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The difference between the 2 different answers at the top could seem small, but the different framing makes all the difference
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hence, low robustness and low resilience (and need to improve sensor system reliability) ...
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Each of these was badly misjudged in the 737 Max case relative to possible upsets (e.g. consequences of sensor failures) and the dynamics of upsets (a narrow window of opportunity to correct for a situation at risk of spinning out of control) ...
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the MCAS system was (a) very persistent with strong control authority (b) its role was invisible or oversimplified in training, practice and displays (c) re-directing MCAS and coordinating with the different automated systems was difficult in real time as the upset progressed
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Remember the findings in cockpit automation research: strong, silent, difficult to direct automation is a trigger to accident sequences and undermines the ability to respond effectively, & then …
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The latter approach requires looking hard at how situations can present difficulties, uncertainties & potentially spin out of control and then working to empower pilots to see and handle emerging difficulties despite uncertainty and time pressure. …
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If Boeing presents their changes as improving reliability, robustness and resilience of the modified 737 Max, then their systems engineering is likely to have redressed their previous technical errors. …
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If Boeing presents their changes to the 737 Max as guards against the limits of pilots, then there is a risk the systems engineering process could be limited or incomplete. …
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How do we know if we can trust Boeing’s re-engineering of the 737 Max? …
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New capabilities trigger wide reverberations including new forms of complexity & risks Failure to anticipate new challenges that are certain to arise following periods of technology change leads to surprising negative unintended consequences that offset apparent benefits
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Envisioning the future is a precarious subject to biases. Past work has shown claims about the effects of future technology change are underspecified, ungrounded, and overconfident, whereas new risks are missed, ignored, or downplayed.
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New safety differently video and trailer has been released! https://www.youtube.com/watch?v=6gREMV6j2A4 … And here is the trailer:https://www.youtube.com/watch?v=AXStSMAQWps …
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1969 was scary for a teenager. Lyrics of album then - 21st century schizoid man, Epitaph & Court of Crimson King - capture our scary world today 50 years later (just got shade a bit off)
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Don’t blame the dog for the water on the floor when there’s a hole in the roof. Woods & Rayo discussing misunderstandings of Safety II
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#REA2019 at first day of the Resilience Engineering Association symposium in Kalmar Sweden. A great gathering of over 140 people from multiple industries exploring how to support resilient performance.Hvala. Twitter će to iskoristiti za poboljšanje vaše vremenske crte. PoništiPoništi -
see issue #2 out today with 2 pieces where I discuss implications of the Boeing 737 Max failures https://airtrafficmanagement.keypublishing.com/the-magazine/
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analysis of ED adaptation to overload. “Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion.” click on this link before July 04, 2019 to download https://authors.elsevier.com/a/1Z37J15SQcXrjo …
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See Gary Klein carefully step by step take down the superficial overuse of confirmation bias https://www.psychologytoday.com/us/blog/seeing-what-others-dont/201905/the-curious-case-confirmation-bias … start with the actual data from original study - a lot didn't show the effect
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"fundamental surprise often is denied ... redefine the incident ... as if ... only a situational surprise ... lead to denial of any need to change or to attribution of the “cause” to local factors with well-bounded responses". Applies now after crashes?
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Stakeholder reactions to the 2 737Max accidents show signs of "The fundamental surprise error is to re-interpret an event that challenges basic assumptions as if it were merely due to narrow local factors.” p. 207 Woods et al., 1994, Behind Human Error
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