Mayday! Software Lessons from Aviation Disasters

Transcript

1. Mayday! Adele Carpenter Software lessons from aviation disasters @iam_carpenter
2. Photo by Graham Dinsdale via Jetphotos
3. Approximation of cabin Photo by Usien via wikipedia commons
4. Photo by Nick Bair via wikipedia commons
5. Chain of events Partnair 394
6. Photo by Chandler Cruttenden on Unsplash F-16 sonic boom? Lockerbie bombing Part II? Photo via wikimedia commons
7. Finn gathers the team... • How can we prove ourselves wrong? • What details might we be ignoring? • What else could cause a mid-air break up? • What are the precise levels? Other sources of residue? • No terrorist groups have claimed credit • Countless possibilities, need to narrow the scope
8. Photo by Chandler Cruttenden on Unsplash F-16 sonic boom? Lockerbie bombing Part II? Photo via wikimedia commons
9. Photo by Ana Municio on Unsplash
10. Question yourself • How can I prove myself wrong? • What details might I be ignoring because it doesn’t fit my theory or solution? • What else could cause this issue or situation?
11. Photo courtesy of BEA Photo courtesy of NTSB
13. Photo by Brian Gordon via picryl
14. Photo by Nick Bair via wikipedia commons
16. Photo by Brian Gordon via picryl
17. Chain of events Partnair 394
18. Counterfeit Code?
19. Improving software quality Finn’s top tips • Outcomes as a chain of events to learn from • Taking our time to investigate all options • Accepting responsibility our code - no “counterfeit code” • Following the evidence • Questioning ourselves rigorously
21. Photo by Dan Parlante on Unsplash
22. Approximation of actual cockpit Photo by Keishi Nukina, KNaviation Captain McBroom First Officer Beebee Second Officer Frosty DC-8-61 Cockpit 28 December 1978 UA 173
23. Approximation of actual cabin Courtesy of Runway Girl Network
24. Approximation of actual cockpit Photo by Keishi Nukina, KNaviation Captain McBroom First Officer Beebee Second Officer Frosty DC-8-61 Cockpit 28 December 1978 UA 173
25. Photo by Randy Peters on Unsplash
26. Courtesy of the Oregonian
27. The cause was the Captain’s failure to properly monitor the aircraft’s fuel state and to respond to both the low fuel state and the crew-member’s advisories regarding the fuel state. The factor contributing to the accident was the failure of Beebee and Frosty to either to fully comprehend the criticality of the fuel state or to successfully communicate their concern to the captain.
28. Courtesy of The Flight Channel
29. Crew Resource Management Recommendations after UA 173 • Participative management for captains: in other words providing a non-threatening environment that actively encourages collaboration • Assertiveness training for other cockpit crew members: how to get your point across effectively in a non-threatening manner
30. Courtesy of the Oregonian
31. Situational Awareness “Knowing what’s going on around you” Fixation -> loss of situational awareness
32. Situational Awareness Contributing Factors • Knowledge of the Automation and Abstractions present • Are you aware of the abstractions that you interact with, even if on a rudimentary level? Could you find the resources you need if the situation required it? Do you have a basic understanding of what happens when you run a Jenkins build? What’s it doing and what could go wrong? • Stress and Workload • How many tickets are assigned to you right now? How many meetings do you have planned? Which deadlines are real and which are arbitrary? Be honest with yourself and others on what you can accomplish
33. Situational Awareness Contributing Factors • Physiological factors • Did you sleep enough? Are you hydrated? Did you eat? Did you poop? • Abilities, Experience, Training • What are your limitations or weak spots with respect to your role? How can you patch them? Who can help you? What knowledge could you share with others? • Preconceptions and bias • Is your gut instinct actually just bias? Why does a certain course of action appeal to you? What evidence do you have to support your position? Evidence against?
34. Situational Awareness Is not a solo endeavour! • Contribute to a psychologically safe work environment • Share your knowledge, no matter your experience level • Speak up when things don’t add up
35. Thank you Adele Carpenter @iam_carpenter