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carbonatedmilk | 2 years ago

One of the best things I've learnt recently is how to apply the zero blame, process improvement approach that (many) air safety regulators take to my own teams.

I'd sat through 'five whys' style postmortems before, but it was reading air safety investigation reports that finally got me to understand it and make it a useful part of how we get better at our jobs.

By comparison, the way we're investigating and responding to self-driving safety incidents still seems very primitive. Why is that?

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cameldrv|2 years ago

My guess is that Waymo does do this internally.

One difference with this situation in terms of the public perception/discussion though is that, say in the 1960s, air safety wasn't very good compared to today, but still there was no question of eliminating air travel altogether due to safety issues. Today there is definitely an anti-self-driving contingent that would like to hype up every accident to get the self driving companies shut down entirely.

extua|2 years ago

Another comparison with air safety, the disaster risk threshold is high enough to ground vehicles with suspected faults or flaws.

In this case two self-driving cars crashed into another road vehicle because they failed to recognise (in time) which direction it was moving. Waymo should be commended for having voluntarily issued a software recall, but this problem is severe enough that the decision shouldn't really be up to Waymo's good judgement.

esafak|2 years ago

Where did you learn about that approach, and how is it different?

sokoloff|2 years ago

Not GP, but:

There is an explicit culture and mechanism of blamelessness around safety concerns and minor violations/deviations, which is incredibly helpful. Read about the ASRS* program (admin'd by NASA, with anonymity for non-intentional issues, prohibition on use of submissions for enforcement purposes, and explicit "get out punishment" card from the FAA): https://asrs.arc.nasa.gov/overview/immunity.html

The FAA is also explicitly including "evidence of voluntary compliance" and "just culture" in its approach to aviation safety, and explicitly changed its goal from enforcement and proof to ensuring compliance [with enforcement being only one available tool]: https://www.faa.gov/about/initiatives/cp (PDF pres: https://www.faa.gov/sites/faa.gov/files/2022-09/The%20Compli... )

I'd also read a bunch of aviation reports: https://www.ntsb.gov/Pages/monthly.aspx (more detailed reports are available approximately 2 years after the occurrence date and more details are available for fatal or air carrier occurrences, so if you don't care which ones to read, filter for those to start).

If you're more video oriented, watch @blancolirio, @NTSBgov, @AirSafetyInstitute, or @pilot-debrief. (I'd skip @ProbableCause-DanGryder.)

For a short summary, there is an intense focus on determining the facts (who, what, when, where, maybe some guesses as to why) and drawing conclusions about primary and contributing causes from there.

* Aviation Safety Reporting System