful.)
genericuser125 3y ago
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tim333 3y ago
We need something like that to deal with the danger of genetically modified viruses causing pandemics. Covid may or may not have leaked from a lab in Wuhan but the investigation has been kind of shockingly bad with scientists in charge calling anyone suggesting that conspiracy theorists while privately saying a lab leak was "so friggin likely." Just recently is was reported that Chinese scientists were experimenting with a new Covid-like virus where every rodent that was infected with the pathogen died within eight days, which the researchers described as 'surprisingly' quick. This time it's a Pangolin virus rather than a bat one though still on humanised mice. I think a rule that anyone doing such research would have to get say $100bn liability insurance first might make them more cautious. Covid cost $12.5 trillion + according to the IMF and with deaths ~100x all aviation accidents in history. (Pangolin virus https://www.firstpost.com/world/china-experimenting-with-100-per-cent-deadly-new-covid-strain-report-13616272.html https://www.firstpost.com/world/china-experimenting-with-100...)
nayuki 3y ago
Great article. I agree a lot with the safety culture in commercial aviation and the commitment to investigate and fix root causes. Now can we please apply the same standards to car crashes? The same human errors and bad infrastructure keep getting repeated over and over again. And the problems are getting worse, with SUVs and distracted driving on the rise. See https://www.reddit.com/r/fuckcars/ https://www.reddit.com/r/fuckcars/ for a community that is sounding the alarm on the insidiousness of car culture. Or see these reasonable urbanists if you think FuckCars is too extreme: https://www.youtube.com/@OhTheUrbanity/videos https://www.youtube.com/@OhTheUrbanity/videos , https://www.youtube.com/@NotJustBikes/videos https://www.youtube.com/@NotJustBikes/videos , https://www.youtube.com/@CityNerd/videos https://www.youtube.com/@CityNerd/videos
- rpmisms 3y ago
  r/fuckcars has members who deflate and slash car tires that belong to vehicles they deem "too big". Do you support that methodology?
  - Orangeair 3y ago
    I've seen hundreds of posts on that sub, but never anything approaching what you're describing. Do you have an example?
    - rpmisms 3y ago
      https://www.reddit.com/r/fuckcars/comments/xr64d8/deflating_suvs_tires_is_poor_behavior/ https://www.reddit.com/r/fuckcars/comments/xr64d8/deflating_... https://www.reddit.com/r/fuckcars/comments/xo6uqu/my_option_on_tyre_deflators/ https://www.reddit.com/r/fuckcars/comments/xo6uqu/my_option_... Cursory search turned these up.
      - Orangeair 3y ago
        I don't necessarily know that you can conclude from a few memes that people are actually out there doing this, I see it more as venting frustration. They're certainly advocating for it, though.
mceachen 3y ago
I had the privilege to work at a company that _actually_ had "blameless postmortems." That phrase is easy to say, but when you're on-call and get woken up at 3 in the morning to deal with someone else's mess, let's just say "blameless" isn't _my_ first reaction. However--getting to the root of the issue, allowing everyone involved come up with solutions, and continuously improving the runbook is clearly the best way forward. Sure, it's reactionary, but proactive guidance is never going to be as imaginative in breaking things as production traffic.
- tetha 3y ago
  In a team of individuals, the term isn't necessarily "blameless". I'd never hold a weird or accidental outage against you personally. The major question would be: Why did that happen? However, you're forever going to be the fucking guy causing a database outage on Christmas. You might have had no choice, but fuck you. All of us have these scars. But then the question is: Why do we all have these scars? Maybe the system we're dealing with is not as great as it should be? Maybe the localized amount of anger is just a thing leading towards a more systematic problem. Oops, back into the ideas of blameless post-mortems.
kitsune_ 3y ago
Over 20 years ago, at my first job, a co-worker told me that the evening before, he got a phone call from their best friend who phoned him in shock and told him they just survived a plane crash: https://en.wikipedia.org/wiki/Crossair_Flight_3597 https://en.wikipedia.org/wiki/Crossair_Flight_3597
ongytenes 3y ago
Crashed once in Nassau when I was a kid. Brakes failed on the left side on a Beechcraft Model 18, spun the plane around on touchdown. Slid sideways down the runway, broke the landing gear then rolled breaking the left wing. Everyone splashed through fuel walking away. There was no fire. A year later I almost crashed in St Thomas in another Model 18. That was pilot error. Carburetor heat was on and we took all the runway trying to get off the ground. We took off towards the ocean and flew a long way so close to the water that we were sucking water up and spraying the plane. I was blissfully unaware as a kid. Thought the pilot was playing around.
MarcoZavala 3y ago
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poundofshrimp 3y ago
When I first started to program professionally, I was fascinated with the blameless postmortem culture that my ex-employer had. I thought (and still do) it is incredibly conducive to systemic improvement. I’m happy it is legally codified in the aviation industry.
berniedurfee 3y ago
Mentour Pilot on YouTube, fabulous channel BTW, talks about the Swiss Cheese Model. I’ve started to use this model when talking about software testing. Unit tests, integration tests, functional tests, UAT, etc are all layers that help prevent defects from reaching production. Those testing layers are deliberately redundant. When we do a postmortem on a defect, it often turns out there was only one layer of testing between the defect and production and the incident would have been less likely to occur with multiple layers in place. https://en.m.wikipedia.org/wiki/Swiss_cheese_model https://en.m.wikipedia.org/wiki/Swiss_cheese_model
averageRoyalty 3y ago
How does the United States "lead the world in air safety" with only one of their airlines (and not one of the major ones) even making the top 10 from a US source[1]? Looking back over the years, the US has never hit this metric. Have I misunderstood how it's being calculated? 1. https://www.forbes.com/sites/laurabegleybloom/2024/01/03/ranked-the-25-safest-airlines-in-the-world-according-to-airlineratingscom/ https://www.forbes.com/sites/laurabegleybloom/2024/01/03/ran...

325 points by throwup238 3y ago

...by Kyra Dempsey, a.k.a. Admiral Cloudberg, who has a long series of in-depth airplane crash investigation articles on Medium: https://admiralcloudberg.medium.com/ https://admiralcloudberg.medium.com/ This is her Medium article on the LAX runway collision: https://admiralcloudberg.medium.com/cleared-to-collide-the-crash-of-usair-flight-1493-and-skywest-flight-5569-or-the-los-angeles-5d24ab5fec46 https://admiralcloudberg.medium.com/cleared-to-collide-the-c... - with further details that would probably have distracted from the point she's trying to make in the Asterisk article (e.g. that the controller who made the fatal mistake was originally hired after Ronald Reagan fired and banned from rehiring 11,345 air traffic controllers in 1981 - https://en.wikipedia.org/wiki/Professional_Air_Traffic_Controllers_Organization_(1968)#August_1981_strike https://en.wikipedia.org/wiki/Professional_Air_Traffic_Contr...)

kubanczyk 3y ago
This is however not her usual writing style as used for the blog.
- mbork_pl 3y ago
  It is, it's just a slightly more formal variant of it.
dotancohen 3y ago
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.
- rob74 3y ago
  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...
  - brazzy 3y ago
    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.
    - swells34 3y ago
      A different, and likely more productive, way of looking at a possible connection between PATCO firings and USAir 1493 is in the form of institutional knowledge lost. I think a decent argument here is that the mass firing of a large portion of existing ATC personnel damaged the institutional knowledge and rigor of the ATC profession as a whole. What highly technical profession wouldn't be damaged by that? And this damage just increased the risk of serious mishap across the board; it suddenly became much more likely an ATC would make a mistake, and this one is one of those mistakes
OJFord 3y ago
And if you like this sort of thing, you might also enjoy the various people that do reconstructions on YouTube - the real audio played over animations/flight sim of what the planes are doing. The most interesting/lively ones are those with a 'possible pilot deviation' or 'number to call' IMO if you want a search term to narrow them down. I'm not a pilot or planespotter or particularly interested in planes generally, I've just fallen down that rabbit hole a couple of times for some reason, can be quite interesting. It has made me wish the in-flight entertainment included a 'listen to pilot/tower comms' option.
- psunavy03 3y ago
  There's a reason it doesn't. The last thing any pilot or controller would want is to have something sensationalized or misconstrued and then spewed all over social media.
  - mazugrin2 3y ago
    United Airlines used to have this back in the days where your seat had an audio jack and a few channels of music to listen to. Channel 9 was the audio from the cockpit. Nowadays you can listen to ATC from nearly anywhere by visiting https://liveatc.net/ https://liveatc.net/
    - Sohcahtoa82 3y ago
      I've listened to liveatc.net, and then took a flight in an Extra 330LS stunt plane and got to listen to ATC from an actual headset... ...and I can't understand hardly a word they say. Even having a slight idea of the phraseology from countless hours in MSFS and watching VATSIM streams on Twitch, when it comes to the real thing, they talk so fast and there's so much static that it blows my mind that anybody can understand them at all.
      - histriosum 3y ago
        Commercial rated pilot here. It's definitely a bit of a learned skill, but it doesn't honestly take that long to learn, and it works better than any other alternative might. The most important thing is for everyone in the system to be willing to speak up if they don't clearly understand what's been said to them. "Say again slower" is a perfectly acceptable response, and is a required one of a pilot or controller who did not understand what was said. Controller cadence is a bit geographical - the busier the airspace the faster the tempo, and the more important it is to speak up. AM simplex radio works amazingly well overall for this purpose, and none of the potential technology that could replace it would be as safe or reliable..
justusthane 3y ago
Thank you for pointing that out! I’m a big fan of Admiral Cloudberg, and was in fact even thinking of her while reading this article, but I did not make the connection. She’s such a fantastic writer. Does anyone know how she became so good at writing about airline disasters? She doesn’t seem to have any sort of aviation background.

deleted 3y ago

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palad1n 3y ago

This is the first time I've heard of "just culture" and wish it would spread to other areas of the world and life.

gooddeed 3y ago
The ability to drop blame from the equation is a credit to the aviation industry and would drastically improve any team, organisation, or industry to adopt it.
- bertil 3y ago
  When the conference LeadDev happens in London, they often have Nickolas Means give a talk about an aeronautic topic. It’s usually 45 minutes of nail-biting in-depth analysis of a very complicated problem, and ends with a 5 minute rotation to how the lessons from that incident apply to engineering management in general. (You also feel like you could engineer an airplane, but no you can’t: that’s just Nickolas’ talent for explanation that is fooling you. Airplanes are very hard to make.) This is all done in such a smart, seamless, obvious way to deliver a lesson that would make the Brothers Grimm feel cheated. Strongly recommend. https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=2sIzfGzf_50 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=099cHWSbAL8 https://www.youtube.com/watch?v=4rOPAYoR80M https://www.youtube.com/watch?v=4rOPAYoR80M
- sokoloff 3y ago
  Exactly. When we have an incident, I want us to be very clear about who did what, what they were thinking that led them to that course of action, and the other facts about the incident. Knowing which individual took which action and when is very, very different from holding an individual responsible (in terms of suffering repercussions) from it. If team members trust they won't suffer from it, you get much clearer data, often without even asking for it. Related, I recommend that teams subject to SOX-404 controls consider adopting a variant of FAR 91.3*. Our SOX docs explicitly permit our incident managers (and two additional high-level tech employee roles) to authorize any action they deem justified during a production emergency. * - https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F/part-91/subpart-A/section-91.3 https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F...

isolli 3y ago

"Cutting straight to the case, Wascher was not punished in any way." Have to appreciate a writer who doesn't force you to read until the very end of their piece in order to get the ending of the story.

karmakaze 3y ago
This is where I stopped reading the story. I couldn't tell that we were getting to the point of answering the titled question. I'm guessing it's the blameless culture/process that keeps information flowing and improvements made. 'Blameless' doesn't work for corporations though.
charles_f 3y ago
Yes I think it even flows better to know that and then focus on discovering why.

moring 3y ago

Related: CAST analysis http://sunnyday.mit.edu/CAST-Handbook.pdf 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't be reading this if you were :)

Vecr 3y ago
Yeah, probably, and the counterfactual where airlines were worse at preventing crashes would probably have worse crash survival rates as well. Maybe planes bumping into each other at very low speeds on the ground would skew the stats in that case, but you know what I mean by "plane crash".
ptaipale 3y ago
In fact about 90 % of plane crashes are survivable and people read about their own accidenyäts.
- bryanrasmussen 3y ago
  ok but 90% of plane crashes are survivable is not the same as 90% of people in plane crashes survive them. According to this https://etsc.eu/increasing-the-survival-rate-in-aircraft-accidents-impact-protection-fire-survivability-and-evacuation/ https://etsc.eu/increasing-the-survival-rate-in-aircraft-acc... >In round and, of course, fluctuating figures it is estimated that of the 1500 who die each year in air transport accidents some 900 die in non-survivable accidents. The other 600 die in accidents which are technically survivable and crashworthiness, fire and evacuation issues are all important. Of these 600 perhaps 330 die as a direct result of the impact and 270 due to the effects of smoke, toxic fumes, heat and resulting evacuation problems. on edit: also this https://www.psbr.law/aviation_accident_statistics.html https://www.psbr.law/aviation_accident_statistics.html
jasonkester 3y ago
I don't know... I once met a guy who had survived two of them: https://news.ycombinator.com/item?id=7370320 https://news.ycombinator.com/item?id=7370320

aramndrt 3y ago

Reminds me of the guy at GitLab, I believe it was, who accidentally and irreversibly deleted a bunch of repositories. GitLab had a fantastic approach to that whole ordeal and public embarrassment. They essentially blamed themselves for not having the proper contingencies in place instead of blaming the individual. It's worth reading up on.

sajforbes 3y ago
Also reminds me of the Reddit thread [0] where someone accidentally used write access credentials that were on an onboarding document and wiped the production database. GitLab guy actually joined the conversation. [0]: https://www.reddit.com/6ez8ag/ https://www.reddit.com/6ez8ag/
mbork_pl 3y ago
Any source would be appreciated, I'd like to read more about it.
- lfkdev 3y ago
  https://www.youtube.com/watch?v=tLdRBsuvVKc https://www.youtube.com/watch?v=tLdRBsuvVKc
- latexr 3y ago
  https://about.gitlab.com/blog/2017/02/01/gitlab-dot-com-database-incident/ https://about.gitlab.com/blog/2017/02/01/gitlab-dot-com-data... From that link you should also be able to find conversations on Hacker News and the like. It was talked in a lot of places at the time. If I’m remembering correctly (take this paragraph as imperfect memory), at the time a lot of people on the outside were looking to assign blame but the team tweeted something to the effect of “yes, we know who did it, and no, they won’t be fired” and didn’t even reveal who it was. Then they live-streamed the process of trying to recover as much as they could. They got a ton of community encouragement and it was widely viewed as the right way to handle things.
xtracto 3y ago
It happened to me and my team like 10 years ago or so: An engineer deleted the production database. We were able to recover it. But the postmortem basically focused on why the he heck did we let that happen. The guy stayed in the company for 8 years more IIRC. We fixed our systemic issue as well. I've read about blameless postmortems from Medical professionals and I always tell my teams: if those guys (doctors) can do blameless PMs after someone has died, we can do them.

ssl232 3y ago

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 how something could go wrong despite no one getting hurt, giving organisations a chance to improve their processes. If a workplace accident does occur, the Health and Safety Executive (who enforce the act in large organisations) can levy enormous fines for preventable accidents especially where there is evidence of a near miss beforehand.

bertil 3y ago
Very true. In general, I think that piece has a bit of a European blind side when starting by “The United States leads the world in airline safety.”
- deleted 3y ago
  [deleted]
josephg 3y ago
With the number of data breaches we see cropping up, I wonder if a similar law could be written to hold companies liable for the safe handling of personal data.
- izacus 3y ago
  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.
  - mnau 3y ago
    How do you define "minimum safety, correctness and quality standard"?

nsoonhui 3y ago

>> Why you have never been in a plane crash? Because those who are in a plan crash are mostly dead?

defrost 3y ago
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 survivability rate is a high 95.7 percent. -- The European Transport Safety Council (ETSC) has also examined the survivability of aircraft accidents worldwide, estimating that 90 percent are survivable (no passengers died) or “technically survivable," where at least one occupant survives. Most of those fatalities were a result of impact and fire-related factors including smoke inhalation after impact. ~ https://abcnews.go.com/International/odds-surviving-plane-crash/story?id=22886654 https://abcnews.go.com/International/odds-surviving-plane-cr...
- mrjin 3y ago
  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.
  - defrost 3y ago
    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.
    - ourmandave 3y ago
      Unless you live in the Final Destination universe. Where the death-by-implausible-circumstances clock starts ticking.

bArray 3y ago

> The United States leads the world in airline safety. That’s because of the way we assign blame when accidents do happen. The communists were great at assigning blame, just usually not to the right person. If I remember correctly during the VW emissions scandal [1] they tried to pin it all on one engineer. The UK Post Office similarly tried to blame Fujitsu for a systemic failure [2]. > In the aftermath of a disaster, our immediate reaction is often to search for some person to blame. Authorities frequently vow to “find those responsible” and “hold them to account,” as though disasters happen only when some grinning mischief-maker slams a big red button labeled “press for catastrophe.” With Health and Safety (H&S) in the UK, every person is each themselves responsible for raising concerns as they see them. If something were to happen in our work place for example, I think questions would rightfully be asked of all employees 'if you saw it and agree it was dangerous, why didn't you say anything?'. To foster this all you need is a work culture that accepts criticism and is open to discussion about it. > 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. It's all good and well, but the blame is then just assigned to a system with no real accountability - any accident can be explained away with tighter control measures. I remember a story about nuclear lab technicians taking photos of radioactive materials and almost causing a serious incident. I couldn't find an article on it, but it happens regularly enough at nuclear facilities [3]. You can't use a system to entirely automate your way out of negligence. If you hire people that have no drive to improve their work place, you will inevitably have issues. Just a few days ago I was at a theme park type event and noticed that a structure that was fully on the ground (easily accessible) had been allowed to rust. Most paints for this use have a 10 year rating, but the employees were young and had no interest in the future of this place. An accident will at some point occur and some rules will be changed, but the company itself will continue to hire people with no incentive for the company's future. [1] https://en.wikipedia.org/wiki/Volkswagen_emissions_scandal https://en.wikipedia.org/wiki/Volkswagen_emissions_scandal [2] https://en.wikipedia.org/wiki/British_Post_Office_scandal https://en.wikipedia.org/wiki/British_Post_Office_scandal [3] https://www.science.org/content/article/safety-problems-los-alamos-laboratory-delay-us-nuclear-warhead-testing-and-production https://www.science.org/content/article/safety-problems-los-...

scosman 3y ago

Survivorship bias?

bmacho 3y ago
Anthropic principle or observation selection effect [0]. If you are observing something, then you are in a position that you can observe it. [0] : https://en.wikipedia.org/wiki/Anthropic_principle https://en.wikipedia.org/wiki/Anthropic_principle
throw1234651234 3y ago
Title is iffy. Tantamount to writing "Why you have never died."

throwaway713 3y ago

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 take a lifetime or more to recoup the revenue lost during that outage. But we don’t assign blame during these sorts of events, so let’s just consider it an expensive learning opportunity to redesign the system so it can’t happen again.”

mulmen 3y ago
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.”
- bheadmaster 3y ago
  > Singling out the engineer isn't blameless. Considering that everyone already knew who was responsible, I think saying "you won't be held accountable for this mistake" is the most blameless thing you can do. > 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. The way I read the comment, it sounds to me exactly like what Zuckerberg said.
  - jacquesm 3y ago
    Not really. If you single someone out as CEO that's a punishment. Even if your words are superficially nice what he really did was blame the engineer and told him not to do it again. He should have left it with the engineer's line manager to make that comment, if at all because essentially he's telling the employee nothing that he didn't know already. You did something well, but we made mistakes.

cgio 3y ago

Because I am reading this?

jagged-chisel 3y ago
No, I don’t think reading this (now) has prevented you being in a plane crash (in the past.)

dbrgn 3y ago

Just this month, there was a court case in Switzerland where an ATC was charged and convicted because he gave wrong instructions to a military jet, which then crashed into a rock wall. The case was quite interesting to follow, due to the various implications of a conviction or acquittal. It had quite some media coverage. https://www.swissinfo.ch/eng/swiss-military-jet-crash--public-prosecutor-seeks-suspended-prison-sentences/49100956 https://www.swissinfo.ch/eng/swiss-military-jet-crash--publi... https://www.swissinfo.ch/eng/air-traffic-controller-blamed-for-fatal-military-crash/49112604 https://www.swissinfo.ch/eng/air-traffic-controller-blamed-f... (Note that this was a military court, not a civil court. Proceedings might be different in these cases, even though both civil and military ATCs work for the same company - Skyguide.)

siva7 3y ago

>> 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.

010101010101 3y ago
I don’t think that’s what’s implied here at all - the focus on blamelessness is to get to the root cause of failure and prevent future occurrences rather than to punish existing failures without affecting any actual change.
sgjohnson 3y ago
> 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.
brazzy 3y ago
No, accountability is a very insufficient answer, because it helps very little in identifying and fixing broken systems. In a lot of cases, this one being a particularly good example, nobody was particularly incompetent, negligent, malicious, or greedy. But the system as a whole lacked safeguards so that a single person's inconspicous mistake could cause a disaster, and overloaded that person's attention. Sure, there's other cases where you can clearly identify negligence, malice, or greed of specific people as causes of the disaster. But there as well, holding those people accountable doesn't fix the system than incentivised the greed, doesn't prevent incompetent, malicious or negligent people from getting into positions where actions based on those traits cause disasters, and doesn't provide safeguards against such actions. The deterrence value of holding individuals accountable for extremely rare events is approximately zero.
rob74 3y ago
The thing with the two MCAS accidents is that you don't have too few people to blame, but too many: - the airlines who wanted a more fuel-efficient plane that should still have the same type certificate as the (at that time) 40+ year old Boeing 737 - Boeing management, who wanted to keep those airlines as customers - Boeing engineering, who did what they did at the management's request - the FAA, who failed to spot the issue - the mechanics of the involved airlines, who dispatched the planes without working angle-of-attack sensors - the airlines who ordered planes without the (optional) "angle-of-attack disagree" alert - the pilots (just for the sake of completeness), who failed to notice the issue and either refuse to fly the plane or correct it in time to avoid the crash Who do you want to single out here?

phkahler 3y ago

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.

sgjohnson 3y ago
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.
- petesergeant 3y ago
  > in reality it was the entire industry Do you have further reading on this? First time I’ve seen someone suggest that Airbus has similar structural issues to Boeing when it comes to safety
  - sgjohnson 3y ago
    I didn’t suggest that Airbus has similar issues. What I meant by the “entire industry” also includes the airlines. I suggested that had nothing changed, it might have been Airbus that was low-key blackmailed into making a new plane that’s of the same type, with similar issues that would become evident only after a couple of crashes. The very root cause of the issue was that Boeing was simply allowed to say “trust me bro, this is just a 737, it’s like any other 737, no retraining of any kind needed”, when, in fact, it wasn’t just the same old 737. Now this can’t happen anymore.
- cainxinth 3y ago
  > 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.

hayst4ck 3y ago

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

class3shock 3y ago
Rickover is an intriguing figure to read about in general. I've heard different versions of his "rules", one set located here: https://www.linkedin.com/posts/kelly-robinson-phd-92842b6_rickover-created-a-culture-of-operational-activity-7080868879614308352-cQQ9/?trk=public_profile_like_view https://www.linkedin.com/posts/kelly-robinson-phd-92842b6_ri... Another I'll include at the bottom of this post. I also just wanted to highlight two things. Not only did he create a highly safety conscious organization but an incredibly technologically innovative one that was born despite huge resistance from the US Navy. Think about trying not only to build a small nuclear reactor, something that had never been done before, but one that could be put on a submarine. Not an easy technical goal. And on top of that, aiming to complete this task in the face of resistance from the highest levels of the organization he made his life, including efforts to get rid of him entirely. He wasn't perfect but what he achieved quite alot. Definitely worth reading more up on particularly if you work more in the mechanical engineering world. Second set of Rickover Rules: Rule 1: You must have a rising standard of quality over time, and well beyond what is required by any minimum standard. Rule 2: People running complex systems should be highly capable. Rule 3: Supervisors have to face bad news when it comes and take problems to a level high enough to fix those problems. Rule 4: You must have a healthy respect for the dangers and risks of your particular job. Rule 5: Training must be constant and rigorous. Rule 6: All the functions of repair, quality control, and technical support must fit together. Rule 7: The organization and members thereof must have the ability and willingness to learn from mistakes of the past.

arethuza 3y ago

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.

sgjohnson 3y ago
I can also recommend Green Dot Aviation and Mentour Pilot

petesergeant 3y ago

Feel like this boils down to “if an average person can make an average mistake and people die, the system is culpable”

bradfa 3y ago

Why don't we as a society apply similar safety culture to driving cars and trucks as we do to aviation? MANY more people are harmed or killed by automobiles than by aircraft per person-mile traveled. A small improvement in automobile safety could make a large impact on society. Many of the types of improvements implemented by aviation mentioned in this article, when applied to the automotive world, would look like improvements or changes to road design. Obviously, if you're a pilot and flying drunk who harms others or a driver who drives drunk and harms others, YOU are clearly to blame. But for the other kinds of crashes, it feels like the automotive world learning from aviation would have a lot of value.

SoftTalker 3y ago
Well we do. That's why automobiles have seatbelts and airbags, rear-view cameras, antilock brakes, traction control, and have to pass crash safety tests.
- bradfa 3y ago
  Sure but we still have tens of thousands of traffic fatalities every year in the USA and the stats are not decreasing in any meaningful way. What we have done is not working to actually reduce automobile deaths.
r_klancer 3y ago
Strong Towns is attempting to change that with the "Crash Analysis Studio": https://www.strongtowns.org/crash-studio https://www.strongtowns.org/crash-studio I can think of many reasons it's difficult, though: * The fact that accident investigations are designed to figure out which driver was at fault, for insurance purposes * The fact that road designers are shielded from liability (good, right?), but only if they can show they followed the standard design handbooks, which not only fail to prioritize safety over traffic flow but also don't require or even contemplate performing a thorough case-by-case investigation into how to prevent a certain type of accident from happening again. (Crash Analysis Studio tries to demonstrate how to do this.) * The sheer scale of the changes to roads that would be needed. In the States, access of hundreds of thousands of businesses and probably millions of homes depend on roads that are supposed to get people from A to B fast but also have lots of access points for businesses on them, which is like just like mixing taxiing and holding with takeoff and landing, but without the air traffic controllers. And don't get me started about unprotected lefts across multiple lanes of traffic. * The lack of buy-in from the citizenry for enforcing professional-like standards on drivers. Despite the blameless culture that helps identify flaws in the system, air traffic controllers, pilots, maintenance crews, train engineers, etc also know that their job depends on making a sincere effort to follow the rules that are written, and in most cases their professional identity is tied up with following the rules. (I've heard that to be a pilot you really have to be comfortable with doing what you're told, all day long.) There's really no obvious way to get the masses of drivers to think and feel that way about their driving, and of course we can't just sanction our way to compliance because people need their licenses to go about their lives. And of course usually there is no reasonably alternative to driving yourself where you need to go.

deleted 3y ago

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braunjohnson 3y ago

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jroseattle 3y ago

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.

xyzelement 3y ago

Something that appealed to me during my years at Bridgewater is the willingness to attribute failure to individuals without making those individuals suffer. In "blameless" there's no personalities mentioned at all but in reality personality and individuals matter. EG if we had an outage because I put code into production w/o review, yes it's a systemic failure but it's also something about me, something about my manager, etc. By talking about those things as well, you make it easier for both the system and the individuals to evolve.

16bytes 3y ago
The issue with attributing failure, no matter how little suffering there is, is that it provides a huge incentive to not self report and/or downplay incidents. Unless you are acting with malice, your actions are a product of the system and procedures in place. Those should be the focus of improvement, not individuals. E.g. preventing prod pushes that contain unreviewed code. Of course we need to talk about individuals, but that's performance management and not incident management.
filleduchaos 3y ago
It's interesting how people carry their preconceived notions into articles like this, especially when those articles are about entirely different industries and/or contexts than they're used to. For example, reading any NTSB report would make it quite clear that the actions of specific individuals - from pilots to controllers to maintenance techs and more - are very much mentioned and dissected under the "blameless" style of investigation that international aviation adheres to. But people already have their own ideas of what "blameless" means that inevitably colours their reading - in some cases, colours it so strongly that not even the evidence of success is enough to budge the conclusion that there must be something wrong with the way "blameless" culture is implemented.

gadders 3y ago

I think it's a fairly safe assumption that if you are alive to read the article, you are unlikely to have been in a plane crash (yes, I agree some plane crashes are survivable). Next article: Why you've never been struck by lightning.

charles_f 3y ago
It sounds like you didn't read the post. It's not an assumption, it's the explanation of why.
- gadders 3y ago
  No, but I read the clickbait title.
  - add-sub-mul-div 3y ago
    This is far more insufferable than clickbait titles.

jonnycat 3y ago

This should be required reading for every software engineering team (and the business & product teams they interact with).

fortran77 3y ago

But I have been in a plane crash! An overshoot of the runway at Burbank airport that narrowly missed hitting a gas station. https://en.wikipedia.org/wiki/Southwest_Airlines_Flight_1455 https://en.wikipedia.org/wiki/Southwest_Airlines_Flight_1455

ibcj 3y ago
Wow, I remember this! Glad you were a-ok. Would love to hear more about your story and your method of egress from that bird. For those that don't know, LAS to BUR is the best way to get from LA to Vegas (save private) and always has been. I've been on that Sunday afternoon flight from LAS->BUR many times; with the afternoon flight informally known as the Hangover Express and the morning flight known as the Stripper Express. Good times. And FWIW, I still prefer FORTRAN over Perl any day...
- fortran77 3y ago
  The slide inflated inside the airplane! Rescue workers laddered uninjured passengers out. I signed an NDA to get my modest settlement. I still fly Southwest. The pilots were fired.

leesec 3y ago

Except my sister and her husband died in a plane crash 2 years ago. A lot of these ultra cautious safety requirements apply a lot more to bigger commercial airlines and less to small private chartered planes.

leetrout 3y ago
Sorry for your loss. I hope something was learned by others so it will not happen again.
- leesec 3y ago
  Thanks, unfortunately it was primarily pilot error so I doubt it. The pilot also passed
  - hanche 3y ago
    Pilot errors also have underlying causes. Was the pilot properly trained for the particular situation that arose? How is the safety culture of the airline? Did some aspect of the airplane design make that mistake more likely, or hinder the possibility of recovery? Was the pilot tired or not well and should not be flying in the first place? There’s a thousand questions like that which can and should be asked in a proper investigation. Hopefully, they were. (I have been binge reading my way through Admiral Cloudberg’s blog on medium lately. Perhaps not to be recommended for you, as reading about a hundred fatal plane crashes may be too emotionally painful.)

genericuser125 3y ago

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tim333 3y ago

We need something like that to deal with the danger of genetically modified viruses causing pandemics. Covid may or may not have leaked from a lab in Wuhan but the investigation has been kind of shockingly bad with scientists in charge calling anyone suggesting that conspiracy theorists while privately saying a lab leak was "so friggin likely." Just recently is was reported that Chinese scientists were experimenting with a new Covid-like virus where every rodent that was infected with the pathogen died within eight days, which the researchers described as 'surprisingly' quick. This time it's a Pangolin virus rather than a bat one though still on humanised mice. I think a rule that anyone doing such research would have to get say $100bn liability insurance first might make them more cautious. Covid cost $12.5 trillion + according to the IMF and with deaths ~100x all aviation accidents in history. (Pangolin virus https://www.firstpost.com/world/china-experimenting-with-100-per-cent-deadly-new-covid-strain-report-13616272.html https://www.firstpost.com/world/china-experimenting-with-100...)

nayuki 3y ago

Great article. I agree a lot with the safety culture in commercial aviation and the commitment to investigate and fix root causes. Now can we please apply the same standards to car crashes? The same human errors and bad infrastructure keep getting repeated over and over again. And the problems are getting worse, with SUVs and distracted driving on the rise. See https://www.reddit.com/r/fuckcars/ https://www.reddit.com/r/fuckcars/ for a community that is sounding the alarm on the insidiousness of car culture. Or see these reasonable urbanists if you think FuckCars is too extreme: https://www.youtube.com/@OhTheUrbanity/videos https://www.youtube.com/@OhTheUrbanity/videos , https://www.youtube.com/@NotJustBikes/videos https://www.youtube.com/@NotJustBikes/videos , https://www.youtube.com/@CityNerd/videos https://www.youtube.com/@CityNerd/videos

rpmisms 3y ago
r/fuckcars has members who deflate and slash car tires that belong to vehicles they deem "too big". Do you support that methodology?
- Orangeair 3y ago
  I've seen hundreds of posts on that sub, but never anything approaching what you're describing. Do you have an example?
  - rpmisms 3y ago
    https://www.reddit.com/r/fuckcars/comments/xr64d8/deflating_suvs_tires_is_poor_behavior/ https://www.reddit.com/r/fuckcars/comments/xr64d8/deflating_... https://www.reddit.com/r/fuckcars/comments/xo6uqu/my_option_on_tyre_deflators/ https://www.reddit.com/r/fuckcars/comments/xo6uqu/my_option_... Cursory search turned these up.
    - Orangeair 3y ago
      I don't necessarily know that you can conclude from a few memes that people are actually out there doing this, I see it more as venting frustration. They're certainly advocating for it, though.

mceachen 3y ago

I had the privilege to work at a company that _actually_ had "blameless postmortems." That phrase is easy to say, but when you're on-call and get woken up at 3 in the morning to deal with someone else's mess, let's just say "blameless" isn't _my_ first reaction. However--getting to the root of the issue, allowing everyone involved come up with solutions, and continuously improving the runbook is clearly the best way forward. Sure, it's reactionary, but proactive guidance is never going to be as imaginative in breaking things as production traffic.

tetha 3y ago
In a team of individuals, the term isn't necessarily "blameless". I'd never hold a weird or accidental outage against you personally. The major question would be: Why did that happen? However, you're forever going to be the fucking guy causing a database outage on Christmas. You might have had no choice, but fuck you. All of us have these scars. But then the question is: Why do we all have these scars? Maybe the system we're dealing with is not as great as it should be? Maybe the localized amount of anger is just a thing leading towards a more systematic problem. Oops, back into the ideas of blameless post-mortems.

kitsune_ 3y ago

Over 20 years ago, at my first job, a co-worker told me that the evening before, he got a phone call from their best friend who phoned him in shock and told him they just survived a plane crash: https://en.wikipedia.org/wiki/Crossair_Flight_3597 https://en.wikipedia.org/wiki/Crossair_Flight_3597

ongytenes 3y ago

Crashed once in Nassau when I was a kid. Brakes failed on the left side on a Beechcraft Model 18, spun the plane around on touchdown. Slid sideways down the runway, broke the landing gear then rolled breaking the left wing. Everyone splashed through fuel walking away. There was no fire. A year later I almost crashed in St Thomas in another Model 18. That was pilot error. Carburetor heat was on and we took all the runway trying to get off the ground. We took off towards the ocean and flew a long way so close to the water that we were sucking water up and spraying the plane. I was blissfully unaware as a kid. Thought the pilot was playing around.

MarcoZavala 3y ago

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poundofshrimp 3y ago

When I first started to program professionally, I was fascinated with the blameless postmortem culture that my ex-employer had. I thought (and still do) it is incredibly conducive to systemic improvement. I’m happy it is legally codified in the aviation industry.

berniedurfee 3y ago

Mentour Pilot on YouTube, fabulous channel BTW, talks about the Swiss Cheese Model. I’ve started to use this model when talking about software testing. Unit tests, integration tests, functional tests, UAT, etc are all layers that help prevent defects from reaching production. Those testing layers are deliberately redundant. When we do a postmortem on a defect, it often turns out there was only one layer of testing between the defect and production and the incident would have been less likely to occur with multiple layers in place. https://en.m.wikipedia.org/wiki/Swiss_cheese_model https://en.m.wikipedia.org/wiki/Swiss_cheese_model

averageRoyalty 3y ago

How does the United States "lead the world in air safety" with only one of their airlines (and not one of the major ones) even making the top 10 from a US source[1]? Looking back over the years, the US has never hit this metric. Have I misunderstood how it's being calculated? 1. https://www.forbes.com/sites/laurabegleybloom/2024/01/03/ranked-the-25-safest-airlines-in-the-world-according-to-airlineratingscom/ https://www.forbes.com/sites/laurabegleybloom/2024/01/03/ran...