10 July 2009

ValuJet 592

This is an old article, but a good one.

Think about it some time. Especially this part:

Administrators can think up impressive chains of command and control, and impose complex double checks and procedures on an operating system, and they can load the structure with redundancies, but on the receiving end there comes a point—in the privacy of a hangar or a cockpit—beyond which people rebel. These rebellions are now common throughout the airline business—and, indeed, throughout society.

It raises some interesting questions about the efficacy of safety systems, and our reactions to accidents/ mistakes by adding more requirements onto a system. As we add more safeguards and redundancies, the system becomes more opaque and the feedback loops less obvious.

It's interesting to look at some of our submarine forces accidents in this light. Does the very existence of multiple redundancies breed complacency? A thinking of: "I don't really need to check this, because some one else will catch any mistakes."

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