My mom died on Feb 23rd, 2021. She was in a retirement home after having lost a lot of her physical capacities (taking care of herself), and after a hip surgery about 3 years ago, she started losing her mental capacities. We'll never know exactly what happened, but my guess was that either the anesthesia for her surgery somehow caused brain damage (she started being confused and not always making sense the day she woke up and never recovered, or whether something else cause micro damage to multiple places in her brain). She didn't have the typical mental illness that people know (as in she always recognized me in person, although not always on the phone, where over time she became less and less able to speak french and would answer me in Dutch for the whole conversation, which made talking harder since my Dutch is pretty basic).
I wish I would have been able to better communicate with her in her last years, but that was not in the cards, so don't waste the time you do have with your own family. I know I could have done better with the time we did have, but at the same time, I also know that she did know I loved her in my own ways and I'm happy that she was able to come visit me in the US a few times before it became not possible for her to travel anymore (I also saw her every Xmas in France).
I know she enjoyed the bike ride around Stevens Creek Trail the first time she came and last time she was able to bike, or the flights I gave her, including flying to Harris' Ranch for steak, and she probably still liked that ride I gave her in my F430 around skyline and that kind of caused her to throw up after a few turns too many (oops). But at the end of the day, she was also very happy reading in our yard, and looking at our birds.
my mom was a good cook, including bread
2000 was the first year she was able to come to my first house in sunnyvale, she help pick things and decorate a bit
I took her on the 49 mile drive around SF, including a few extra stops I added
dutch family embordery
each time I came for Xmas, she made sure I was well fed :)
yummy souflé
another year she came, we went to the Chinese and Japanese Gardens in Golden Gate Park
a picture she got with flowers I got sent to her for her BD
2013 birthday
nice french restaurant, I took her at for Xmas
tour of Google in 2007
I took her for a couple of flights, one to Harry's Ranch for steak and a bay tour to Monterey
Had lunch on Monterey
She came for my wedding and our cat was happy to make friends
Wedding day
as long as she was able to travel, we went to Holland every year for a family reunion
Our cat, five, was happy to see her again in 2011
We went for a tour of Stanford
After 2011, she wasn't able to travel anymore, so I only saw her in France for Xmas, including a yearly Xmas day lunch that my brother and Diane helped more and more with over time.
By 2017, she wasn't able to care for herself anymore, including getting up if she fell, so we had to move her to a retirement home. I flew to france last minute to help with her affairs, emptying her house, and helping getting it sold. She ended up staying there 3.5 years as her health and mind got worse over time, until her heart attack (by then she wasn't able to walk at all anymore, and gained a fair amount of weight):
Last Xmas, 2020, was challenging. Travelling was restricted between both countries, but since I was a citizen of one country, and resident of the other one, I was allowed to travel. It was not a fun 12H flight wearing an N100 mask the whole way, but I'm glad I made it. Her facility made us wear scrubs for covid, which felt a bit over the top, but whatever. Last time I saw her:
my last picture of her
We were allowed to see her 1h in a special room instead of the normal 30mn due to covid restrictions. I think she was happy to see us, although it was hard to tell. I could have gone to see her a second time before leaving Paris (2H trip for 30mn allowed visit), but I didn't really have it in me, especially with the covid restrictions added, the visit was difficult and bittersweet.
I tried to talk to her on the phone these last few weeks. the first time, she sounded confused, could only reply in Dutch, and it wasn't clear she understood that I was calling her. The 2nd time a week later, she barely managed to pick up the phone, dropped it and the line went dead.
She finally died of a heart attack during lunch about a week later. The staff tried to revive her, but did not succeed. She was 77.
It's a tough thing to say, but as far as I was concerned, she had very little quality of life left (although at least she wasn't physically suffering, but I'm reasonably sure she could tell she was losing her brain over time, and to me, that would be more painful than physical pain), and as hard as it is to say, I was conflicted about whether she was still able to enjoy life. I know it was painful for me to see her over time (the few times I was in france), so in some way I was kind of waiting for it to be over.
It would be easier if I could believe that she's in a better place, but I only get to believe that her time on earth ended and hope she got to enjoy most of it as much as possible.
Spend quality time with your loved ones as if it could be the last time, as you'll never know when it was, until after the fact.
More photos, courtesy of google photos auto face recognition and sorting: https://photos.app.goo.gl/cjBkLgzn4AV7UVAS7
Normally I'd be fighting with airports and how to get back to France (tricky since I'm snowboarding in Utah, don't have my passport, and need to fly in the wrong direction first to get it, plus covid tests, before finding some flights back towards Europe, the direct flights having gone from 3 per day to 2 per week at this time), but my mom opted to give her body to science, and given travel restrictions and the covid risks to the rest of the family, we won't have a ceremony at this time, but this page is my remembrance of her.
It had been a while since we had gone out to see a bit of nature, so for our anniversary, we drove towards the coast to visit the coast and beaches on Hwy 1 from Pescadero to Half Moon Bay.
We then went to the Ritz-Carlton and their semi-private beach:
A few more beaches:
We then ended by going to West Point Parking lot in Half Moon Bay, walked the Jetty and Frenchman reef trail:
a few views from HAF airport
end of the trail, before turning back
poor Half Moon Bay airport, not getting much use with Covid-19
This is the summary of Gimpy's Life, our very special needs butterfly that was born with only portions of a few feet (not enough to walk right), and non fully functional wings, and lost the round part of one antenna for reasons unknown, not long after emerging from his chrysalis. We didn't know its sex, but we called him gimpy.
We poured our hearts into helping this little bugger survive: we built him little houses where he could enjoy a few flowers, hopefully feed without falling in his food and getting too sticky (that happened several times and tried out best to remove all the sugar glue each time). We tried to help him achieve the best butterfly life that was possible for him.
In the end, he survived 9 days out of 14 or so (expected lifetime), but it was a not an easy life: he was unable to feed himself, so we had to extend his proboscis in food and he was able to slurp then. By the 8th day he probably stopped being able or willing to eat and by the 9th day (July 4th), he would not slurp food or water when we gave him some, so he ended up dying of exhaustion, hunger, or thirst while we tried our best to help him (doing so, was difficult the last few days as he started getting more scared of us, so we were not able to help it feed as much, and we weren't able to check on him as carefully).
RIP Gimpy
Caterpillar/Butterfly kits
1.5 years ago, I got Jennifer a butterfly kit from her birthday from insectlore. You can read about our first experience taking care of caterpilars here. At the time, I should have found their FAQ, which would have made it clear that getting butterflies in november, was not the best idea. We hope they survived after we released them, but the temperatures were borderline.
What they don't warn you about, though, is that you're likely to have to make life and death decisions, and they don't equip you much for them. We only found out later that outside of crushing a dying butterfly, you can also put it in the freezer and it will go to sleep in less than a minute.
The first time, one butterfly came out wrong and was totally mangled. It looked that in his struggle to get out, it also severed body parts and was bleeding. At the time, it was pretty simple (even if not easy), to crush the poor thing so that it didn't have to keep suffering while bleeding to death:
poor thing, you can barely tell that it was supposed to be a butterfly
This time, I got a kit for Jennifer in June, a better time of the year. One caterpillar died in his Chrysalis, 8 of them turned into happy butterflies that we released in our yard. And last one was gimpy. Gimpy had issues getting unstuck when he got out, and after I saw him struggle, I helped him out. Unfortunately in the process, he seemed to have lost portions of his legs that were just too stuck to get out (yes, had I been prepared with the right surgical tools, I might have been able to help better, but either way gimpy didn't have proper control of his wings):
Gimpy looked almost ok, except that butterflies leave their wings closed by default, gimpy could not close them
soon, it was also clear that while he could control both wings, it was not in a balanced way (flight would not be possible)
We left gimpy with the other butterflies in the habitat for the first day (they don't all come out at the same time), but unfortunately we had no idea he couldn't actually feed on his own. As we found out later, he could not really go somewhere on purpose, nor could he extend his proboscis on his own to feed:
Gimpy, Day 2
By the 2nd day, the last butterflies had emerged, so we let them free in our yard, and it was clear that gimpy as not going to be able to live on his own:
we gave him a bit of sun and showed him outside
it was clear that he was not really able to get around though, or even feed, also by then he somehow had lost tip of his right antenna
we finally figured out that we had to manually unroll/extend his proboscis into the food, and this was likely the first time the poor little thing got to eat
jennifer made different foods for him, but his partial legs were so short that it was difficult for him to reach
so she found ways to prop it up
We were worried when we found out that he didn't have full control of his proboscis, the straw that bufferflies can unroll to feed. It could eat through it if we put it in food, and he could move it just a bit, but he did not seem able to unroll it and place it in food on his own. That made it difficult to know if he was hungry as we also found out he would make small motions with his proboscis rolled in the air, and that didn't have to mean it was hungry (actually it was Jennifer's sharp eye that noticed that what looked like a small antenna on the side of its head was actually the proboscis moving, and maybe trying to suck food out of the air).
You can see in this clip that he can move a bit, and his proboscis is curled on the left of the head, moving, but not able to reach any food (unless we put him in there manually). Poor gimpy probably wanted to enjoy that orange, but wasn't able to (we gave him orange juice later):
Gimpy, Day 3-6
we got hime fresh flowers from our yard, even if they died fast. We're hoping he was able to enjoy the smells.
Those were probably Gimpy's best days, despite the challenges due to his infirmities. One problem was that he couldn't walk with purpose given his missing or damaged half legs, and would sometimes end up in the sticky sugar.
Jennifer tried different ways to prop him up to the food
Did I mention how hard Jennifer tried? Here she made him a new little house with recessed floor to fit a cut cup of food
she became a butterfly cook
Jennifer made a mixture of plum and orange from our yard, and sugar water
his sectionned front left leg made it difficult for him to walk, but he did his best
The recessed cup of food that Jennifer had designed was better but gimpy still could fall into it. We also tried another method with a less amount of sticky food (arguably it was still too much in that picture):
he seemed happy being on a flower (when balanced right), and having food brought up (we still had to manually extend the proboscis)
the surface tension of the sugar water was helpful for keeping the proboscis in
You can see gimby eating a bit:
At least twice he even fell upside down (wings first) in the sugary food, so we had to clean him and dry him:
we then helped him dry
We hope he enjoyed the flowers we gave him:
despite his damaged feet, he was able to climb flowers as often as he could, that was exciting
Gimpy, Day 7-8
Unfortunately each time he got scared or excited, he tried to fly and ended up upside down and then couldn't flip back, so we had to help him (actually, during a couple of days he became strong and skilled enough to jump up from upside down and eventually flip back right side up). What upset the poor thing was diverse and hard to know for sure, but the few times that he sensed AC air did not work. Surprisingly putting him in the sun, seemed to upset him too for reasons that are not clear (maybe it was too warm and he couldn't close his wings or regulate temperature).
In this clip Gimpy got upset at the sun and flipped himself over. We soon had to learn that our buttefly just didn't like being in the sun:
To make things harder, we think he eventually got a bit scared of us, as part of what we had to do, to help him, must not always have felt great (like wetting and un-gluing wings stuck with sugar). Obviously at times we must also have done a few things he plain didn't like when we were trying to do our best to help him.
By day 7th, he started flapping his wings and flipping over for more reasons, and it was harder to feed him. Jennifer tried really hard to find solutions, including this new feeder which was a great idea, but did not work out (it was too steep for gimpy who couldn't stand well with its leg stubs):
Jennifer was very observant and noticed that even his broken shorted leg didn't look quite right, and it had gotten glued to the body due to sugar, so she had to help him out. After flipping over out of frustation, Jennifer was able to see the leg stuck to the body's hair, and free it up while Gimpy laid very still.
We didn't know he was turning around like this but eventually Jennifer figured that it was because of the stuck foot:
sorry gimpy, this must have felt uncomfortable, but you really wanted your foot stuck with sugar, to get unstuck
By then poor little thing was looking more beaten up with all the wing flapping, flipping over, one time a wing even got stuck to the cardboard due to sugar and a small corner of the wing was lost:
We tried to find new ways to feed him so that his poor injured feet had a bit of traction and that he wouldn't fall in the food:
Always made sure he had flowers to enjoy:
Unfortunately by mid-day he would get more restless and often looked like he was upset, at us or something else. All we could do was to put a a cover on the box so it got dark to calm him down. This was hard to watch, we were worried that maybe he was in pain or suffering in some way, or maybe he was just upset to see us (ultimately the only communication we got when something was wrong is he would flip over, which is kind of limited). It was upsetting not to know what was wrong and how to help:
So many questions, he didn't seem to be able to move forward much, but was he moving backwards (not a normal thing to do). Was it because it was easier for him to move that way, or because he was afraid of us?
And in the process of all this, he really surprised us by having enough power to hang on to a flower and move it with his wings:
This is where things get sad. Because he seemed scared of us, we gave it more space and didn't try to feed him in the evening when he was more restless and more likely to fall in the food and get all sticky. Because he died 5 days before his expected time, we think he didn't eat when we gave him food in the morning of day 8 (it was easy in the morning as he was still waking up and less likely to be feisty), and we didn't know (he had the proboscis in the food, but we didn't know if he sucked any). He didn't really seem weak during the day, but of course, it's hard to tell for sure.
I put the lid on the box that evening so he didn't get too excited (yes, of course, there was room for air exchange).
Gimpy, Day 9
The next morning, I brought gimpy to his food as he was waking up, and maybe I should have taken a clue that his antenna was dipping in the food.
when I was looking at him, he wasn't doing the suction
Soon after, we found him with one wing arched (maybe due to to dehydration) and the other wing dipped into the food:
Jennifer thought he was dehydrated because his wings we arched, so she misted him and tried to get the sugar out of his wing. In hindsight, we should have tried to give it pure water at that point, even if it was probably already too late:
it was very hard to do, only Jennifer had the eye and precision to do it
By then, we realized that he looked dead. I had already written gimpy off as he hadn't moved at all in a while, but Jennifer said we should take him to the sun, and she was right. We saw a bit of life back in him but it was apparent that he was having his last moments (we wanted him to eat/drink and recover, but that was not to be). We had a small piece of parchment paper between his wings so that they didn't get stuck again:
he wouldn't eat, but he was probably too weak to make the suction to eat by then.
Given his number of infirmities, Jennifer wondered if his proboscis stopped working because it got plugged by sugar or a piece of fruit, but obviously that's kind of hard to check. If it were true somehow, by then it was way too late and Gimpy was too weak to do any suction. Yet, as a last ditch effort, we put his proboscis in water and tried to stimulate it a bit, and Gimpy responded by moving it a few times ever so slightly, but those were clearly his last dying breaths (not that you can see a butterfly breathing):
If you look really really closely, you'll see one of his last signs of life at offset 0:29. We were hopeful he could drink water and perk back up, but it was too far gone unfortunately:
In the end, Gimpy lived 9 days (those butterflies live 14 days on average, so he should have lived a bit longer). It died on the morning of July 4th. In hindsight, it was likely that he didn't feed at all in at least 24H, but it was hard for us to know, because butterflies do not expel waste unless they ate way too much (that happened a couple of times with gimpy when he was eating way too much early on). The other problem was that in the last 3 days, he had gotten what looked like more restless with us, so that he would try to fly and eventually flip upside down when we were too close. As a result, we gave him more space and were not able to observe him as closely (Jennifer before that was checking carefully and knew when he was bigger because he had eaten, or could easily tell when one of his legs or wings got stuck because of sugar).
A bit later, we found that his wings had bent/arched and he hadn't shown any movement in over 30mn, so we said our good-byes. Hopefully his last moments weren't too uncomfortable and we hope we helped him have the best butterfly life that he could in the 9 days that he shared with us.
RIP, Gimpy
Conclusion
So, most of you are probably going to at least smile, if not laugh at us, for the amount of time and effort we've spent over those 9 days trying to give this poor little butterfly as good a life as possible. I understand, I probably would have done the same thing too, but given that I'm the one who didn't manage to help him better get unstuck from his cocoon, and probably is at least partially responsible for him missing a leg or two, I've felt responsible for helping the poor little bugger out as much as possible (the wings never fully inflated and the part of antenna missing, is likely another problem that may not be our fault).
We've tried to give it as much of a "proud butterfly life" by showing him outside a few times, first when we released his siblings, including taking him out for lunch with us, until he didn't like the sun and wind. After being back indoors, we make sure he got fruit juice or sugar water, and we moved him around with the sun during the day so that he could enjoy the heat on his wings (he first seems to enjoy that, but soon enough it looked like not, maybe too much of a good thing?). For his last moments, Jennifer also took him back outside to experience the outdoors and the sun one last time.
We learned a lot about butterflies, but we were also left with a lot of questions, including the ones related to his challenges:
We had to learn that he didn't like sun, maybe because he couldn't fold his wings and it was too hot or too drying
There are times, he went backwards, was he scared of us, or was he so unable to walk properly that it was easier to move backwards?
Was he trying to fly just to fly, or was it indeed the only way for him to show that he was upset/scared?
We never found out why he had some control over his proboscis but didn't seem to be able to extend it in food, while being able to use it once it was there
We hope he was able to enjoy the flowers despite missing the part of his feet that can smell, and one part of one antenna
We never were really sure if he liked what we tried to do for him, like getting a floor that's not as tough given that he had to drag his body, but if it was too smooth, he had no grip to move around
More generally we hope he never was in pain or suffering, but it's very possible he had gangrene on his broken legs. Our biggest hope is that the days of life with gave him were worth living and his quality of life was sufficient to make worth it. We also hope we were able to help him achieve the best butterfly life he could have.
Did he die a natural death a few days early, or did he become unable to feed because it had problems with his proboscis (did sugar cause a clog, and we could have gotten gimpy to feed on water after each time it had sugar?) or maybe it did have gangrene and an infection from his half severed feet?
One thing I got a hint of, is how caretakers of people with special needs must feel. We wanted to help gimpy so much, accepted his disabilities, adjusted our hopes and expectations accordingly, and did the best we could to help it. The other butterflies were fun, we released them outside on flowers, they left, and never came back (as expected of course, it's not like they're supposed to be pets). Gimpy had so many problems, but he never gave up: he made us so happy when he succeeded in doing things like climbing a lavender and standing proudly on top, or when we saw him hover while holding and moving the lavender under him. We definitely rooted for him.
Gimpy never gave up, and tried to be the best butterfly it could be despite its physical challenges.
Yes, it would have been a lot easier if he could have fed a few more days and just died peacefully in his sleep, but that wasn't meant to be. Seeing him make his last movements as he died was very hard to watch, but I guess 9 days of life, hopefully at least 6 of them being as good as they could be, is still better than nothing (realistically many people would not have seen him struggle and let him die after birth, or not noticed he wasn't able to feed on his own and let him die of starvation after birth).
Yes, we could have euthanized him if we knew he was not going to make it, but we kept hope that he would surprise us again and pull through. Would you have been ok killing a butterfly that you were not absolutely sure, was already dying?
RIP Gimpy, we hope you'll re-incarnate in a better life, thank you for the teachings you gave us, and sorry for any ways we did not know how to better take care for you (although hopefully we did about as well as anyone could have been reasonably expected to).
After he died, we decided to keep him. I tried to flatten his wings, unstick the ones that were often stuck and pointed wrong, and made him a little home with flowers from our yard:
and him got a home with the other butterflies I inherited from an uncle
(before you ask, I do not support buying butterfly displays, I don't trust that the butterflies died a natural death. That one is over 60 years old and I inherited it from an uncle in France when I was a kid, while I enjoy it, I would never buy one):
Summary video:
[rigimg:1024:1.5 years ago, I got some caterpillars for Jennifer's BD and they grew into butterflies that were released in the yard, although it was a bit cold in november. We you can read about our first experience taking care of caterpilars here.]
Given that were were not going anywhere for a while, I thought it would be fun to have another batch in nicer warm weather, so I got another set of 10 and this time the caterpillars were already a lot bigger when we got them, which we didn't mind, watching the caterpillars grow slowly was kind of the boring part of the experience for us:
they were fat within a few days
and they went to create a chrysalis quickly
Two of them were not attached right, so we used pins to attach them. One of those 2 never survived (not because of the pin that we carefully put outside of the cocoon):
Not long after, the first butterflies started to emerge with folded wings that got straight once filled with blood:
Butterflies are generally not afraid of us, especially after being just born:
Once all of them were born (there was a 2 day variance), we took them to our yard when it was warm and sunny:
they obviously liked our lantanas
this one already started feeding (you can see its proboscis)
Ok, it's not "real" wildlife, but it's still fun to see a few animals in your backyard.
Then, we have little lizards everywhere (well, big and small). The small ones are easy to catch :)
grippy claws :)
We've also heard racoons at night, and I was able to snap a couple of pictures. Thankfully they don't seem too bold and too much of a pest like we've heard they can be:
Howeer, what we have quite a bit is lovely possums, we mistakenly caught a few and of course released them:
such a cutie
it wasn't too scared to eat
we got another one the next day, or was it the same?
Ah, but the subject of pests brings us to gophers. Those fuckers have been making swiss cheese out of our lawn. Since repellents don't help, I've been using smokers in their tunnels, and poisnned worms they're supposed to eat. That seems to have helped with the problem, but I think we still have a couple left.
A while ago, I bought a bird feeder because I thought it would be fun in our yard, and sure enough, it was an instant hit. We got to see many interesting bird, including a baby woodpecker probably related to the big woodpecker that's living in our of our trees and making swiss cheese out of it :)
I have many pictures of those birds, but these are hopefully the best:
a junko was feeding the wrong bird, oops
that was a lot of doves
After a while, built aa new mostly squirrel proof bird feeder:
We also got beautiful woodpeckers:
[rigimg:1024:501*|]
We also got a few wounded birds:
And we also got a few hummingbirds. Those are cool:
Squirrels started by being cute before the bird feeder:
The only problem were the squirrels that started by eating fallen seeds, but eventually went to the source:
they look good when they start
clean the seeds by your doorstep
then they climb
and climb
and jump
and climb
and jump
The squirrels really became a problem, so I had to trap them and get rid of them:
I tried to build a defense, but it was pointless
on the plus side, I could capture all the grain the birds were dropping
Afer being cooped up for 2 weeks, it was time to go out for a bit of fresh air, stretching my car's legs, and going to the beach for a few walks:
quick stop on skyline
before long, we reached Pescadero beach
Caltrans nicely were closing all the beach parking lots as we arrived
We then drove down Hwy 1 to hit a few beaches:
found a nice surfer
the next beach
where skyline of the beach, ends up
We ended up going to Shark Fin Cove or lunch:
railroad to nowhere
I went to check out the cave which was really a storm drain
didn't smell so good :)
nice hole in the rock
Jennifer found a nice rock to eat
After lunch, we drove back up on bonny doon road. which was find until we hite what looked like snow on the road. How as that possible? Turns out, it hailed so much that the hail accumulated on the ground and looked like snow:
it was melting, but super slick
Eventually, after driving not as fast as I wished due to the uncertain roads, we got to 236 and big basin redwoods, which was closed as expected:
After that, it wsa a fun drive up 236, and 9 back home.
After weeks of training and practise, Jennifer was able to perform for the first time in Hamiltunes (unfortunately all previous times had date conflicts). She did well :)
Jennifer is however quite sad to already know that the next performance date will conflict with the 3 days she not available to attend in May :(
The other people in the cast also did really well. Some of them had performed Hamiltunes several times by now and some gave pro/semi-pro performances.
While a small portion of the cast has had some performance/singing training, others did not and learned on the job. All the performers are doing this for fun, some even got their own costumes.
Not too sure why a wildlife preserve is called an 'ecomuseum', but putting that aside, this small but interesting preserve for animals that were usually wounded and cannot go back to the wild.
Mormally when you go in the dead of winter, and it's -15C outside, you shouldn't expect to see much, but of course Canadian animals are used to the cold, so outside of a couple that were hibernating, the rest were out and about :)
It was a fun 2.5H, outside of how damn cold it was and my not having enough layers to stay outside in such cold that long :)
you don't look like a red fox to me :)
The lynx were a highlight for me, they totally looked and behaved like house cats that happen to be bigger and walk in the snow :)
hard to know if they would have bitten your hand off had you tried to pet them :)
liking their paws and soft pads, just like cats
out, looking for trouble :)
There were other animals of course:
even the ducks were fine with the cold
They had a few indoor exhibits, which were great to warm me up
Despite the cold, it was definitely fun, it's a bit out of the way if you are in Montreal, but on your way to the airport, it's a perfect stop
As part of Linux.conf.au 2020, I gave my main talk Planning for and handling failures from open hardware, aviation, to production at Google.
The talk focussed on failures I've encountered in multiple fields, and what I learned from reading from other people's failures, a common practise in aviation that has saved countless lives in not re-creating failures and accidents out of ignorance.
As they say in aviation "experience is a cruel teacher: she gives you the test first, and if you survive, then you get to learn the lesson".
After looking at examples of failures we experienced at Google, I give a fair amount of examples from aviation, from AF447, QF32, and the Boeing 737 Max disaster which is so many failures in so many ways that it takes a while to describe in details. My hope is that engineers in a similar situation where they know they are getting overruled, can use other escallation steps to avoid disaster for others.
You can get the talk PDF or openoffice source from here. Otherwise, you can read the slides below and watch the video recording:
