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Count to ten when a plane goes down

1112 pointsby UltraMagnusalmost 11 years ago

23 comments

noisy_boyalmost 11 years ago
Firstly, firing the intern doesn&#x27;t make sense - it was a mistake waiting to happen and he just happened to do it at the wrong time.<p>Secondly, the punishment meted out should be:<p>1. Proportional to the degree of carelessness (in this case not that much since he accidentally hit a wrong key adjacent to the right one, didn&#x27;t mow down anybody while driving drunk)<p>2. Inversely proportional to the likelihood of the error (in this case the likelihood was very high since the reset key was a. uncovered&#x2F;single-press b. right next to single reset key).<p>3. Proportional to intention (this was a completely unintentional error)<p>If you say, that the punishment should also be dependent on the degree of damage, I would say that the responsibility of managing the risk of such damage wasn&#x27;t his but of the person responsible for implementing such a high risk design. If such a person is not around, find the person who approved such a design. Government departments are usually very good with paper trail.
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mikegrecoalmost 11 years ago
The author states they felt it was appropriate when they were fired. In what world would it be appropriate to get fired for a single, simple, incredibly easy to make mistake? Doubly insane when there were exactly zero safeguards in place to prevent the mistake from being made.
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ck2almost 11 years ago
How about when Russia returned the data recorders after years of refusing to South Korea - made a press spectacle of it - and then South Korea discovered the recorders were empty and missing the data tapes when the press was gone.<p>Or the US navy crew who received medals after shooting down the Iranian airline.<p>Once there is loss of life, it is 100% politics afterwards with little to no practicality, just look at all the mass shootings where there were zero changes afterwards. We simply do not value life, it is politics first.
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jackschultzalmost 11 years ago
The issue form most new stories is that even when the truth comes out, the great majority of people will never hear the actual facts. One issue is because news stations move on from caring about the story quickly. Or, the bigger issue in my opinion, is that people won&#x27;t believe the new, correct facts since the old ones will have been engrained in their head. Solving both these issues would be really helpful for society, but are obviously damn hard to solve since we haven&#x27;t really gotten anywhere in this space.
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justizinalmost 11 years ago
It&#x27;s a sign of poor management that someone has to be fired when something goes wrong, outages are learning situations for all involved, and it is widely held that the person who took the action that caused an outage is not responsible, but that all involved are responsible.<p>See John Allspaw&#x27;s Swiss Cheese Theory : <a href="http://www.kitchensoap.com/2012/02/10/each-necessary-but-only-jointly-sufficient/" rel="nofollow">http:&#x2F;&#x2F;www.kitchensoap.com&#x2F;2012&#x2F;02&#x2F;10&#x2F;each-necessary-but-onl...</a> .<p>[ Edit: I guess it&#x27;s not Allspaw&#x27;s model, but he applies it to systems engineering rather well - <a href="http://en.wikipedia.org/wiki/Swiss_cheese_model" rel="nofollow">http:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;Swiss_cheese_model</a> ]<p>&quot;Accidents emerge from a confluence of conditions and occurrences that are usually associated with the pursuit of success, but in this combination—each necessary but only jointly sufficient—able to trigger failure instead.&quot;<p>The person who pushed the button is not at fault, the manager is not at fault, the guy who designed the button is not at fault - all are jointly responsible.<p>Blaming the intern does, however, reflect extremely poorly on Itoh and everyone else in the chain of command. A superior who demands retribution for a simple mistake that happened to cause him or her pain is basically worthless.<p>But, I forget, we&#x27;re talking about Ronald Reagan.
tokenadultalmost 11 years ago
I remember this time sequence very well because I was living in Taiwan when the incident happened. Yes, people who lived in east Asian time zones saw news reports that appeared to be based on knowledgeable sources that the plane might have landed safely with all passengers alive. This explanation of why the Western-aligned diplomats and military officials based in east Asia didn&#x27;t have complete information when they were interviewed by the press is quite interesting, and explains puzzling memories I have from that day.
jerealmost 11 years ago
&gt;And let’s hope that there is no stupid 23-year-old with his finger on an important keyboard in this information chain.<p>No. This is something you would read in <i>Design of Everyday Things</i> where Don Norman would totally shame the the engineers who made that system. Software shouldn&#x27;t be designed with the assumption that no one makes errors.
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koseialmost 11 years ago
Really brave of the author to share this story. I know most people would be afraid to admit this kind of a public &quot;mistake&quot;.
dictumalmost 11 years ago
Further reading for those who want to be disabused of the concept of <i>human errors</i>:<p><a href="https://en.wikipedia.org/wiki/The_Design_of_Everyday_Things" rel="nofollow">https:&#x2F;&#x2F;en.wikipedia.org&#x2F;wiki&#x2F;The_Design_of_Everyday_Things</a>
abcd_falmost 11 years ago
&gt; <i>That Korean announcement and the slow response by the US President — both caused by delayed real information — caused decades of conspiracy theories.</i><p>I appreciate that the OP was a part of the situation, but conspiracy theories were <i>not</i> caused by this.<p>It was time of <i>very</i> high tension between the US and Soviet Union. So when a plane veers off the course into not just Soviet airspace, but into an explicitly cordoned off top secret area, ignores all communication attempts, ignores the presence of fighter jets and just keeps on flying, then the situation itself is a fertile soil for conspiracy theories.
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steven2012almost 11 years ago
Wow. I got goosebumps when I read that article. I&#x27;m old enough to actually remember when KAL 007 was shot down, and while I wasn&#x27;t old enough to hear about the conspiracy theories, I do remember the thing about people being safe and landing in Russia. To think that this was just a small mistake on the part of someone, which caused international ripple effect, and who later blogged about it is really something incredible.
userbinatoralmost 11 years ago
&quot;With great power comes great responsibility.&quot;<p>Incidentally, &quot;features&quot; like this are why I don&#x27;t trust systems that have some centralised control - IMHO giving any one individual (or organisation, in many cases these days) such power over others is not a good thing.
disputinalmost 11 years ago
Scapegoat. The ritual expulsion of the evil spirits wrapped neatly in a little parcel to appease the elders and thereby prevent them blaming each other - harmony continues in the hall of power. Meanwhile the problem was in the process, not the employee, so nothing has been fixed, and the guy who had learned the lesson is no longer there, and so the problem will recur with the next lamb to the slaughter.
ryanobjcalmost 11 years ago
I disagree that it was appropriate that you were fired, but interesting story all about.
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lotsofmangosalmost 11 years ago
I often suspect that most of the work involved in keeping a power hierarchy going, is involved with trying to pretend that this kind of shit doesn&#x27;t happen all the time.
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privatedanalmost 11 years ago
My first thought after reading the article was that it was ridiculous to fire&#x2F;scapegoat the author for hitting the wrong key, too. This has happened to me before, where a single keystroke ( in my case, a line break in a config file ) caused me to take down a production system. My punishment? Designing a more robust system that would protect itself from a badly formatted config file. To this day, ten years later, a similar error has not been repeated, despite several attempts of people to push bad config files to our production systems. If I had been instead fired, no doubt a similar, but perhaps not exact, error would have been repeated every year or so.<p>If I had made the same mistake twice without any attempts to fix the situation long term, then, yes, I think that would have been a fire-able offense.<p>If you&#x27;re working with people who care primarily about their own positions and egos without regard to the team as a whole, well, be prepared to be thrown under the bus when it comes time for those people to protect themselves.
Schwolopalmost 11 years ago
Thanks for posting this. I found <a href="https://news.ycombinator.com/item?id=8062683" rel="nofollow">https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=8062683</a> yesterday but yours appears to be the direct link to the author&#x27;s blog, which I had missed.
joewaltmanalmost 11 years ago
Great story....thanks for your willingness to share.
peterwwillisalmost 11 years ago
<i>&gt; On this day, I highlighted her workstation and hit the F6 key to reset. But my screen went temporarily black and then seemed to be starting again. I realized that I had mistakenly hit F7 and reset all the workstations in the embassy.</i><p>Ugh.<p>Those with automation capabilities: keep this lesson in mind, because it will happen to you in production one day. &#x27;dsh -a reboot&#x27; is incredibly easy to type and can have disastrous effects. Creating abstraction layers around common admin tasks can help catch simple mistakes and give prompts before dangerous behavior.
jherikoalmost 11 years ago
I hope you fought that firing...<p>... incompetence like that comes from having F6 next to F7 and no checks or authorisation needed for a potentially dangerous action etc. Processes should be designed for people to make the common mistakes... its what they do.
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hyperlineralmost 11 years ago
&quot;My boss, a &gt;&gt; Japanese &lt;&lt; computer engineer named Itoh, poked his head in the door. &quot;<p>hmmm, I am pretty sure Mr. Itoh was not Japanese working in the American embassy. I am pretty sure he was American.
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joshuaheardalmost 11 years ago
I thought the headline meant to count to ten when a plane goes down...while you are in it!
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feldalmost 11 years ago
Reset all computers in the embassy with F7? No warning prompt?<p>Fire the idiot who wrote that function.
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