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.
- An accident is a combination of the system being in a hazardous state and unfavourable environmental conditions that turn the hazard into an accident.
- A near miss is when the system was in the hazardous state but the environmental conditions were in our favour so the accident didn't happen.
We can't control environmental conditions, we can just make sure to keep the system out of the hazardous state. This means a near miss contains all we need to perform a proper post mortem. The environmental conditions are really immaterial.
Near misses are absolutely like gifts from the heavens. I was part of a post-investigation for a near miss that would've looked like this if things had gone a bit differently:
By this logic, the recent Boeing 737 incident should be considered a gift from the heavens. Which I think is actually a good way to look at it, though we don’t yet know whether this gift will be squandered.
I think a company taking things seriously would view it as a gift from the heavens, but the fact that Boeing is seeking an exemption for certification doesn't really seem like they're putting safety ahead of profits.
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.
I've been obsessed with the US Chemical Safety Board videos on YouTube that describe in great detail the events that lead up to industrial accidents. One of the common themes I've seen among them is that there's usually some sort of warning sign or near miss that goes ignored by the people responsible for them since they don't cause any major damage. Then a few days or months later that system fails in an entirely predictable way with catastrophic consequences. A good example of this is the fatal phosgene gas release at a DuPont chemical plant[1].
It is worth keeping in mind that you don't see the other side of the equation in these reports: how many warning signs and near misses that didn't result in a major accident. Part of that is just the odds, and why people and organisations can become complacent to them, and part of it is that while most of them may be addressed, some can still slip through the cracks.
YEs. Almost everyone has seen at factories the prominently posted signs updated daily: "XX Days Since a Time Lost Accident". Some years ago, I noticed in some more technically advanced shops a change: "XX Days Since a Near Miss", along with an invitation and method to report near-misses.
Seems like progress; a near-miss noticed is indeed a real gift, if followed-up.
> 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.
I've not been following closely, but I suspect the Post Office did not follow this. Are there ramifications happening along these lines for the Post Office fiasco? Or is it already a big enough thing that this would just be "oh, and also that too I guess" kind of thing?
Amongst many other complications in the UK Post Office scandal that make it different from what's being discussed here: the victims in the post office scandal were franchisees, not employees.
...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/
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.
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...
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.
So, "fun" tale: the https://en.wikipedia.org/wiki/American_Airlines_Flight_191 crash had a new feature, a closed circuit television system that showed passengers the view from the cockpit. They very possibly got to watch their demise first hand from that camera. For that reason, it might never happen again.
Too bad really. So what if you get to watch yourself die horribly, you die either way! You will still be pasta sauce on the other end of the incident, you really shouldn't care. You might have a stronger spike of adrenaline than otherwise, but that's not going to hurt you any more than being pulverized will.
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.
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.
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.
The cognitive dissonance people have around this issue is astonishing. We are willing to ground the 737MAX fleet when a few people get a (surely terrifying) open air flying experience; but 44,000 people are killed on the road in the US _every_ year (and rising!) and very few people seem to care. In most age cohorts, death by car is the largest killer. In the US you have a 1 in 107 chance of dying in a car crash in your lifetime. Even simple and completely reasonable measures to reduce these insane numbers are seen as some kind of tyrannical affront to ones freedom (see the current CA measure to add speed limiters).
The car industry, car culture, and car centric thinking in the US and much of the world is totally out of control.
I too have thought a lot about this cognitive dissonance. I think that there are several differences to the two issues, and so, in people's attitude towards it too.
One, I think, is that flying is something that is being done to us, and driving is something that we do ourselves. So the agency, the point of view is very different. Something bad happening while being passive is much more horrifying because of the powerlessness.
The other is that cars and driving environments differ a lot, while planes are much more similar to each other. What I mean by this is that it's easier to dissociate the car deaths, because that happens to some other people over there, nothing like me, but plane badness happens to everyday folk in a big winged tube, like me.
I think that if we drove the planes ourselves, the issues would be much more similar. And similarly, if everyone took the train, the bus, or a ship, and similar things would happen to a train, bus or ship, the freakout would be similar to what we see now with planes.
TIL that car fatalities were declining until 2019, and then reversed and are getting worse.
What happened in the last five years? Safety features of the cars themselves are improving (emergency braking). Alcohol may be a factor, but why in the last five years? Cars have been big for a while. WFH probably reduced commuting time. Other countries appear to be on the decline.
Ironically, heavy traffic is one of the better "safety features" of our automobile transportation system. Since crowded roads are higher-conflict roads, there is a bit of luck in the fact that traffic slows down when it gets crowded. There may be more collisions, but they are less deadly.
Suddenly there is a pandemic, and there are orders of magnitude fewer people on the roads. The number of collisions goes down, but the number of deaths goes up, because all of the collisions are at higher, deadlier speeds.
---
Driving Went Down. Fatalities Went Up. Here's Why. by Charles Marohn
> TIL that car fatalities were declining until 2019, and then reversed and are getting worse.
Per your link, fatalities per mile drive bottomed out in 2014 and barely dropped after 2010. There's been some speculation that this reversal in safety was tied to the rise of smartphones and a corresponding increase of distracted driving.
Note that deaths per vehicle mile traveled (VMT) went up during Covid. Reducing commuting time doesn't necessarily reduce deaths under that metric -- just the opposite! Commuter trips are probably the safest per VMT since they're the most familiar.
There were stories about this effect, even as total collisions went down because of the bigger drop in VMT[1]. I speculated that this was a combination of
a) the above effect (stripping out the safer commuter trips), plus
b) the roads being dominated by people least willing to follow the advice to stay home, which correlates with being anti-social and reckless (mean though that sounds! [2])
My facebook friends suggested
c) the immense stress of coping with the Covid world made the average person less able to concentrate.
I also suspect:
d) traffic enforcement was reduced and drivers gradually started branching out into more aggressive maneuvers as they became aware of this.
Note that people saw their car insurance rates go down during covid because the typical personal policy only cares about accidents per unit time, and rarely adjusts for miles driven.
But I don't know why it hasn't regressed to the pre-covid levels -- probably because WFH hasn't completely reversed.
The driving majority has members who support buying tall heavy SUVs and pickup trucks "for their family's safety", running over pedestrians, speeding wherever they please, and protesting any kind of traffic calming or enforcement. And then there are the teens who run over cyclists for fun, such as in the case of Andreas Probst. Do you support that methodology?
I would never recommend this methodology to a friend or a family member. Drivers are vindictive, violent people and the risk is too high to be worth it.
<whiney rant> After notjustbikes got big, he dropped any humility and started preaching to the choir, calling people who didn't agree with him racist idiots. I complained in the comments that I used to be able to recommend his videos sight-unseen to the people who needed to be convinced. He replied and insulted me as someone who just found his channel and couldn't take the truth. </whiney rant>
Unpopular opinion, but the truth: We have to drive and it's a right. I agree about the infrastructure issues. Still the modern "safe driving" mentality that people want is at odds with that REALITY.
This could change with public transit, however we don't do this. Even the best countries fall short, and most don't get close. It's actively discouraged in the USA.
Actually, you could argue that people already have to deal with too much BS to drive. The paperwork, rules, and so forth clearly are challenging for people to adhere to. So we throw the majority of people into a situation they aren't equipped for on a daily basis. Then this becomes a major cause of legal efforts, that alienate perfectly good citizens from society and cause us to forfeit our civil rights.
You can claim that people just need to be responsible, or we need to pass some safety law but it's delusional. The truth is we don't have a replacement for this. The average person can't afford to be carted around, and we would need to get to a place where driving was purely recreation.
So we are going to need very good public mass transit options, and IMO some kind of vast network of professional drivers that are more affordable than Uber, for the occasional "cargo trips" or to go "the last mile" (more like 10-50).
WTF? Driving is by definition a privilege. You're maneuvering a 2-ton murder machine.
We got into the current mess because people treat driving as a right - I have to have parking, I have to get there fast, I have to bend everything society to fit my car. And when someone gets caught for a DUI, judges go lenient because they know that taking away their license will obliterate their means to work and live.
> So we are going to need very good public mass transit options, and IMO some kind of vast network of professional drivers that are more affordable than Uber
Sort of. We need denser cities and mixed-use neighborhoods so that people can live close to the goods and services they need. Transit is a feasible problem as evidenced by Europe and Asia. No society has operated under the assumption of a vast network of professional private vehicle drivers (so, disregard bus drivers).
> go "the last mile" (more like 10-50)
That's the problem. We have to stop designing cities like that.
At least in the US I can see a reasonable argument for most people needing to drive, but it's much less obvious people need to drive the vehicles they do the way that they do to meet basic transportation requirements. One obvious if almost certainly unpopular solution would be to have the basic drivers license you get now with essentially no effort only cover small speed limited cars that would pose far less risk to everyone else on the road. If you want or need something larger or faster, require a separate license with testing, experience, and re-certification requirements in-line with the extra responsibility operating such a vehicle should involve. You abuse that even a little, back to a GPS speed limited Corolla hatchback you go.
This addresses the issue with a lack of driving alternative while also addressing the cases where people need more than basic transportation. But I guarantee people would lose their minds and start setting fire to their local DMV if such a change were even theoretically proposed. Because the problem with car culture in the US (and elsewhere) isn't that driving is a necessity, it's that being a driver comes with such a massive sense of unearned entitlement that any restrictions at all for any reason are treated as a massive violation of God given rights. Even attempts to enforce existing laws are met with absurd levels of hostility, like the opposition to red light or speed cameras.
I say this as someone who likes driving and likes cars, but as someone who is also a private pilot, the reason we don't have a driving safety culture like we have a flying safety culture is that the absolute worst possible example of an unsafe pilot you could imagine is basically the average driver. And not only is that driving behavior accepted in a way it never would be in the aviation community, but it's treated as an unassailable right.
People only have to drive because they (either directly or via elected officials) chose to design large swaths of land that were only livable if cars were elevated to the preferred mode of travel. Better infrastructure design (in general, points of interest being built closer together) would obviate something like 90% of car trips.
But being forced to drive was absolutely a choice, and one that, with some effort, can be undone.
There are a lot of factors that really complicate this system.
Enforcement focuses on the wrong parameters. Police love to remind us that, "Speed is always a factor." Well, it's certainly the most easily measured one. The trouble is, what speed is wrong? Is it the 5 cars who want to drive 90mph on the freeway, or the 2 cars who want to drive 65 in both lanes? By obsessively enforcing speed limits, police have managed to perversely incentivize the difference in speed between drivers who are willing to risk a ticket, and drivers who self-righteously bottleneck traffic. I have never even heard of the law, "keep right except to pass" being enforced, even though it seems pretty obvious that it would help.
People don't want to drive. People have to drive. That reality perversely incentivizes drivers to minimize effort. There is very little motivating drivers to drive better than they need to. How could we possibly change this incentive? Fear tactics are not working. Threats are not working. This is an open question: what if it has no answer?
Infrastructure demands backwards-compatibility. We can't just build a new part of a city without roads. Where would people put their cars? If people living there didn't have cars, then where could they go? Where could they work? Could anyone visit? Utopia must have a compatibility layer: somewhere that alternative transit can transition to highways. But where? If you have to park your car away from home, then you need to manage the risk of unattended property. If you have to get a ride in someone else's car, is that affordable? If you are going to take a bus, how long will you have to wait? How many busses will you have to transfer between? No matter what we do, the compatibility layer will always be inefficient.
Infrastructure demands infrastructure. The only solution to more traffic is more road. The only solution to more road is longer driving distance. The only solution to longer driving distance is more time in traffic, which is identical to more traffic. The only way to stop growing this system is to stop growing the amount of drivers. How can that be done? In order to become a non-driver, you need a minimum viable alternative, otherwise you will have to drive just like everyone else. In order for alternative transit to be viable, there needs to be enough of it around that it feeds its own infrastructure demand. If alternative transit is built with a highway-compatibility layer, then that compatibility will effectively remove the need for alternative-transit growth. Realistically, alternative transit won't start demanding itself until its utility is equal to the highway system. We can't build that all at once, so how can we overcome the already-present highway infrastructure demand cycle?
No matter how you look at it, the highway system is feeding the worst aspects of itself into its own growth. The only way to change this cycle is to build a lot of alternatives really fast, and make them dirt cheap. It's a political nightmare. Even so, I would much rather live in that nightmare than the one where rubber meets the road.
I don't really agree that this is the "trouble". Any competent transit-related professional knows what type of driving is wrong. Even American cops know [0] that in terms of traffic the key thing is to not impede traffic and target dangerous driving.
However, hunting school zone speeders, left lane hoggers and traffic weavers will never generate as much revenue as using an automatic machine that points at cars going faster than arbitrary number.
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.
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.
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.
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.
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.
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 :)
Whoever got curious enough to enter this comment section: carve out some time to read the CAST handbook. It changed how I look at accidents but also how I look at organisations and the rest of the world. Should be mandatory reading for anyone in any position of responsibility.
I have long wanted to write a review/summary of it on my blog but it's so dense in useful content it's hard to compress further. (There's a reason I have not published it so please try not to judge it for its rough edges, but this is what the draft looked like when I gave up last time: https://two-wrongs.com/root-cause-analysis-youre-doing-it-wr...)
Thank you for posting your summary! I appreciate summaries because each individual finds something different to emphasize about the text.
Have you looked at the book "Handbook of Systems Thinking Methods" (2023, Salmon, Stanton, et al)? It's all about applying systems thinking to safety and talks about the STAMP-CAST model.
Thanks for that, I really appreciated this breakdown of the accident at Three Mile Island and the concept of 'the second story' with regards systems thinking; https://www.youtube.com/watch?v=1xQeXOz0Ncs
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".
>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.
> Also nitpicking about the headline: You haven't been in a place crash because you wouldn't be reading this if you were :)
Do you mean to imply that being in a plane crash is certain to result in death? Because that's definitely not true. Even when they crash hard enough to explode, there are sometimes still survivors.
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.
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:
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.
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.
Readit News
- An accident is a combination of the system being in a hazardous state and unfavourable environmental conditions that turn the hazard into an accident.
- A near miss is when the system was in the hazardous state but the environmental conditions were in our favour so the accident didn't happen.
We can't control environmental conditions, we can just make sure to keep the system out of the hazardous state. This means a near miss contains all we need to perform a proper post mortem. The environmental conditions are really immaterial.
https://en.wikipedia.org/wiki/NOAA-19#Damage_during_manufact...
Deleted Comment
But of course the developers will revolt against that.
[1]: https://www.youtube.com/watch?v=ISNGimMXL7M
Back to aviation, I can recommend these channels that explain air accidents: https://www.youtube.com/@MentourPilot/videos , https://www.youtube.com/@MiniAirCrashInvestigation/videos , https://www.youtube.com/@AirSafetyInstitute/videos
Seems like progress; a near-miss noticed is indeed a real gift, if followed-up.
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 Comment
https://cohost.org/mononcqc/post/888958-paper-going-solid
I've not been following closely, but I suspect the Post Office did not follow this. Are there ramifications happening along these lines for the Post Office fiasco? Or is it already a big enough thing that this would just be "oh, and also that too I guess" kind of thing?
This is her Medium article on the LAX runway collision: 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_Contr...)
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.
Too bad really. So what if you get to watch yourself die horribly, you die either way! You will still be pasta sauce on the other end of the incident, you really shouldn't care. You might have a stronger spike of adrenaline than otherwise, but that's not going to hurt you any more than being pulverized will.
Does anyone know how she became so good at writing about airline disasters? She doesn’t seem to have any sort of aviation background.
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/ 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/@NotJustBikes/videos , https://www.youtube.com/@CityNerd/videos
The car industry, car culture, and car centric thinking in the US and much of the world is totally out of control.
One, I think, is that flying is something that is being done to us, and driving is something that we do ourselves. So the agency, the point of view is very different. Something bad happening while being passive is much more horrifying because of the powerlessness.
The other is that cars and driving environments differ a lot, while planes are much more similar to each other. What I mean by this is that it's easier to dissociate the car deaths, because that happens to some other people over there, nothing like me, but plane badness happens to everyday folk in a big winged tube, like me.
I think that if we drove the planes ourselves, the issues would be much more similar. And similarly, if everyone took the train, the bus, or a ship, and similar things would happen to a train, bus or ship, the freakout would be similar to what we see now with planes.
TIL that car fatalities were declining until 2019, and then reversed and are getting worse.
What happened in the last five years? Safety features of the cars themselves are improving (emergency braking). Alcohol may be a factor, but why in the last five years? Cars have been big for a while. WFH probably reduced commuting time. Other countries appear to be on the decline.
Ironically, heavy traffic is one of the better "safety features" of our automobile transportation system. Since crowded roads are higher-conflict roads, there is a bit of luck in the fact that traffic slows down when it gets crowded. There may be more collisions, but they are less deadly.
Suddenly there is a pandemic, and there are orders of magnitude fewer people on the roads. The number of collisions goes down, but the number of deaths goes up, because all of the collisions are at higher, deadlier speeds.
---
Driving Went Down. Fatalities Went Up. Here's Why. by Charles Marohn
https://www.strongtowns.org/journal/2022/1/10/driving-went-d...
Per your link, fatalities per mile drive bottomed out in 2014 and barely dropped after 2010. There's been some speculation that this reversal in safety was tied to the rise of smartphones and a corresponding increase of distracted driving.
There were stories about this effect, even as total collisions went down because of the bigger drop in VMT[1]. I speculated that this was a combination of
a) the above effect (stripping out the safer commuter trips), plus
b) the roads being dominated by people least willing to follow the advice to stay home, which correlates with being anti-social and reckless (mean though that sounds! [2])
My facebook friends suggested
c) the immense stress of coping with the Covid world made the average person less able to concentrate.
I also suspect:
d) traffic enforcement was reduced and drivers gradually started branching out into more aggressive maneuvers as they became aware of this.
Note that people saw their car insurance rates go down during covid because the typical personal policy only cares about accidents per unit time, and rarely adjusts for miles driven.
But I don't know why it hasn't regressed to the pre-covid levels -- probably because WFH hasn't completely reversed.
[1] https://www.npr.org/sections/coronavirus-live-updates/2020/0...
[2] https://news.ycombinator.com/item?id=39179818
It is much more likely we hit a plateau in improvement and now we are just fluctuating around an equilibrium.
Planes: sometimes pilot error, often mechanical/maintenance. Almost never because the pilot is flying like a wanker.
Cars: sometimes driver error/inexperience, sometimes mechanical/maintenance, almost always because the driver is driving like a wanker.
Still, I appreciate the people who do it.
This could change with public transit, however we don't do this. Even the best countries fall short, and most don't get close. It's actively discouraged in the USA.
Actually, you could argue that people already have to deal with too much BS to drive. The paperwork, rules, and so forth clearly are challenging for people to adhere to. So we throw the majority of people into a situation they aren't equipped for on a daily basis. Then this becomes a major cause of legal efforts, that alienate perfectly good citizens from society and cause us to forfeit our civil rights.
You can claim that people just need to be responsible, or we need to pass some safety law but it's delusional. The truth is we don't have a replacement for this. The average person can't afford to be carted around, and we would need to get to a place where driving was purely recreation.
So we are going to need very good public mass transit options, and IMO some kind of vast network of professional drivers that are more affordable than Uber, for the occasional "cargo trips" or to go "the last mile" (more like 10-50).
> We have to drive and it's a right.
WTF? Driving is by definition a privilege. You're maneuvering a 2-ton murder machine.
We got into the current mess because people treat driving as a right - I have to have parking, I have to get there fast, I have to bend everything society to fit my car. And when someone gets caught for a DUI, judges go lenient because they know that taking away their license will obliterate their means to work and live.
> So we are going to need very good public mass transit options, and IMO some kind of vast network of professional drivers that are more affordable than Uber
Sort of. We need denser cities and mixed-use neighborhoods so that people can live close to the goods and services they need. Transit is a feasible problem as evidenced by Europe and Asia. No society has operated under the assumption of a vast network of professional private vehicle drivers (so, disregard bus drivers).
> go "the last mile" (more like 10-50)
That's the problem. We have to stop designing cities like that.
This addresses the issue with a lack of driving alternative while also addressing the cases where people need more than basic transportation. But I guarantee people would lose their minds and start setting fire to their local DMV if such a change were even theoretically proposed. Because the problem with car culture in the US (and elsewhere) isn't that driving is a necessity, it's that being a driver comes with such a massive sense of unearned entitlement that any restrictions at all for any reason are treated as a massive violation of God given rights. Even attempts to enforce existing laws are met with absurd levels of hostility, like the opposition to red light or speed cameras.
I say this as someone who likes driving and likes cars, but as someone who is also a private pilot, the reason we don't have a driving safety culture like we have a flying safety culture is that the absolute worst possible example of an unsafe pilot you could imagine is basically the average driver. And not only is that driving behavior accepted in a way it never would be in the aviation community, but it's treated as an unassailable right.
But being forced to drive was absolutely a choice, and one that, with some effort, can be undone.
Enforcement focuses on the wrong parameters. Police love to remind us that, "Speed is always a factor." Well, it's certainly the most easily measured one. The trouble is, what speed is wrong? Is it the 5 cars who want to drive 90mph on the freeway, or the 2 cars who want to drive 65 in both lanes? By obsessively enforcing speed limits, police have managed to perversely incentivize the difference in speed between drivers who are willing to risk a ticket, and drivers who self-righteously bottleneck traffic. I have never even heard of the law, "keep right except to pass" being enforced, even though it seems pretty obvious that it would help.
People don't want to drive. People have to drive. That reality perversely incentivizes drivers to minimize effort. There is very little motivating drivers to drive better than they need to. How could we possibly change this incentive? Fear tactics are not working. Threats are not working. This is an open question: what if it has no answer?
Infrastructure demands backwards-compatibility. We can't just build a new part of a city without roads. Where would people put their cars? If people living there didn't have cars, then where could they go? Where could they work? Could anyone visit? Utopia must have a compatibility layer: somewhere that alternative transit can transition to highways. But where? If you have to park your car away from home, then you need to manage the risk of unattended property. If you have to get a ride in someone else's car, is that affordable? If you are going to take a bus, how long will you have to wait? How many busses will you have to transfer between? No matter what we do, the compatibility layer will always be inefficient.
Infrastructure demands infrastructure. The only solution to more traffic is more road. The only solution to more road is longer driving distance. The only solution to longer driving distance is more time in traffic, which is identical to more traffic. The only way to stop growing this system is to stop growing the amount of drivers. How can that be done? In order to become a non-driver, you need a minimum viable alternative, otherwise you will have to drive just like everyone else. In order for alternative transit to be viable, there needs to be enough of it around that it feeds its own infrastructure demand. If alternative transit is built with a highway-compatibility layer, then that compatibility will effectively remove the need for alternative-transit growth. Realistically, alternative transit won't start demanding itself until its utility is equal to the highway system. We can't build that all at once, so how can we overcome the already-present highway infrastructure demand cycle?
No matter how you look at it, the highway system is feeding the worst aspects of itself into its own growth. The only way to change this cycle is to build a lot of alternatives really fast, and make them dirt cheap. It's a political nightmare. Even so, I would much rather live in that nightmare than the one where rubber meets the road.
I don't really agree that this is the "trouble". Any competent transit-related professional knows what type of driving is wrong. Even American cops know [0] that in terms of traffic the key thing is to not impede traffic and target dangerous driving.
However, hunting school zone speeders, left lane hoggers and traffic weavers will never generate as much revenue as using an automatic machine that points at cars going faster than arbitrary number.
[0] - https://www.youtube.com/watch?v=yn6C6ZkBdb0
I want to drive. I love to drive. It's one of my favourite hobbies. What better way to get out and see such a diverse amount of the countryside?
I frequently drive 4 hours through a mountain pass to the other side of the island and it's absolutely breathtaking.
Road trips are our preferred holiday.
There is no public transport in these places and if there was why would I want to spend time with a bunch of random mouth breathers?
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.
'Blameless' doesn't work for corporations though.
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.
[0]: https://www.reddit.com/6ez8ag/
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.
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 :)
I have long wanted to write a review/summary of it on my blog but it's so dense in useful content it's hard to compress further. (There's a reason I have not published it so please try not to judge it for its rough edges, but this is what the draft looked like when I gave up last time: https://two-wrongs.com/root-cause-analysis-youre-doing-it-wr...)
Have you looked at the book "Handbook of Systems Thinking Methods" (2023, Salmon, Stanton, et al)? It's all about applying systems thinking to safety and talks about the STAMP-CAST model.
We have a kick-ass politician in switzerland who survived a avalanche (1993) and a Plane-crash [1] (2001)
[1]https://en.wikipedia.org/wiki/Crossair_Flight_3597
https://en.wikipedia.org/wiki/Jacqueline_Badran
According to this 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
Do you mean to imply that being in a plane crash is certain to result in death? Because that's definitely not true. Even when they crash hard enough to explode, there are sometimes still survivors.
https://news.ycombinator.com/item?id=7370320
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.
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-leadersh... 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.
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.