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The Lessons we can learn
from the Aviation Industry
Conor Fitzgerald
conorfi.com
@conorfi
Grounded
@conorfi
A Journey of Exploring@conorfi
Aviation @conorfi
@conorfi@conorfi
B17 Bellyflop Crashes
@conorfi
Which Lever?
@conorfi
Redesign (Shape Coding)
@conorfi
@conorfi@conorfi
1. Checklist
@conorfi
1. Checklist
”They came up with an ingeniously simple approach:
they created a pilot’s checklist."
The pilots went on to fly the Prototype Model 299 a total
of 1.8 million miles without one accident."
B-17 became the third-most produced bomber of all time
The Checklist Manifesto: How to Get Things Right
Atul Gawande
@conorfi
1. Checklist
” Provide reminders of only the most critical and
important steps, the ones that even the highly skilled
professional using them could miss.
Good checklists are, above all, practical.”
The Checklist Manifesto: How to Get Things Right
Atul Gawande
@conorfi
2. Black Box Thinking
@conorfi
● Bright Orange
● Electronic
Instructions
● Cockpit
Conversations
2. Black Box Thinking
@conorfi
”It is about the willingness
and tenacity to investigate
the lessons that often exist
when we fail, but which we
rarely exploit."
Black Box Thinking
Matthew Syed
3. Blameless Culture
● Report Errors
● No blame (Root
Cause)
● Correct Errors
Quickly
@conorfi
4. A Culture of Questioning
● Cultural
Reorientation
● Speak Up
Outliers by Malcolm Gladwell
@conorfi
5. Functioning with Others
@conorfi
● No Heroes
● Crew Resource
Management
5. Functioning with Others
1. Expectation of selflessness
2. Expectation of skill
3. Expectation of trustworthiness
4. Expectation of discipline: discipline in following
prudent procedure and in functioning with others.
The Checklist Manifesto: How to Get Things Right
Atul Gawande
@conorfi
Learnings from Aviation
@conorfi
1. Checklists
2. Blackbox Thinking
3. Blameless Culture
4. Culture of Questioning
5. Functioning with Others
Outcomes
@conorfiRed line: 5 year average Statistics/data from: http://aviation-safety.net/
HealthCare @conorfi
Prevention
Prevention is Better than Cure
• Preventable Medical Errors
• Third biggest killer in the United States
• 200,000 preventable medical deaths every year*
• Equivalent to 3 fatal Airlines Crashes per Day
@conorfi
*https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710114/
Cultural Issues
• Blame and Hierarchy
• Questioning Discouraged
• Poor Communication
• Teamwork Ratings low
• No Reporting of Errors
• Investigations are Challenging
@conorfi* January 2007, the World Health Organization a two day meeting
Checklist/Questioning
@conorfi
• Columbus Children's Hospital
• “Cleared for Takeoff ” checklist
• Metal tent
”After ten months,100 per cent of
patients got the right antibiotics at
the right time”
The Checklist Manifesto: How to Get Things
Right
Atul Gawande
Blameless/Blackbox thinking
@conorfi
• Virginia Mason Hospital(Seattle)
• Reporting system(Aviation/Toyota)
• Patient Safety Alerts Increased
• Praised not blamed
• One of the safest hospitals in the
world
Black Box Thinking
Matthew Syed
Functioning with Others
@conorfi
• Toronto, Hopkins and
Southern California
• “Surgery Preflight Checklist”
• Team Huddle
• Willingness to Speak Up
Nurse turnover - dropped from
23 percent to 7 percent The Checklist Manifesto: How to Get Things
Right
Atul Gawande
Tech @conorfi
1. Checklists
Checklists
• API/UI
• Definition of Done
Once defined Automate
@conorfi
2. Black Box Thinking
• Retrospectives
• Incident Post-mortems
@conorfi
3. Blameless Culture
Etsy's Blameless Culture
1.Assume Goodwill
2.Identify Causes not Culprits
3.Take your Time
@conorfi
4. A Culture of Questioning
“Programmers like to talk about their work,
ask them questions.”
Lessons Learned in Software Testing: A Context-Driven Approach
Cem Kaner, James Bach, Bret Pettichord
BDD
“Biscuit Driven Development”
Alexandra Schladebeck
@conorfi
5. Functioning with Others
● Banish Hero Culture
● Teamwork
● Pairing/Mobbing/Bug Bash
“Fresh Eyes Find Failures”
Lessons Learned in Software Testing: A Context-Driven Approach
Cem Kaner, James Bach, Bret Pettichord
@conorfi
Wrap Up
@conorfi
Learnings from Aviation
@conorfi
1. Checklists
2. Blackbox Thinking
3. Blameless Culture
4. Culture of Questioning
5. Functioning with Others
Personal Learnings
@conorfi
1. People
2. Quality and Culture
3. Blackbox Thinking
1. People
@conorfi
”No matter how it looks at first, it's always a people
problem.”
The secrets of consulting
Gerald M. Weinberg
“People, not methodologies or tools, make projects
successful.”
Agile Testing: A Practical Guide for Testers and Agile Teams
Lisa Crispin Janet Gregory
1. People
@conorfi
“The Improvements in the
Customer Experience in Aviation
and HealthCare has come from
focusing on the Employee rather
than the Customer”
Conor Fitzgerald
2. Quality and Culture
@conorfi
“Quality is doing it right when no one is watching”
Henry Ford
3. Blackbox Thinking
@conorfi
“We instead want to view mistakes, errors,
slips, lapses, etc. with a perspective of
learning.”
John Allspaw – Former CTO (Etsy)
“This is the Paradox of Success: its built upon
failure.”
Matthew Syed– Author Black Box Thinking
Explore other Industries and
Disciplines @conorfi
Q&A
@conorfi
Books
● Black box thinking
Matthew Syed
● The Checklist Manifesto: How to get Things Right
Atul Gawande
● The Design of Every Day Things
Dan Norman
@conorfi@conorfi
Books
● Lessons Learned in Software Testing: A Context-Driven Approach
Cem Kaner, James Bach, Bret Pettichord
● More Agile Testing: Learning Journeys for the Whole Team
Janet Gregory and Lisa Crispin
● Perfect Software: And Other Illusions about Testing
Gerald M. Weinberg
@conorfi@conorfi
737 MAX
What went wrong
https://www.nytimes.com/interactive/2019/business/boeing-737-crashes.html
Boeing 737 MAX Certification Flight Waiting on Software Validation
https://www.aviationtoday.com/2020/04/30/boeing-737-max-certification-flight-
waiting-software-validation/
@conorfi

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Conor fitzgerald aviation_online_testconf_finalversion

  • 1. The Lessons we can learn from the Aviation Industry Conor Fitzgerald conorfi.com @conorfi
  • 3. A Journey of Exploring@conorfi
  • 11. 1. Checklist ”They came up with an ingeniously simple approach: they created a pilot’s checklist." The pilots went on to fly the Prototype Model 299 a total of 1.8 million miles without one accident." B-17 became the third-most produced bomber of all time The Checklist Manifesto: How to Get Things Right Atul Gawande @conorfi
  • 12. 1. Checklist ” Provide reminders of only the most critical and important steps, the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.” The Checklist Manifesto: How to Get Things Right Atul Gawande @conorfi
  • 13. 2. Black Box Thinking @conorfi ● Bright Orange ● Electronic Instructions ● Cockpit Conversations
  • 14. 2. Black Box Thinking @conorfi ”It is about the willingness and tenacity to investigate the lessons that often exist when we fail, but which we rarely exploit." Black Box Thinking Matthew Syed
  • 15. 3. Blameless Culture ● Report Errors ● No blame (Root Cause) ● Correct Errors Quickly @conorfi
  • 16. 4. A Culture of Questioning ● Cultural Reorientation ● Speak Up Outliers by Malcolm Gladwell @conorfi
  • 17. 5. Functioning with Others @conorfi ● No Heroes ● Crew Resource Management
  • 18. 5. Functioning with Others 1. Expectation of selflessness 2. Expectation of skill 3. Expectation of trustworthiness 4. Expectation of discipline: discipline in following prudent procedure and in functioning with others. The Checklist Manifesto: How to Get Things Right Atul Gawande @conorfi
  • 19. Learnings from Aviation @conorfi 1. Checklists 2. Blackbox Thinking 3. Blameless Culture 4. Culture of Questioning 5. Functioning with Others
  • 20. Outcomes @conorfiRed line: 5 year average Statistics/data from: http://aviation-safety.net/
  • 22. Prevention Prevention is Better than Cure • Preventable Medical Errors • Third biggest killer in the United States • 200,000 preventable medical deaths every year* • Equivalent to 3 fatal Airlines Crashes per Day @conorfi *https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710114/
  • 23. Cultural Issues • Blame and Hierarchy • Questioning Discouraged • Poor Communication • Teamwork Ratings low • No Reporting of Errors • Investigations are Challenging @conorfi* January 2007, the World Health Organization a two day meeting
  • 24. Checklist/Questioning @conorfi • Columbus Children's Hospital • “Cleared for Takeoff ” checklist • Metal tent ”After ten months,100 per cent of patients got the right antibiotics at the right time” The Checklist Manifesto: How to Get Things Right Atul Gawande
  • 25. Blameless/Blackbox thinking @conorfi • Virginia Mason Hospital(Seattle) • Reporting system(Aviation/Toyota) • Patient Safety Alerts Increased • Praised not blamed • One of the safest hospitals in the world Black Box Thinking Matthew Syed
  • 26. Functioning with Others @conorfi • Toronto, Hopkins and Southern California • “Surgery Preflight Checklist” • Team Huddle • Willingness to Speak Up Nurse turnover - dropped from 23 percent to 7 percent The Checklist Manifesto: How to Get Things Right Atul Gawande
  • 28. 1. Checklists Checklists • API/UI • Definition of Done Once defined Automate @conorfi
  • 29. 2. Black Box Thinking • Retrospectives • Incident Post-mortems @conorfi
  • 30. 3. Blameless Culture Etsy's Blameless Culture 1.Assume Goodwill 2.Identify Causes not Culprits 3.Take your Time @conorfi
  • 31. 4. A Culture of Questioning “Programmers like to talk about their work, ask them questions.” Lessons Learned in Software Testing: A Context-Driven Approach Cem Kaner, James Bach, Bret Pettichord BDD “Biscuit Driven Development” Alexandra Schladebeck @conorfi
  • 32. 5. Functioning with Others ● Banish Hero Culture ● Teamwork ● Pairing/Mobbing/Bug Bash “Fresh Eyes Find Failures” Lessons Learned in Software Testing: A Context-Driven Approach Cem Kaner, James Bach, Bret Pettichord @conorfi
  • 34. Learnings from Aviation @conorfi 1. Checklists 2. Blackbox Thinking 3. Blameless Culture 4. Culture of Questioning 5. Functioning with Others
  • 35. Personal Learnings @conorfi 1. People 2. Quality and Culture 3. Blackbox Thinking
  • 36. 1. People @conorfi ”No matter how it looks at first, it's always a people problem.” The secrets of consulting Gerald M. Weinberg “People, not methodologies or tools, make projects successful.” Agile Testing: A Practical Guide for Testers and Agile Teams Lisa Crispin Janet Gregory
  • 37. 1. People @conorfi “The Improvements in the Customer Experience in Aviation and HealthCare has come from focusing on the Employee rather than the Customer” Conor Fitzgerald
  • 38. 2. Quality and Culture @conorfi “Quality is doing it right when no one is watching” Henry Ford
  • 39. 3. Blackbox Thinking @conorfi “We instead want to view mistakes, errors, slips, lapses, etc. with a perspective of learning.” John Allspaw – Former CTO (Etsy) “This is the Paradox of Success: its built upon failure.” Matthew Syed– Author Black Box Thinking
  • 40. Explore other Industries and Disciplines @conorfi
  • 42. Books ● Black box thinking Matthew Syed ● The Checklist Manifesto: How to get Things Right Atul Gawande ● The Design of Every Day Things Dan Norman @conorfi@conorfi
  • 43. Books ● Lessons Learned in Software Testing: A Context-Driven Approach Cem Kaner, James Bach, Bret Pettichord ● More Agile Testing: Learning Journeys for the Whole Team Janet Gregory and Lisa Crispin ● Perfect Software: And Other Illusions about Testing Gerald M. Weinberg @conorfi@conorfi
  • 44. 737 MAX What went wrong https://www.nytimes.com/interactive/2019/business/boeing-737-crashes.html Boeing 737 MAX Certification Flight Waiting on Software Validation https://www.aviationtoday.com/2020/04/30/boeing-737-max-certification-flight- waiting-software-validation/ @conorfi