ChaosConf 2018

Transcript

1. STAYING ALIVE PATTERNS FOR FAILURE MANAGEMENT FROM THE BOTTOM OF THE OCEAN 1 — ChaosConf 2018 @rondoftw
2. Ronnie Chen Engineering Manager at Twitter @rondoftw 2 — ChaosConf 2018 @rondoftw
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9. RISKS MAY INCLUDE... 1. hypoxia 2. hyperoxia 3. nitrogen narcosis 4. carbon dioxide buildup 5. oxygen sensor failure 6. deep tissue isobaric counterdiffusion (ICD) 7. high pressure nervous syndrome (HPNS) 8. exhausting your carbon dioxide scrubber 9. carbon dioxide channeling from a poorly packed scrubber 10. carbon buildup causing an spark leading to an oxygen fire. underwater. 11. flooding of breathing loop or circuitry 12. water mixing with the scrubbing agent to produce a toxic caustic soda that will give you chemical burns on your mouth, airway, and lungs 13. plain old decompression sickness 9 — ChaosConf 2018 @rondoftw
10.   If you own a rebreather for five years, two percent of you are going to die on it. — Jill Heinerth, underwater explorer 10 — ChaosConf 2018 @rondoftw
11. How failures really happen 11 — ChaosConf 2018 @rondoftw
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13. CATASTROPHES ARE CAUSED BY A FAILURE CASCADE ▸ you have a rebreather malfunction ▸ which you might have caught if you didn't skip your pre-dive check ▸ your backup tank had a leak and is running low because of a faulty o-ring ▸ your buddy is far away and distracted by something else ▸ the dive light doesn't get their attention because the beam has less contrast in the day ▸ you accidentally kick up some silt and the visibility drops ▸ your air consumption goes up and then you breathe through the last of the air in your tank ▸ so you swim for the surface even though you have a decompression obligation 13 — ChaosConf 2018 @rondoftw
14. A post-mortem that blames this incident on a simple mechanical malfunction would only cover 12.5% of the issues that led up to this accident. 14 — ChaosConf 2018 @rondoftw
15. WHAT IS SAFETY? 15 — ChaosConf 2018 @rondoftw
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17. TRAIN FOR PRESSURE 17 — ChaosConf 2018 @rondoftw
18. TEAM TRAINING: INEXPERIENCED PEOPLE TO THE FRONT ▸ Most inexperienced person leads ▸ Experienced person advises, only intervening when necessary 18 — ChaosConf 2018 @rondoftw
19. INEXPERIENCED PEOPLE TO THE FRONT ▸ One of the best ways to equalize a gap in experience ▸ Opportunity to revise and improve problematic systems 19 — ChaosConf 2018 @rondoftw
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21. Judgment is what enables you to adapt to a changing environment 21 — ChaosConf 2018 @rondoftw
22. REFINING JUDGMENT ▸ Post-Mortems ▸ Pre-Mortems ▸ Fire Drills ▸ Revisit Past Decisions 22 — ChaosConf 2018 @rondoftw
23. POST-MORTEMS ▸ Look at the safety procedures that failed to stop the cascade ▸ Understand contributing factors ▸ Look for opportunities to create new safety systems 23 — ChaosConf 2018 @rondoftw
24. PRE-MORTEMS ▸ Don't wait for failures to build safety frameworks ▸ Identify potential avenues of of failure and make plans ▸ Include both likely failures and high regret failures 24 — ChaosConf 2018 @rondoftw
25. FIRE DRILLS ▸ Vet your plans and safety systems ▸ Perform targeted training ▸ Evaluate effectiveness of tools and documentation 25 — ChaosConf 2018 @rondoftw
26. REVISIT PAST DECISIONS ▸ Examine successful operations to see what key insights were helpful ▸ Identify any dependency on luck in previous projects ▸ Share rationale for decisions 26 — ChaosConf 2018 @rondoftw
27. RECOGNIZING SUCCESS 27 — ChaosConf 2018 @rondoftw
28. I WANT TO LEARN MORE! 1. Richard I. Cook - How Complex Systems Fail 3. Steve Lewis aka decodoppler (Technical Diving Instructor) - Staying Alive 4. Sidney Dekker - Drift into Failure 5. Diane Vaughn - The Challenger Launch Decision 28 — ChaosConf 2018 @rondoftw
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