As testers, we typically focus on metaphors from Engineering and Manufacturing and learn from the related disciplines, yet there is so much to gain by learning about other industries and Disciplines. The Aviation industry recently has had a lot of bad press yet it still much we can learn from in terms of Quality Culture. Aviation has a history of continually learning and improving through the use of checklists, black box recorders, blameless culture, cockpit re-design and Crew Resource Management (CRM). In this talk, the stories of the origins of these innovations will be shared based on the findings from two significant Books that have focused on the Aviation Industry, The Checklist Manifesto by Atul Gawande, and Black Box Thinking by Matthew Syed. – The Relationship between Culture and Quality. – Willingness to learn from other Industries and Disciplines, and apply the lessons learned. – Keys Learnings from the Aviation Industry that you can apply in your testing role

1. The Lessons we can learn
from the Aviation Industry
Conor Fitzgerald
conorfi.com
@conorfi

2. Grounded
@conorfi

3. A Journey of Exploring@conorfi

4. Aviation @conorfi

5. @conorfi@conorfi

6. B17 Bellyflop Crashes
@conorfi

7. Which Lever?
@conorfi

8. Redesign (Shape Coding)
@conorfi

9. @conorfi@conorfi

10. 1. Checklist
@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/

21. HealthCare @conorfi

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

27. Tech @conorfi

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

33. Wrap Up
@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

41. Q&A
@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