IS YOUR TEAM INSTRUMENT RATED? (OR DEPLOYING 89,000 TIMES A - - PowerPoint PPT Presentation

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IS YOUR TEAM INSTRUMENT RATED? (OR DEPLOYING 89,000 TIMES A - - PowerPoint PPT Presentation

Jan 21, 2024 136 likes •705 views

IS YOUR TEAM INSTRUMENT RATED? (OR DEPLOYING 89,000 TIMES A DAY) J. Paul Reed Principal Consultant Friday, May 9, 14 J. P AUL R EED Fifteen years as a build/release engineer Sober Build Engineer @SoberBuildEng Friday, May

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IS YOUR TEAM INSTRUMENT RATED?

(OR DEPLOYING 89,000 TIMES A DAY)

  • J. Paul Reed

Principal Consultant

Friday, May 9, 14

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  • J. PAUL REED
  • Fifteen years as a build/release engineer
  • “Sober Build Engineer”
  • @SoberBuildEng

Friday, May 9, 14

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AVAILABLE ON ITUNES!

www.theshipshow.com @ShipShowPodcast

@eciramella @buildscientist @cheeseplus @sascha_d

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IN PREPARATION FOR OUR FLIGHT...

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“CULTURE?”

Set of shared mental assumptions that guide interpretation and action in organizations by defining appropriate behavior for various situations.

– Ravisi & Schultz, via Wikipedia

(via Damon’s talk)

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“CULTURE” FOR TODAY Incentives + Human Factors

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“CULTURE” FOR TODAY Incentives + Human Factors

(organizational, behavioral, and economic) (methods for facilitating and fostering those incentives)

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WHY AVIATION?

Craft Provided unique requirements, individuals perfecting their own methods & techniques Trade Groups of “craftspeople” sharing domain knowledge Science Processes consistently repeatable by others, under different environments/conditions Industry Reduce/combine processes to

  • ptimize for specific business

requirements or outcomes

“ P r

  • g

r e s s ”

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WHY AVIATION?

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WHY AVIATION?

But... when we’re talking incident response, the house is already on fire

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WHY AVIATION? Dev Ops

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WHY AVIATION? Dev Ops

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WHY AVIATION?

Scale much?

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VISUAL FLIGHT RULES

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VISUAL FLIGHT RULES

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VISUAL FLIGHT RULES

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INSTRUMENT FLIGHT RULES

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INSTRUMENT FLIGHT RULES

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INSTRUMENT FLIGHT RULES

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  • Standardization
  • Communication
  • Expectations
  • Remediation

WHAT IT IS

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STANDARDIZATION

A set of

  • perational

primitives based

  • n your
  • rganizational

and business requirements.

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STANDARDIZATION

Leveraged to define your

  • perational

procedures.

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STANDARDIZATION

Leveraged to define

  • perational

procedures. Leveraged to define your

  • perational

procedures.

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  • Standardization
  • Communication
  • Expectations
  • Remediation

WHAT IT IS

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COMMUNICATION

“We're cleared to New York's JFK Airport via the SAN FRANCISCO EIGHT, radar vectors to Linden, direct JSICA, direct Wilson Creek, Jet 80, Kansas City, Jet 24, Saint Louis, direct Brickyard, direct Rosewood, Jet 29, Jamestown, Jet 70, Wilkes Barre, to the LENDY FIVE arrival into JFK; climb and maintain fifteen, one-five-thousand; expect three- five-zero in ten; squawk six-three-seven-seven.”

– Redwood Flight 34’s Inaugural Clearance

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COMMUNICATION

SFO SFO8 LIN JSICA ILC J80 MCI J24 STL VHP ROD J29 JMS J70 LVZ LENDY5

– Redwood Flight 34’s Inaugural Clearance

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COMMUNICATION

In other words, trying to avoid this...

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  • Hesitance to use appropriate terms to communicate the

situation

  • A transcontinental Boeing 707 arrives low on fuel & to bad

weather; pilots do not use the single phrase necessary–“we’re declaring an emergency”–which would have activated emergency services (Avianca Flight 52)

  • Misuse of defined terminology
  • In 1995, a controller clears a 757 “directly” to the airport,

setting off an accident chain (American Airlines Flight 965)

COMMUNICATION

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  • Standardization
  • Communication
  • Expectations
  • Remediation

WHAT IT IS

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EXPECTATIONS

Once standards are established and requirements/ intentions communicated, expectations and responsibilities can be derived.

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  • Standardization
  • Communication
  • Expectations
  • Remediation

WHAT IT IS

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WHAT IT IS

With expectations and responsibilities clarified, remediation processes can be integrated into processes & automation, not tacked

  • n or “invented on the fly.”

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  • Static
  • Blind reliance on automation, tooling, or process
  • “Fun-Verboten”

WHAT IT IS NOT

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NOT STATIC

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  • Static
  • Blind reliance on automation, tooling, or process
  • “Fun-Verboten”

WHAT IT IS NOT

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NOT AUTOMATION?!

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  • Misreading/looking at the wrong metrics
  • A 737 suffers an engine “disturbance”; after not looking at all

the appropriate instruments, pilots shut down the good engine; the remaining (bad) engine eventually fails fully (British Midlands Flight 92)

  • Partial automation failure and resulting confusion
  • After a series of instrument failures in the highly-automated

A-330, the junior pilot pulls the plane into a prolonged stall (Air France 447)

NOT AUTOMATION?!

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NOT AUTOMATION?!

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  • Static
  • Blind reliance on automation, tooling, or process
  • “Fun-Verboten”

WHAT IT IS NOT

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NOT “FUN VERBOTEN”

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NOT “FUN VERBOTEN”

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  • Define organizational vocabulary & process primitives
  • Formalize roles, responsibilities, and priorities
  • Understand (current) limitations
  • Investigate outcomes

GETTING “INSTRUMENT RATED”

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DEFINE YOUR APPROACHES

  • Define what you do today,

focusing on the “operational requirements”

  • Derive (or define)

primitives

  • Define your operational

dictionary

  • Make sure they’re owned!

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  • Define organizational vocabulary & process primitives
  • Formalize roles, responsibilities, and priorities
  • Understand (current) limitations
  • Investigate outcomes

GETTING RATED

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FORMALIZE “2R+P”

  • Be able to answer “Who is responsible for that?”
  • Drill/train or delegate
  • Determine “priority classes”

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  • Define organizational vocabulary & process primitives
  • Formalize roles, responsibilities, and priorities
  • Understand (current) limitations
  • Investigate outcomes

GETTING RATED

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LINE UP AND WAIT

For organizational change to even be a possibility, the current limitations need to be internalized.

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KNOW WHEN TO HOLD ‘EM

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  • Define organizational vocabulary & process primitives
  • Formalize roles & responsibilities
  • Understand (current) limitations
  • Investigate outcomes

GETTING RATED

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“OOPS” WILL HAPPEN

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  • NASA Aviation Safety Reporting System
  • Separation of investigation roles
  • National Transportation Safety Board
  • “No Blame” postmortems
  • (Though not for the reason you might think!)

AFTER THE “OOPS”

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OPERATIONAL MODELS Incentives + Human Factors

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  • J. Paul Reed

www.soberbuildengineer.com @SoberBuildEng

www.releng-approaches.com Simply Ship. Every Time.

Friday, May 9, 14