[carbonatedmilk]

Even though the author is critical of the GPIAAF's report, it's amazing to see how thoroughly incidents like this one are investigated - With a real focus on process improvement. Frustrating that the obvious mechanical fix for this (have different shaped connectors for each aerilon cable) wasn't adopted by Embraer, but still a great reminder of how we can do incident handling better in software dev

[mannykannot]

I find Embraer's rationalization for this (and, presumably, its acceptance by the relevant regulatory agencies) to be particularly galling. Even if it was true at the time that no procedure called for both cables to be disconnected at the same time, did they have any equivalent proof that no such procedure might be introduced later? Did they have any equivalent proof that no-one would misunderstand the instructions, or that it could go undetected if that happened? Could they be sure that this constraint, or its relevance, would not be overlooked at some point in the future? Well, we know they did not. Nobody addressed the question, "what could possibly go wrong?" with sufficient rigor.

[dingaling]

Investigate for cause, not blame

[unsafecast]

Even something as simple as coloring them like RCA connectors would've worked. It's insane how lightly this was treated in designing it.