Fledgling and chaotic, what’s it all mean?

3 01 2010

It may strike some as odd that a blog about safety and security in aviation would shoot off references to chaos and disorder.

This blog’s reference to chaos is more scientific and quantifiable than naive and presumptive.  In the 196os, Edward N. Lorenz coined the term “butterfly effect” to covey the gist of a theory called ‘chaos’.  Chaos theory takes a stab at explaining how the outcome of a system that changes with time – like a flight – can vary wildly if changes are made to the original circumstances surrounding that system.

The original connection was with the idea that the flap of a butterfly’s wings can forever change the course of weather (that should clear some things up), but for the purposes of this blog, you have to view aviation operations for what they are: a system that is dynamic with many external attractors and not linear or inherently prim and proper.  As meticulously-orchestrated, precisely-executed, and well-intentioned as every flight may appear to be, even that 45-minute jump from NYC to Boston is more than just sequential pulling and pushing on the yoke.  An “unsafe” event can still occur if connecting passengers are late and the crew is excessively interrupted during their preflight cockpit flows.  Or if a dispatcher calls in sick at the last minute.  Or if a butterfly skipped a beat in Argentina.

60934869.1927_EmiratesA345_A6ERC_JFK31Ldepoverspeed_BF

Many of the bumps with baggage carts, misinterpreted clearances, runway incursions, technical malfunctions, and sudden cushionless meetings of stone and metal (thanks, Mr. Gann) have palpable causes, an unsurprising chain of events, and conceivable mitigation strategies that are well within the realm of feasibility for aircraft operators but were never implemented or otherwise acted on.  A focus on human factors and risk management has never been far from the industry and there is no shortage of acronyms to describe the work that has already been done.  After ASAP, FOQA, IEP, CRM, and SMS, chaos can expand on the famed Swiss Cheese model by making us aware of the way imperfections in all of our safeguards interact and work together.

The aviation industry is not greater than the sum of its parts – it IS the sum of its parts.  As any poster in a flight school will say, safety is not an accident, and most definitely will not happen by any sort of ‘strength in numbers’ logic.  My effort here is to realize the inherent complexity of aviation systems and its vulnerability to shortcomings in any and all areas of a given operation.

Aviation happens to be impervious to safety because of how intricate it is.

Please join me with your thoughts, comments, and criticisms.  I’m really looking forward to discussing and learning.

Brian Futterman

Advertisements

Actions

Information

One response

7 07 2009
Dan Langworthy

Brian, I look forward to your future posts. I loved the Swiss Cheese model. For years, I had the Error Chain, and the necessity to break the chain, drilled into me . When a ground school instructor brought up the swiss cheese model, I raised my hand and asked if we should now “Cut the Cheese.” Thanks for the blog and I look forward to reading more.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s




%d bloggers like this: