Murphy's Law trying to tell us something......

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Murphy's Law trying to tell us something......

#1

Postby avi-addict » Sat May 20, 2017 12:01 pm

Murphy is Trying to Tell Us Something
John J Nance

What CAN go wrong, WILL go wrong!

Ah, yes. Señor Murphy and his law. Our rueful, semi-philosophical joke that’s not a joke - the 3-way intersection of aviation, safety, and realism.

A long, long time ago (but in this same galaxy), before I was lured past the event horizon of aviation safety, high reliability organizations, and patient safety, I regarded Murphy’s Law as somewhere between cynical (expecting the worst of humanity) and pessimistic. The eighties, however, more-or-less beat that out of me. You simply can’t take apart and write about an accident like Air Florida (the 737 that hit the 14th street bridge in DC in 1982) or Tenerife (featuring two destroyed 747’s and 583 body bags on the Canary Island of the same name) and not realize that Murphy was onto something very profound: Anticipation.

(Cue Carly Simon’s song, “Anticipation” as a background here.)

One of the primary reasons (among many) that we were crashing airliners and killing people regularly before the late eighties involved the startling fact that humans (read: Carbon-Based units, thanks to Star Trek) could be relied upon to continuously make really bad mistakes, and further, that those mistakes accounted for more than 90% of the major crashes worldwide (including Tenerife). Building on that startling reality was the fact that despite increased cockpit automation, we weren’t going to get rid of us in commercial aviation anytime soon, and thus the conclusion became inevitable that if we can’t eliminate us, and we can’t eliminate all our errors, then we have no choice but to concentrate on building systemic ways of safely absorbing those potentially lethal errors and mistakes we can’t otherwise prevent.

Say what?

It all sounds somewhat quaint, now that we have the philosophy of teamwork and barrierless communication embedded in our flight training. But for those “experienced” enough (sounds better than “old enough”) to recall the “Zero Defects” programs of the 70’s, you’ll also recall that such programs had sent us on the happy fool’s errand of trying to pressure humans to do something we simply can’t do: eliminate virtually all mistakes in order to eliminate all disasters.

In other words, none of those programs worked.

Oh, certainly, they reduced the error rates, but any programmatic attempt to zero out all human-caused or latent errors in a human system ultimately has to fail because we human beings carry an embarrassing truth with us everywhere: We cannot be perpetually perfect. And, please follow me on this, if we can’t be perpetually perfect - but the penalties for being imperfect even once are potentially great (airline crash, refinery explosion, unnecessary patient death) - then we are left institutionally with only two choices: Accept the idea of an occasional disaster as an inevitable cost of doing business, or put into place something brand new and outlandishly different to blunt that pessimistic certainty.

We chose the new and outlandishly different, and that choice is what has revolutionized industrial safety and aviation safety, and will eventually revolutionize medical safety.

What we essentially did was build a two-stage safety system: Stage One is the traditional approach, putting forth our best efforts (using training, experience, simulation, teamwork, situational awareness and more) to reduce as close to zero as possible any human or systemic errors. Stage Two is accepting the fact that despite Stage One, potentially lethal mistakes will still be made, but by building a systemic method of spotting, capturing, and defusing any such mistakes, we can halt the process long before it metastasizes into a disaster.

So, for instance, when an excellent airline captain who, due to being a fallible human, misunderstands a radio call as being a takeoff clearance when it’s not, he or she can be stopped in the process of pushing up the throttles by a copilot who heard the tower controller differently and is worried about the apparent inconsistency. If another aircraft is waiting invisibly in the middle of a fog-shrouded runway ahead, tragedy will be averted only if the cockpit culture thoroughly accepts the possibility of errors by any one at any time, and creates a safe method of questioning each other.

This very balance would have prevented the Tenerife tragedy, the single worst airline accident in history. Stage One. You see, is all the training and experience and gravitas of a good captain (in the case of Tenerife, the captain was the chief pilot of KLM), but that captain is still human. Stage Two, however, recognizes the inevitability of human errors, and by anticipating them and empowering all crew members to “stop the line” when one is spotted, the possibility that a single mistake could build into a major tragedy is prevented.

Murphy would have us expect that if anything can go wrong, it will. But therein lies the path to salvation, so to speak, because if we can see the same thing Murphy has spotted, even if we can’t stop “it” from going wrong, we can safely divert the consequences.

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Re: Murphy's Law trying to tell us something......

#2

Postby Bell 407 » Sat May 20, 2017 2:55 pm

Interesting read that Avi :good:

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Re: Murphy's Law trying to tell us something......

#3

Postby gear up » Sat May 20, 2017 7:33 pm

Good reading Avi :thanx:
Dylan Cunha

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Re: Murphy's Law trying to tell us something......

#4

Postby Propnut » Mon May 22, 2017 7:33 am

Murphy lurks in hard to reach areas. He is never seen, but claims responsibility when no one else has an explanation.

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Re: Murphy's Law trying to tell us something......

#5

Postby Bell 407 » Mon May 22, 2017 8:23 am

Propnut wrote:Murphy lurks in hard to reach areas. He is never seen, but claims responsibility when no one else has an explanation.

:bowdown:

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Re: Murphy's Law trying to tell us something......

#6

Postby avi-addict » Mon May 22, 2017 9:18 am

....a very very black weekend....two choppers and one fixed wing down claiming lives in all three accidents this weekend 19-21 May 2017.....Murphy? Bad decision making, risky flying, bad maintenance of aircraft, risky weather.......who knows the reasons but one thing's for sure....GA is building a very nasty record.....


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