Back in 2009 when I was backpacking around Europe I remember waking up on the morning of June 1 and reading about how an Air France flight had disappeared somewhere over the Atlantic.
The lack of information on what happened to the flight intrigued me, and given the traveling I was doing, I was left wondering “what if I was on that plane?”
Keeping an ear out for updates, in December 2011 I stumbled upon the Popular Mechanics article describing the final moments of the flight. I was left fascinated by how a technical system so advanced could fail so horribly, apparently because of the faulty meatware operating it.
Around the same time I began reading the works of Sidney Dekker. I was left in a state of cognitive dissonance, trying to reconcile the mainstream explanation of what happened in the final moments of AF447 (the pilots were poorly trained, inexperienced, and simply incompetent) with the New View that the operators were merely locally rational actors within a complex system, and that “root cause is simply the place you stop looking further” - with that cause far too commonly attributed to humans.
I decided to do my own research, which resulted in me producing a talk that has received the strongest reaction of any talk I’ve ever given.
On June 1, 2009 Air France 447 crashed into the Atlantic ocean killing all 228 passengers and crew. The 15 minutes leading up to the impact were a terrifying demonstration of the how thick the fog of war is in complex systems.
Mainstream reports of the incident put the blame on the pilots - a common motif in incident reports that conveniently ignore a simple fact: people were just actors within a complex system, doing their best based on the information at hand.
While the systems you build and operate likely don’t control the fate of people’s lives, they share many of the same complexity characteristics. Dev and Ops can learn an abundance from how the feedback loops between these aviation systems are designed and how these systems are operated.
In this talk Lindsay will cover what happened on the flight, why the mainstream explanation doesn’t add up, how design assumptions can impact people’s ability to respond to rapidly developing situations, and how to improve your operational effectiveness when dealing with rapidly developing failure scenarios.
The subject matter is heavy, and I while it’s something I’m passionate about, it was an emotionally taxing talk to prepare, and a talk that angers me when presenting.
Time to let it sit and rest.
