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Comment by YZF | Hacker News Reader

This is part of the Israeli Air Force safety culture: https://www.talentgrow.com/podcast/episode92

"By implementing a unique culture and methodology, the Israeli Air Force became one of the best in the world in terms of quality, safety, and training, effectively cutting accidents by 95%."

Near misses and mistakes are investigated and there's a culture supporting the reporting of these and that has resulted in a huge change to the overall incident rate.

Software is a little like this as well. The observable quality issues are sort of the tip of the iceberg. Many bugs and architectural issues can lurk underneath the surface and only some random subset of those will have impact. Focus only on the impactful ones without dealing with what's under the surface may not have a material impact on quality.

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> Software is a little like this as well. The observable quality issues are sort of the tip of the iceberg.

Most of the places I've worked cannot even resolve all of their observable quality issues, let alone the hidden ones. Hell, at most places I've worked, either it's a P0 emergency, a P1 must-do, or the defect will basically never be fixed, despite how visible it is or easy it is to diagnose and correct. The bug list always grows far faster than things get resolved, until it gets to a certain size and someone decides to "declare bankruptcy" and mass-close everything older than N days. Then, the cycle continues.

Similar situation. The P0 interest tends to immediately cease when there is sticky tape mitigation in place as well. There is no resolution. It just dangles waiting to bite again.

> Most of the places I've worked cannot even resolve all of their observable quality issues, let alone the hidden ones.

Just remember...

> Nobody gives a hoot about profit. — W. Edwards Deming

Yep, the only approach I've ever seen to quality from the top is hot air.

It’s demoralizing how the number of times an event has to happen for action to occur is quadratic to the severity (1 being highest).

Troubling things have to happen three or four times and super annoying has to happen dozens before anyone acts, let alone gets a mandate to do so.

There's nothing wrong with improving organizational reporting culture, but the "cutting accidents by 95%" claim seems highly dubious to me. If you take it from the opposite angle, how could a poor reporting culture alone cause twenty times more accidents?

I don't think it's reasonable to expect similar improvements as those claimed here in most settings, and indeed it would be dangerous to do so if it means compromising other safety measures. Much is made of the good reporting culture in civil aviation, for instance, but that only helps if every other aspect of civil aviation has safety regarded as a priority. Reporting culture won't help you when your Boeing 737 MAX 8 has just started an uncommanded nosedive!

> Reporting culture won't help you when your Boeing 737 MAX 8 has just started an uncommanded nosedive!

It should have helped by reporting this many, many times before said uncontrolled nosedive.

Looking at Lion Air Flight 610, all deaths could have been avoided given perfect communication about the fault:

People familiar with the investigation reported that during a flight piloted by a different crew on the day before the crash, the same aircraft experienced a similar malfunction but an extra pilot sitting in the cockpit jumpseat correctly diagnosed the problem and told the crew how to disable the malfunctioning MCAS flight-control system.

...

After the accident, the United States Federal Aviation Administration and Boeing issued warnings and training advisories to all operators of the Boeing 737 MAX series, reminding pilots to follow the runaway stabilizer checklist to avoid letting the MCAS cause similar problems.

...

These training advisories were not fully followed, however, and similar issues caused the crash of Ethiopian Airlines Flight 302 on 10 March 2019, prompting a worldwide grounding of all 737 MAX aircraft.

Agreed. I know enough about aviation that this is simply "goosing the metrics" by redefining "accident" and "frequency".

Related to Boeing, everyone knew their goose was cooked as soon as they didn't have sign-offs and checklists on those door bolts. Hell, even the AvGas delivery guy at a dirt-strip muni airport with no tower MUST have sign-offs and checklists in triplicate.

> Reporting culture won't help you when your Boeing 737 MAX 8 has just started an uncommanded nosedive!

Yet, it took until the second MCAS caused crash for the 737 MAX 8 to get grounded. Discounting the role of good incident reporting and investigation based on that example seems silly.

> how could a poor reporting culture alone cause twenty times more accidents?

If you assume that the majority of accidents are caused unrecognized design or process defects, then near miss reporting and investigation can allow these defects to be identfied before they cause an accident. The plausibility of a 95% reduction depends a great deal on how poor the safety record was going into that change.

The first incident of an uncommanded nosedive in a MAX that later crashed was actually avoided by the crew, who disabled electronic trim before it overwhelmed the ability to correct the issue with the smaller manual trim wheels of the MAX. So there was a near miss before the first crash. The next crew didn't disable electronic trim in time, and the decreased manual trim wheel size meant they couldn't move the horizontal stabilizer back into trim.

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