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"...The man (the authors seem to know it was a man, at least) who wrote the software for this machine did so alone, without documenting what he was doing. The company then sort of vaguely tested it."

Lone wolf programmer, no docs, vague testing. What kind of manager(s) would let this out the door knowing this? Never mind the lone wolf programmer. Find the managers and beat them with sticks

There is a quote from Chesley Sullenberger (The pilot that landed an airliner in the Hudson river):

"Everything we know in aviation, every rule in the rule book, every procedure we have, we know because someone somewhere died... We have purchased at great cost, lessons literally bought with blood that we have to preserve as institutional knowledge and pass on to succeeding generations."

We forget that often process and procedures which we now take as "common sense" or "bare minimum" were introduced as a best practice exactly because someone somewhere made a mistake that would have been avoided with those procedures in place.

Another thing I think is important to bring up, is that in software teams we often think that procedures are in place for 'other' complacent people or inexperienced juniors.

The reality is that procedures enforce consistency. And that consistency is needed for you as well not just for 'others'.

Today you write something elegant, tomorrow you could have trouble at home, be sleep deprived, pushed for a deadline, pressured by management and suddenly you in that instance become the 'others'.

Procedures in the end eliminate any wiggle for negotiable 'business compromises' or relaxing quality 'just this once'.

Hang on, pardner!

We agree that management was faulty. So why do we give them the presumption of good faith by taking their word for how the programmer operated?

We haven’ heard from the programmer, just from people who are covering up their identity. I’m not saying the following is likely, but it’s possible:

What if the programmer argued with them that they needed to do more testing and allow more time for development? Or that their should be a budget for a redesign, rather than cobbling the -25 from the bits and bobs of the -6 and -20, but management rushed it into production over their objections?

Then people die, and the programmer quits.

Management goes on to settle while being careful to make it impossible to talk to the programmer, who may very well have a lot to say about management.

We agree that management is at fault. Why take their word for it that the programmer operated without documentation? Why take their word for it that the lack of testing was the programmer’s choice?

Maybe the programmer produced a huge document explaining why the product should not be shipped, and management buried it to save their own skins?

If I remember, the earlier systems had a hardware lock that prevented an overdosing for whatever reason, including software fault. Sure, the software was still faulty, but don't forget if software was developed for a particular hardware such that a certain concern could be discounted (even if it ought to have been tested for) - is it really the developer's fault when the manufacturer (presumably for economic reasons) decides to remove safety features and increase the risk surface?

According to Wikipedia, the new model was actually deemed safer in an audit on the grounds that unlike a mechanical lock, the software could wear out or get damaged. So it seems more likely that people generally had a very mistaken view of software reliability.

I assume you mean software could NOT wear out or get damaged


Back then? Everybody. There was no Agile, few Computer Science degrees, mostly Cowboy programmers with little formal training. Managers knew nothing of these new computer devices, they just hired a six-pack of programmers and set them to work.

I worked at that time in the industry. Half the people I worked with were musicians getting some extra dough by programming.

... and some of those folks became or already were genius programmers.

At the time, programmers could be divided into "corporate" types and "computer nerds", people like the ones who founded Apple or the various software firms of today. Software wasn't an industry, it was a function within companies that did other things. You needed software to do useful things with computers and even to boot them up, so you had someone write it.

Not knowing the identity of the person who wrote this code is NBD. He likely never even knew there was a bug or problem, and if he did he couldn't be held responsible in any way, nor could the managers of the time.

If anyone should be held responsible, it would be the FDA for not getting ahead of the technology curve at the time and regulating computerized devices better than they did sooner than they did.

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