ppb2 wrote:
Perhaps they are not mistakes as such, at least not in a way that answering
2+2 = 5 is. It just could be that given a particular set of (generally
stressful) circumstances repeated often enough, an incorrect response will be
produced. Maybe that some individuals are susceptible more then others and
the problem may be in identifying how to overcome the fallibility rather then
simply identifying the cause, such as keep safe flying speed in the circuit.
Which gets us to a concept called "resilience".
A resilient system is one which delivers an acceptable result even if
some of its components fail.
The opposite to a resilient system is a "brittle" one, which is one
which fails catastrophically in the face of a mistake.
Aviation should be built out of resilient systems, because we know
that humans are fallible and as long as we're making the pilot part
of the system we know that we're going to have to deal with mistakes.
Occasionally accidents reveal that systems aren't as resilient as we
believed. When that happens, we examine the systems to see how/if they
should be changed.
An example of a resilient system is the one which lowers our undercarriage:
- A mechanism is presumably well-maintained.
- Even if it isn't well-maintained, it's probably over-engineered by
the factory.
- We're all in the habit of putting our wheel down before landing.
- Just in case the habit breaks, we have a checklist.
- In the event that the habit is broken and the checklist has been
ignored simultaneously, many aircraft have undercarriage warnings.
The fact that suitably equipped and maintained aircraft still occasionally
land with the wheel up and the undercarriage buzzer bleating while the
pilot blissfully steers the glider into the ground stands as evidence that
"resilient" != "perfect", but we can but try.
In an ideal world, you never rely on the resiliency of the system.
If you've had to use backstops and fail-safes to get yourself out of
trouble, that means something bad has happened.
All of the important, life-saving or airframe-saving things we do in
the air have some kind of system wrapped around them. Perhaps we should
occasionally examine those systems to work out how resilient they are.
How should they be improved? Are there any places where we're allowing
components to regularly break down where the resiliency of the system
is saving us?
Reviewing these questions occasionally can only help to improve our
operational safety.
- mark
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I tried an internal modem, [EMAIL PROTECTED]
but it hurt when I walked. Mark Newton
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