Iceberg, Dead Ahead!<br />Lessons from real life disasters for the database professional<br />5/11/2011 – Mike Walsh<br />
About Mike<br />SQL Server MVP<br />SQL Server Practice Lead at Winxnet<br />Seacoast SQL Server Users Group (NH)<br />htt...
Real Disasters Will Be Discussed<br />Professional Development<br />No T-SQL & No Demos<br />Obviously!<br />Iceberg, Dead...
The Main Point<br />“I have yet to be in a game where luck was involved. Well-prepared players make plays. I have yet to b...
Goals<br />Understand Disaster Causing Attitudes<br />Leave Prepared<br />Iceberg, Dead Ahead! <br />5<br />
Our Approach<br />Some Accidents<br />One Success<br />Plagiarism<br />Iceberg, Dead Ahead! <br />6<br />
Avianca 52 <br />Bogota to JFK in 1990<br />Boeing 707<br />Missed One Approach<br />Impacted Hill – 73 of 158 Died<br />W...
Contributors To Crash<br />Ultimately: Flame Out<br />Poor Planning/Dispatch<br />No updated weather info, no follow up<br...
Our Lessons From Avianca 52<br />Plan For The Worst<br />Rollbacks<br />Go/No-Go Meetings<br />Scenario Based<br />Communi...
United 173<br />DC8 From Denver to Portland, 12/28/78<br />Happened On Approach<br />Landing Gear Issue <br />Loud thud an...
What Went Wrong?<br />Gear Check Light Troubleshooting<br />That took much longer than it should have<br />Evacuation Disc...
Our Lessons From UAL 173<br />Troubleshooting Skills<br />Don’t “Stick” On One Data Point<br />Don’t Forget To Fly While T...
Air Canada 621	<br />DC8 From Montreal in 1970<br />Well Acquainted & Experienced Flight Crew<br />Plane Bounced Off Runwa...
What Happened?<br />Some History<br />Air Canada’s rule – Arm on approach<br />Capt./FO Disagreed & Compromised<br />Capt ...
Our Lessons From Air Canada 621<br />Policies and Routines Can Be Good<br />Exceptions Can Be Dangerous<br />Don’t Ignore ...
Complacency<br />“Those masks give you headaches, you can’t talk with them on and the statistics are pretty low of sudden ...
Tenerife Island – Los Rodeos Airport<br />Two Young & “Clean” 747s<br />Experienced Pilots<br />Deadliest Aviation Disaste...
What Happened At Tenerife?<br />Additive Factors<br />Airport Diversion<br />Sudden Heavy Fog<br />Understaffed Tower<br /...
Two Cockpits – Two Conversations<br />KLM<br />Changed Routine<br />ATC Clearance Late<br />Impatience<br />“We’re Going”<...
Tenerife Lessons For Us<br />Departures From Routine Don’t End Well<br />Having “A Team of Equal Weight”<br />Team Oriente...
US Airways Flight 1549<br />Source: commons.wikimedia.com<br />Iceberg, Dead Ahead! <br />21<br />
Why Did 1549 Turn Out Like That?<br />“I have yet to be in a game where luck was involved. Well-prepared players make play...
Or Maybe?<br />“Luck Favors The Prepared”<br />- Louis Pasteur<br />
1549’s CVR Highlights<br />“My aircraft”“Your aircraft”<br />“Get the QRH” “If fuel remaining, engine mode selector..”<br ...
We Can Land On The Hudson, Too<br />Troubleshooter Wanted – Leave Shotgun Home<br />Checklists (“QRH”)<br />Teamwork (“Got...
Checklists<br />Routine and Emergency<br />Think About What Can Go Wrong<br />Test Checklist<br />Keep Best Practices In M...
Iceberg, Dead Ahead! <br />27<br />
Best Practices & Standards<br />Don’t Just Write Them<br />Follow Them<br />Understand Them<br />Explain The “Why”<br />Di...
Simulators Can Help<br />Who Has Practiced a Restore?<br />With log backups? With the tail backed up?<br />What Happens Wh...
Lessons Learned<br />The Point Isn’t Blame<br />Identify Lapses<br />Prevent Future Occurrences<br />Some Failures/Near Mi...
Plan For The Worst, Expect The Best<br />Level 1 text is 28 pt Arial<br />Level 2 text is 24 pt Arial<br />Level 3 text is...
Your Homework<br />Test Something (Restore Plans?)<br />Create a Checklist (Disaster Response?)<br />Get Paranoid (But onl...
We Saw Failures In<br />Communication<br />Teamwork<br />Planning<br />Standards/Policies<br />Routine<br />Attitude<br />...
We Saw Failures In<br />Troubleshooting Narrowly<br />Appreciating Need for Help<br />Assertiveness<br />Listening<br />Ic...
Slides, Notes and Links<br />www.straightpathsql.com/disaster<br />mwalsh@winxnet.com<br />THANKS!<br />Iceberg, Dead Ahea...
Please Complete the Evaluation Form<br />Pick up your evaluation form:<br />In each presentation room<br />Drop off your c...
THANK YOU!<br />For attending this session and PASS SQLRally Orlando, Florida<br />Presented by Dell<br />Session Code  | ...
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Iceberg, Dead Ahead - Lessons From Aviation Disasters

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What can a real world disaster teach us about running better projects, changing our attitudes and putting our best foot forward as professionals and technologists? Quite a lot actually. In this very interactive presentation, I discuss attitudes and actions that lead to disaster, how we can find them in ourselves and some tools and techniques for avoiding them.

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Iceberg, Dead Ahead - Lessons From Aviation Disasters

  1. 1. Iceberg, Dead Ahead!<br />Lessons from real life disasters for the database professional<br />5/11/2011 – Mike Walsh<br />
  2. 2. About Mike<br />SQL Server MVP<br />SQL Server Practice Lead at Winxnet<br />Seacoast SQL Server Users Group (NH)<br />http://seacoastsql.sqlpass.org<br />Blog: http://www.StraightPathSQL.com<br />Former Firefighter/EMT-I<br />Paranoid? Worry-Wart?<br />Well Qualified to Talk About Failing<br />asfTitle <br />2<br />
  3. 3. Real Disasters Will Be Discussed<br />Professional Development<br />No T-SQL & No Demos<br />Obviously!<br />Iceberg, Dead Ahead! <br />3<br />You Can Leave<br />
  4. 4. The Main Point<br />“I have yet to be in a game where luck was involved. Well-prepared players make plays. I have yet to be in a game where the most prepared team didn't win.” <br />– Urban Meyer<br />
  5. 5. Goals<br />Understand Disaster Causing Attitudes<br />Leave Prepared<br />Iceberg, Dead Ahead! <br />5<br />
  6. 6. Our Approach<br />Some Accidents<br />One Success<br />Plagiarism<br />Iceberg, Dead Ahead! <br />6<br />
  7. 7. Avianca 52 <br />Bogota to JFK in 1990<br />Boeing 707<br />Missed One Approach<br />Impacted Hill – 73 of 158 Died<br />Why?<br />Iceberg, Dead Ahead! <br />7<br />
  8. 8. Contributors To Crash<br />Ultimately: Flame Out<br />Poor Planning/Dispatch<br />No updated weather info, no follow up<br />Failure To Declare Emergency<br />Culture? Disobedience? Language?<br />“Avianca fifty two, climb and maintain three thousand.”<br />“Ah, negative sir. We just running out of fuel. We okay three thousand. Now okay.”<br />Failure to Divert Earlier<br />Aborted First Landing Attempt<br />Iceberg, Dead Ahead! <br />8<br />
  9. 9. Our Lessons From Avianca 52<br />Plan For The Worst<br />Rollbacks<br />Go/No-Go Meetings<br />Scenario Based<br />Communication<br />Phraseology<br />Ask For Help In Spite Of Barriers<br />Pride?<br />Politeness?<br />Iceberg, Dead Ahead! <br />9<br />
  10. 10. United 173<br />DC8 From Denver to Portland, 12/28/78<br />Happened On Approach<br />Landing Gear Issue <br />Loud thud and yaw when lowered<br />Indicator light failed to indicate<br />Eventual Crash Landing, 10 of 189 died<br />Why?<br />Iceberg, Dead Ahead! <br />10<br />
  11. 11. What Went Wrong?<br />Gear Check Light Troubleshooting<br />That took much longer than it should have<br />Evacuation Discussion/Preparation<br />That took much longer than it should have<br />Captain Paid No Attention To Fuel<br />Remaining Crew’s Fuel Attitude<br />Concerned but not direct/forceful<br />Corrosion On Landing Gear Indicator Wires<br />Iceberg, Dead Ahead! <br />11<br />
  12. 12. Our Lessons From UAL 173<br />Troubleshooting Skills<br />Don’t “Stick” On One Data Point<br />Don’t Forget To Fly While Troubleshooting<br />Communication<br />Having “A Team of Equal Weight”<br />Team Oriented Leadership<br />Status Checks<br />Routine Maintenance<br />Iceberg, Dead Ahead! <br />12<br />
  13. 13. Air Canada 621 <br />DC8 From Montreal in 1970<br />Well Acquainted & Experienced Flight Crew<br />Plane Bounced Off Runway, Lost an Engine<br />Broke Apart as Pilot Tried to Salvage Landing<br />All 109 On Board Killed<br />Anyone know why?<br />Iceberg, Dead Ahead! <br />13<br />
  14. 14. What Happened?<br />Some History<br />Air Canada’s rule – Arm on approach<br />Capt./FO Disagreed & Compromised<br />Capt to FO: “When you fly we arm on approach”<br />FO to Capt: “When you fly we arm/deploy on ground”<br />Captain Changed Mind During Approach<br />“Give them to me on the flare. I have given up. I’m tired of fighting it”<br />First Officer Had Routine Broken Twice<br />No External Factors<br />Iceberg, Dead Ahead! <br />14<br />
  15. 15. Our Lessons From Air Canada 621<br />Policies and Routines Can Be Good<br />Exceptions Can Be Dangerous<br />Don’t Ignore Non-Compliance of Standards<br />Plan & Document Approach Before Doing<br />“Peer Pressure” Pitfalls<br />Iceberg, Dead Ahead! <br />15<br />
  16. 16. Complacency<br />“Those masks give you headaches, you can’t talk with them on and the statistics are pretty low of sudden depressurization anyway. Have you ever seen them?” – A Learjet pilot<br />Payne Stewart’s Crash – Masks Part of Cause?<br />Monitoring/Warning Systems<br />Qantas Near Miss?<br />Sterile Cockpit<br />Recent Controller “Issues”<br />Iceberg, Dead Ahead! <br />16<br />
  17. 17. Tenerife Island – Los Rodeos Airport<br />Two Young & “Clean” 747s<br />Experienced Pilots<br />Deadliest Aviation Disaster In History<br />Iceberg, Dead Ahead! <br />17<br />
  18. 18. What Happened At Tenerife?<br />Additive Factors<br />Airport Diversion<br />Sudden Heavy Fog<br />Understaffed Tower<br />Clogged Runway<br />Back Taxiing<br />12 Feet<br />700 yards<br />Communication, Attitude, Teamwork<br />Iceberg, Dead Ahead! <br />18<br />
  19. 19. Two Cockpits – Two Conversations<br />KLM<br />Changed Routine<br />ATC Clearance Late<br />Impatience<br />“We’re Going”<br />“We are Now At uh Take-off”<br />“Is He Not Clear, That Pan American?”<br />“Oh Yes”<br />Pan-Am<br />Confusion On Turnoff<br />Disagreement w/ Tower?<br />“And We’re Still On The Runway”<br />
  20. 20. Tenerife Lessons For Us<br />Departures From Routine Don’t End Well<br />Having “A Team of Equal Weight”<br />Team Oriented Leadership<br />Communication <br />Phraseology & Language<br />Clear & Concise<br />Confirmation<br />Make Calm Decisions<br />Iceberg, Dead Ahead! <br />20<br />
  21. 21. US Airways Flight 1549<br />Source: commons.wikimedia.com<br />Iceberg, Dead Ahead! <br />21<br />
  22. 22. Why Did 1549 Turn Out Like That?<br />“I have yet to be in a game where luck was involved. Well-prepared players make plays. I have yet to be in a game where the most prepared team didn't win.” <br />– Urban Meyer<br />Iceberg, Dead Ahead! <br />22<br />
  23. 23. Or Maybe?<br />“Luck Favors The Prepared”<br />- Louis Pasteur<br />
  24. 24. 1549’s CVR Highlights<br />“My aircraft”“Your aircraft”<br />“Get the QRH” “If fuel remaining, engine mode selector..”<br />“This is the Captain, brace for impact”<br />“Got any ideas?” “Actually not”<br />“We’re gonna brace”<br />During This Time – Calm ATC contact, checklists, multiple attempts to relight/power engines.<br />Iceberg, Dead Ahead! <br />24<br />
  25. 25. We Can Land On The Hudson, Too<br />Troubleshooter Wanted – Leave Shotgun Home<br />Checklists (“QRH”)<br />Teamwork (“Got any ideas?”)<br />Notification (“Brace for impact”, “We’re gonna be in the Hudson”)<br />Clear, Concise Communication (“Unable”)<br />Training & Muscle Memory<br />Iceberg, Dead Ahead! <br />25<br />
  26. 26. Checklists<br />Routine and Emergency<br />Think About What Can Go Wrong<br />Test Checklist<br />Keep Best Practices In Mind<br />Iceberg, Dead Ahead! <br />26<br />
  27. 27. Iceberg, Dead Ahead! <br />27<br />
  28. 28. Best Practices & Standards<br />Don’t Just Write Them<br />Follow Them<br />Understand Them<br />Explain The “Why”<br />Discuss, Plan and Document Variances<br />We Need To Move Away from “Do as I Say”<br />Iceberg, Dead Ahead! <br />28<br />
  29. 29. Simulators Can Help<br />Who Has Practiced a Restore?<br />With log backups? With the tail backed up?<br />What Happens When _____ ?<br />Test It – You Can’t Know Unless/Until You Do<br />Iceberg, Dead Ahead! <br />29<br />
  30. 30. Lessons Learned<br />The Point Isn’t Blame<br />Identify Lapses<br />Prevent Future Occurrences<br />Some Failures/Near Misses Can be Blessings<br />Iceberg, Dead Ahead! <br />30<br />
  31. 31. Plan For The Worst, Expect The Best<br />Level 1 text is 28 pt Arial<br />Level 2 text is 24 pt Arial<br />Level 3 text is 20 pt Arial<br />Level 4 text is 20 pt Arial<br />Level 5 text is 20 pt Arial<br />Iceberg, Dead Ahead! <br />31<br />
  32. 32. Your Homework<br />Test Something (Restore Plans?)<br />Create a Checklist (Disaster Response?)<br />Get Paranoid (But only a little)<br />Ask for a Postmortem (Sedation Helps First)<br />Adopt and Write Standards (Sensible)<br />Find your flaws (Review the accidents for tips)<br />Iceberg, Dead Ahead! <br />32<br />
  33. 33. We Saw Failures In<br />Communication<br />Teamwork<br />Planning<br />Standards/Policies<br />Routine<br />Attitude<br />Iceberg, Dead Ahead! <br />33<br />
  34. 34. We Saw Failures In<br />Troubleshooting Narrowly<br />Appreciating Need for Help<br />Assertiveness<br />Listening<br />Iceberg, Dead Ahead! <br />34<br />
  35. 35. Slides, Notes and Links<br />www.straightpathsql.com/disaster<br />mwalsh@winxnet.com<br />THANKS!<br />Iceberg, Dead Ahead! <br />35<br />
  36. 36. Please Complete the Evaluation Form<br />Pick up your evaluation form:<br />In each presentation room<br />Drop off your completed form<br />Near the exit of each presentation room<br />At the registration area<br />Presented by Dell<br />Session Title <br />36<br />
  37. 37. THANK YOU!<br />For attending this session and PASS SQLRally Orlando, Florida<br />Presented by Dell<br />Session Code | Session Title <br />37<br />

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