Staying Alive: Patterns for Failure Management From the Bottom of the Ocean

Transcript

1. STAYING ALIVE PATTERNS FOR FAILURE MANAGEMENT FROM THE BOTTOM OF THE OCEAN RONNIE CHEN SLACK 1 — Ronnie Chen @rondoftw
2. WHY DID I BECOME A DIVER? 2 — Ronnie Chen @rondoftw
3. A WHOLE NEW WORLD 3 — Ronnie Chen @rondoftw
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9. TECHNICAL DIVING ▸ longer dive times ▸ deeper dives ▸ overhead ceiling ▸ decompression obligations ▸ more gear. a lot more. ▸ higher pressure ▸ more risks 9 — Ronnie Chen @rondoftw
10. RISKS MAY INCLUDE... 1. hypoxia 2. hyperoxia 3. nitrogen narcosis 4. carbon dioxide buildup 5. oxygen sensor failure 6. deep tissure isobaric counterdiffusion (ICD) 7. high pressure nervous syndrome (HPNS) 8. software failure 9. exhausting your carbon dioxide scrubber 10. carbon dioxide channeling from a poorly packed scrubber 11. carbon buildup causing an spark leading to an oxygen fire. underwater. 12. flooding of breathing loop or circuitry 13. water mixing with the scrubbing agent to produce a toxic caustic soda that will give you chemical burns on your mouth, airway, and lungs 14. plain old decompression sickness 10 — Ronnie Chen @rondoftw
11.   If you own a rebreather for five years, two percent of you are going to die on it. — Jill Heinerth, underwater explorer 11 — Ronnie Chen @rondoftw
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15. HOLD UP! 15 — Ronnie Chen @rondoftw
16. THIS IS A TALK ABOUT COMMUNICATION AND PROCESS ? ? ? 16 — Ronnie Chen @rondoftw
17. (it was a trap) 17 — Ronnie Chen @rondoftw
18. YOU CAME TO HEAR COOL STORIES... 18 — Ronnie Chen @rondoftw
19. BUT YOU'RE GETTING A MEANDERING MEDITATION ON BEST PRACTICES* WHEN DEALING WITH COMPLEX SYSTEMS INSTEAD * These guidelines have only been shown to work for life or death situations under the ocean. They have not been proven to work for tech. 19 — Ronnie Chen @rondoftw
20. How failures really happen 20 — Ronnie Chen @rondoftw
21. Complex systems are designed to protect against simple failures. 21 — Ronnie Chen @rondoftw
22. But accidents still happen. 22 — Ronnie Chen @rondoftw
23. CATASTROPHES ARE CAUSED BY A FAILURE CASCADE ▸ you have a rebreather malfunction ▸ which you would have caught it if you were testing your equipment on a regular basis ▸ your backup tank had a leak and is running low and that wasn't caught either ▸ and your buddy is too far away and isn't checking in with you ▸ and your dive light that you use to communicate at a distance is out of power ▸ and in the excitement you kick up silt and the visibility drops ▸ and in your panic 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 23 — Ronnie Chen @rondoftw
24. 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. 24 — Ronnie Chen @rondoftw
25. Complex system failures don't happen because a single part of the system fails. They happen because all the safety procedures that are supposed to protect them from the simple system failure didn't work. 25 — Ronnie Chen @rondoftw
26. CORE RULES OF SAFETY SYSTEMS 1. An unused safety system doesn't exist. 26 — Ronnie Chen @rondoftw
27. NORMALIZATION OF DEVIANCE That natural human tendency, particularly in pressure circumstances, to take a safety shortcut. To accept a lower standard of performance. — Colonel Mike Mullane, astronaut 27 — Ronnie Chen @rondoftw
28. FALSE FEEDBACK the absence of something bad happening means that it was safe ADAPTATION experience is no longer a suitable gauge of risk SOCIAL PRESSURE this is just how we do things 28 — Ronnie Chen @rondoftw
29. CORE RULES OF SAFETY SYSTEMS 2. An untested safety system doesn't exist either! 29 — Ronnie Chen @rondoftw
30. CORE RULES OF SAFETY SYSTEMS 3.Unused or untested safety systems are more dangerous than not having one at all. Therefore, safety systems must be tested at regular intervals. The length of this interval should be determined not only by how likely it is for this system to fail but also how great the impact will be if it does. 30 — Ronnie Chen @rondoftw
31. A QUICK SIDENOTE ON ASSESSING RISK ▸ Make assessments based on likelihood of occurrence. ▸ Make assessments based on magnitude of regret. If you are only evaluating risk based on the chance of it happening, you must be prepared to experience the corresponding level of regret if it does. 31 — Ronnie Chen @rondoftw
32. failures will happen 32 — Ronnie Chen @rondoftw
33. WHAT IS SAFETY? 33 — Ronnie Chen @rondoftw
34. FAILURE MANAGEMENT ▸ A framework for redundancy ▸ The training and judgment to use it 34 — Ronnie Chen @rondoftw
35. FAILURE MANAGEMENT FOR SYSTEMS ▸ Have redundancy for systems that you cannot survive without. ▸ Have a redundant pathway to success: a procedure for graceful degradation for systems that are important but not critical. ▸ Have a process for changing over from primary to redundant systems. 35 — Ronnie Chen @rondoftw
36. FAILURE MANAGEMENT FOR SYSTEMS (CONT) ▸ Keep failures contained so that they don't bring down other systems ▸ Make it easy to do the right thing and hard to do the dangerous things 36 — Ronnie Chen @rondoftw
37. FAILURE MANAGEMENT FOR HUMAN SYSTEMS 37 — Ronnie Chen @rondoftw
38. TRAINING FOR PRESSURE 38 — Ronnie Chen @rondoftw
39. TRAINING: INEXPERIENCED PEOPLE TO THE FRONT ▸ Most inexperienced person leads ▸ Experienced person advises and intervenes only when necessary ▸ Team is invested in personal success to ensure mission success 39 — Ronnie Chen @rondoftw
40. TRAINING: INEXPERIENCED PEOPLE TO THE FRONT (CONT) ▸ Frees up more experienced people from micromanaging ▸ Opportunity to revise and improve problematic systems ▸ One of the best ways to equalize a gap in experience 40 — Ronnie Chen @rondoftw
41. GOOD JUDGMENT Good judgment enables the reshaping of rules and frameworks to adapt to a changing environment. 41 — Ronnie Chen @rondoftw
42. REFINING JUDGMENT ▸ Post-Mortems ▸ Pre-Mortems ▸ Fire Drills ▸ Revisit Past Decisions 42 — Ronnie Chen @rondoftw
43. POST-MORTEMS ▸ Look at the safety procedures that failed to stop the cascade ▸ Look for opportunities to create new safety systems at critical points 43 — Ronnie Chen @rondoftw
44. PRE-MORTEMS ▸ Don't wait for failures to build safety frameworks ▸ Identify potential avenues of of failure and make plans for them ▸ Include both likely failures and high regret failures 44 — Ronnie Chen @rondoftw
45. FIRE DRILLS ▸ Vet your plans and safety systems ▸ Perform targeted training ▸ Evaluate effectiveness of tools and documentation 45 — Ronnie Chen @rondoftw
46. 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 46 — Ronnie Chen @rondoftw
47. RECOGNIZING SUCCESS 47 — Ronnie Chen @rondoftw
48. I WANT TO LEARN MORE! 1. Diane Vaughn - The Challenger Launch Decision 2. Richard I. Cook - How Complex Systems Fail 3. Mike Mullane - https://www.youtube.com/watch?v=Ljzj9Msli5o 4. Steve Lewis aka decodoppler - Staying Alive 5. Sidney Dekker - Drift into Failure 48 — Ronnie Chen @rondoftw
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50. Any Questions? 50 — Ronnie Chen @rondoftw