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Here’s a working draft of the introduction and first chapter of my book…. Enjoy ūüôā

We are hectored on an almost daily basis as to the imminent threat of islamic extremism and how we must respond firmly to this real and present danger. Indeed we have proceeded far enough along the escalation of response ladder that this, presumably existential threat, is now being used to justify talk of internment without trial. So what is the probability that if you were murdered, the murderer would be an immigrant terrorist?

In NSW in 2014 there were 86 homicides, of these 1 was directly related to the act of a islamist terrorist (1). So there’s a 1 in 86 chance that in that year¬†if you were murdered¬†it was at the hands of a mentally disturbed asylum seeker (2). Hmm sounds risky, but is it?¬†Well not really, there was approximately 2.5 million people in NSW in 2014 so the likelihood of being murdered (in that year) is in the first instance 3.44e-5. If we multiply this by the likelihood that it was at the hands of a `terrorist’ then we end up with 4e-7 or 4 chances in 10 million. If we consider subsequent and prior years where nothing happened that likelihood becomes even smaller.

Yet based on this 4 in 10 million chance for one year the NSW government intends to build a super-max 2 prison in NSW, and fill it with ‘terrorists’ while the Federal government enacts more anti-terrorism laws that take us down the road to the surveillance state, if we’re not already there yet. The glaring difference between the perception of risk and the actuality is one that our political class seem oblivious to (3).

Notes

1. One death during the Lindt chocolate siege that could be directly attributed to the `terrorist’.

2. Sought and granted in 2001 by the Liberal National Party government.

3. An action that also ignores the role of prisons in converting inmates to Islam as a route to recruiting their criminal, anti-social and violent sub-populations in the service of Sunni extremists.

The Sydney Morning Herald published an article this morning that recounts the QF72 midair accident from the point of view¬†of the crew and passengers, you can find the story at this link. I’ve previously covered the technical aspects of the accident here, the underlying integrative¬†architecture¬†program that brought us to this point here and the consequences¬†here.¬†So it was interesting to reflect on the event from the human perspective. Karl Weick points out in his influential paper on the Mann Gulch fire disaster that small organisations, for example the crew of an airliner, are vulnerable to what he termed a cosmology episode, that is an abruptly one feels deeply that the universe is no longer a rational, orderly system. In the case of QF72 this was initiated by the simultaneous stall and overspeed warnings, followed by the abrupt pitch over of the aircraft as the flight protection laws engaged for no reason.

Weick further posits that what makes such an episode so shattering is that both the sense of what is occurring and the means to rebuild that sense collapse together. In the Mann Gulch blaze the fire team’s organisation attenuated and finally broke down as the situation eroded until at the end they could not comprehend the one action that would have saved their lives, to build an escape fire. In¬†the case of¬†air crew they implicitly rely on the aircraft’s systems to `make sense’ of the situation, a significant¬†failure such as occurred on QF72 denies them both understanding of what is happening and the ability to rebuild that understanding. Weick also noted that in such crises organisations are important as they help people to¬†provide order and meaning in ill defined and uncertain circumstances, which has interesting implications when we look at the automation in the cockpit as another member of the team.

“The plane is not communicating with me. It’s in meltdown. The systems are all vying for attention but they are not telling me anything…It’s high-risk and I don’t know what’s going to happen.”

Capt. Kevin Sullivan (QF72 flight)

From this Weickian viewpoint we see the aircraft’s automation as both part of the situation `what is happening?’ and as a¬†member of the crew, `why is it doing that, can I trust it?’¬†Thus the crew of QF72 were faced with both a vu jaŐÄdeŐĀ moment and the allied disintegration of the human-machine partnership¬†that could help them make sense of the situation. The challenge that the QF72 crew faced was not to form a decision based on clear data and well rehearsed procedures from the flight manual, but instead they faced much more unnerving loss of meaning as the situation outstripped their past experience.

“Damn-it! We’re going to crash. It can’t be true! (copilot #1)

“But, what’s happening? copilot #2)

AF447 CVR transcript (final words)

Nor was this an isolated incident, one¬†study of other such `unreliable airspeed’ events, found¬†errors in understanding were both far more likely to occur than other error types and when they did much more likely to end in a fatal accident.¬†¬†In¬†fact they found that all accidents with a fatal outcome were categorised as involving an error in detection or understanding with the majority being errors of understanding. From Weick’s perspective then the collapse of sensemaking is the knock out blow in such scenarios, as the last words of the Air France AF447 crew so grimly illustrate. Luckily in¬†the case of QF72 the aircrew were able to contain this collapse, and rebuild their sense of the situation, in the case of other such failures, such as AF447, they were not.

 

For those of you who might be wondering at the lack of recent posts I’m a little pre-occupied at the moment as I’m writing a book. Hope to have a first draft ready in July.¬†; )

A recent case in Australia has again emphasised that an employer does not have to provide training for tasks that are considered to be ‘relatively’ straight forward. The presiding judge also found that while changes to the workplace ¬†could in theory be made, in practice it would be unreasonable to demand that the employer make such changes. The judge’s decision was subsequently upheld on appeal.

What’s interesting is the close reasoning of the court (and the appellate court)¬†to¬†establish what is reasonable and¬†practicable in the circumstances. While the legal system is not perfect it does have a long standing set of practices and procedures for getting at the truth. Perhaps we may be able to learn something from the legal profession when thinking about the safety of critical systems. More on this later.

Cowie v Gungahlin Veterinary Services Pty Ltd [2016] ACTSC 311 (25 October 2016)

Second part of the SBS documentary on line now. Looking at the IoT this episode. 

Screwtape(Image source: end time info)

More infernal statistics

Well, here we are again. Given recent developments in the infernal region it seems like a good time for another post. Have you ever, dear reader, been faced with the problem of how to achieve an unachievable safety target? Well worry no longer! Herewith is Screwtape’s patented man based mitigation medicine.

The first thing we do is introduce the concept of ‘mitigation’, ah what a beautiful word that is. You see it’s saying that it’s OK that your system doesn’t meet its safety target, because you can claim credit for the action of an external mitigator in the environment. Probability wise if the probability of an accident is P_a then P_a equals the product of your systems failure probability P_s and. the probability that some external mitigation also fails P_m or P_a = P_s X P_m. 

So let’s use operator intervention as our mitigator, lovely and vague. But how to come up with a low enough P_m? Easy, we just look at the accident rate that has occurred for this or a like system and assume that these were due to operator mitigation being unsuccessful. Voila, we get our really small numbers. 

Now, an alert reader might point out that this is totally bogus and that P_m is actually the likelihood of operator failure when the system fails. Operators failing, as those pestilential authors of the WASH1400 study have pointed out, is actually quite likely. But I say, if your customer is so observant and on the ball then clearly you are not doing your job right. Try harder or I may eat your soul, yum yum. 

Yours hungrily, 

Screwtape.