Swiss cheese model. Each slice is a system, each hole a fault/mistake. An accident/incident happens when all the holes line up.
I find this stuff fascinating. I would really like a job in this. In my previous job I’ve been tangentially involved in the investigation into a couple of recent high profile accidents, and the main thing I’ve learnt is don’t believe anything the media publishes early on, and ignore all eyewitness reports.
My father was a military and commercial pilot. He regularly said that ‘people fail to the level of their training’.
One of the first things a pilot is taught is that when an anomaly occurs, make sure you keep flying the plane.
Yes, that’s how it goes. I have my glider pilot license (haven’t flown in a couple years) and it’s usually one mistake that kicks it all off and things go worse from there. Like the first poor decision to fly in the first place - despite marginal weather conditions or lack of sleep.
On pilot skills - there’s a new old trend in recent years to ensuring pilots have seat-of-the-pants training, old-style. Being sold on electronic / automated solutions to everything has left many pilots without the flying common sense needed to engage with a difficult situation. Much as aircraft act like buses, when they go wrong, they don’t go wrong like buses.
e.g. the 1971 FAA Private Pilot Syllabus (EA-AC 61-16A) - available as a pdf all over the place - is fantastic for this, and well over-emphasises the point.
That said, I’ve found the “Final Destination” movies apt metaphors for how errors accumulate, but many of them are signalled beforehand. Yes, I do treat the movies only as metaphor!
What I like about is gliders is the simplicity - it’s all seat of the pants, quite literally as when you find the thermal you’re looking for you can feel it in the seat of your pants. As far as the instrument panel you have the altimeter, a vario, and air speed indicator. To see if you’re flying straight, look at the string tied to the pitot tube. And in the trainers it’s all mechanical. They don’t even have a radio built in. The air force academy starts pilots out in gliders
And good instructors teach you to fly without them. At the club that taught me to fly, they used to carry suction soap holders in their pockets and inflict random instrument failures by obscuring the dials with them. So when I lost ASI and altimeter in a motor glider there was no drama.
In the context of last week, the Boeing 777 airframe involved in the MH370 flight is one of the safest passenger airframes on record. Only 3 hull loss incidents in the last 18 years and only one of those a fatal crash - two of those were ice on Rolls Royce engine heat exchangers, and then the last one that famous Asiana Airlines landing at SFO where the pilots came in too slow.
BA38 was the only hull loss due to FOHE icing. The second hull loss was an Egypt Air cockpit fire.
I’m a proponent of the system level approach to addressing faults, errors and so forth ( Reason’s Swiss cheese model is a classic example of how they might occur). It takes a dedicated, step-wise review of all potential causal factors (root cause analysis -RCA) by a knowledgeable multidisciplinary team to come to a consensus conclusion on why an undesired outcome occurred and what, if anything, could be enacted to keep that outcome from happening again.
This isn’t to say an expert with all the details couldn’t make a very good guess. But that isn’t the way causal investigations work. More brains and less bias --the idea being a separate, equally qualified team, would draw the same conclusions when presented with the same evidence (sort of the opposite of the current media conjecture-thon).
Of course, there is the fact that we don’t know what happened yet.
Well no wonder I haven’t been able to bring any down yet! Multiple factors… hmmm…
I was gonna say “the ground getting in the way” but gravity works too.
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