Review
This historical incident report fails to mention the true root cause, which has since been addressed: Wolves were not yet locally driven to extinction.
I thought the true root cause was that people were still raising animals for human consumption?
in sufficiently complex systems, there is often no single root cause, even if you could see the entire causal graph. This seems like a case where that applies to me.
... but also, what jeff said
It's the "Boy who cried wolf" fable in the format of an incident report such as what might be written in the wake of an industrial disaster. Whether the fictional report writer has learned the right lessons I suppose is an exercise left for the reader.
See also: Swiss cheese model
tl;dr: don't overanalyze the final cause of disaster; usually it was preceded by serial failure of prevention mechanisms, any one or all of which can be improved for risk reduction.
Yeah but false positive. Every time anyone mentions all the ignored warnings they never try to calculate how many times the same warning occurred and everything was fine?
It's easy to point to O rings after the space shuttle is lost. But how many thousand other weak links were NASA/contractor engineers concerned about?
(Epistemic status: lyrics)
I’m not too clear about what you just spoke. Is that a parable, or a very subtle joke?
If you're making false claims of your incomprehension, it's clear that you've missed the moral dimension. When you truly can't get what someone is saying, remember today and the games you were playing. It takes people effort to give added proof...and they won't put that in for the boy who cries wolf.
Incident #210
Status
Complete, one action item outstanding.Summary
Sentinel consumed by wolf after repeated false alarms.Impact
Loss of sentinel. No flock impact.Root causes
Sentinel generated noisy alerts due to premature deployment, incomplete training, and overly monotonous task. Oncalls failed to respond to true positive due to alert fatigue.Trigger
Wolf.Resolution
Gathered flock. Deployed replacement sentinel.Detection
Sentinel did not report at end of shift.Action Items
Lessons Learned
What went well
What went wrong
Where we got lucky
Timeline
All times localMarch 3rd:
March 4th:
March 5th:
- 17:03 (Reconstructed) Outage begins, sentinel notices wolf.
- 17:03 Oncalls paged "wolf".
- 17:04 Oncalls paged "wolf".
- 17:04 Oncalls paged "real wolf".
- 17:05 (Reconstructed) Wolf consumes sentinel.
- 18:45 Sentinel does not report at end of shift.
- 19:05 Primary oncall dispatched to field.
- 19:10 Oncall diagnoses issue.
- 19:10 Incident begins, secondary and tertiary oncalls paged.
- 19:15 First sheep located.
- 19:52 Last sheep located.
- 20:05 Flock safe in pens.
- 20:05 Outage ends, flock protection fully restored.
- 20:45 Replacement sentinel identified.
March 6th:Comment via: facebook, mastodon