Same, seemingly trivial, failure, but very different consequences depending on at which point of the dive you notice it.
By the way I mainly dive with GUE now who mandate a primary light and two backups as part of standard kit!
Your comment was what I needed.
Do you know if that example is somewhere that can be cited on the wiki to make it more accessible?
But you just stared down the incident pit?
You still have multiple layers of security, but normalizing the removal or weaking of one goes against the point of having the multiple layers in the first place.
In your example you seem screwed immediately?
The "problem" with modern regulated torch designs is that they don't appreciably dim as the power runs down; they're bright and then they just stop over the course of a few seconds. Old designs you could easily spot when the batteries were ready to be replaced/recharged well in advance.
I am clearly not good diver material.
If this is the kind of thing you find interesting, you should also read How Complex Systems Fail (http://web.mit.edu/2.75/resources/random/How%20Complex%20Sys...).
There is a well produced reenactment of an anesthesia team falling victim to the "vortex" (resulting in fatal injury to their patient): https://vimeo.com/103516601
In fire and EMS we generally refer to the concept of an "accident chain". In any event where rescue personnel are injured or killed, there is a chain of events that had to take place leading up to that accident. Breaking the chain at any point would prevent the accident from occurring, and many of our procedures are built around the idea of breaking accident chains as early as possible. This is a concept that (as far as I know) originated in the aviation industry.
It's the same basic idea though... The further along the chain you allow the event to progress (even if you don't know the end result), the less margin for error you have.
It's interesting to me that, also coming from an EMS background, my (armchair) reaction to that situation is to escalate the intervention much, much more rapidly (I would have tubed the patient as soon as her HR started dropping, and tried an OPA much sooner). I suspect that this has a lot to do with my internal mental framing of airway management: in the field, airway problems can quite quickly lead to death -- the framing emphasizes risk -- but in a hospital setting, especially a surgical one, mild-to-moderate airway problems are frequently encountered, and the framing emphasizes minimizing negative impact to the patient.
I actually think the graph is great, once explained. It gives a good visual summary of both things it's trying to convey (the overall point, and the different speed at which incidents can develop).
Also interesting to think of this writ large. How many companies do you know of that are hanging out in the middle section without realizing how close they are to a point of no return?
I see a lot of bureaucratic NHS slides that are meaningless until someone talks you through them.
As a big fan of Alastair's work I'm hoping for a good read to get over the last failure!
It's probably not, since the book is 10 years old, but this is how it's done properly, I think.
Iraq war, housing bubble, housing collapse, bailouts, rise of ISIS, student debt explosion, ...
Eventually there is a point where confidence is lost.
Many startup founders are effectively pot committed. The potential reward of an acquisition is very high; the cost of staying in business is just the opportunity cost of your time. Running the company until either bankruptcy or acquisition often has a higher expected value than quitting to do something else, even if the situation looks dire.
Don't fall off the track.