Error Chains
CRMDEEN (CRMDEEN_at_aol.com)
Tue, 27 Jan 1998 08:16:12 EST
It would seem the mood-topic is now entering into Error Chains. I talk
to this a lot in my classes. Lately, I've challenged the students to
consider this perspective:
We, in the research and teaching activities, are getting really good at
recognizing an Error Chain through a historical perspective. That is to say,
we go to a crash site, and investigate what happened. Then we publish the
account of the crash as a story that unfolded through an Error Chain, or a
sequence of contributing causes. With this knowledge, we often conclude that
we understand how the crash occured, now that we know the sequence of events.
We then, in a class, try to teach the next aviator to "NOT do that".
This forms my question: "How do you know you are in an Error Chain",
present time. Some of the reports we read fault "poor planning", but I ask
aviators "did you ever go to the airplane with the knowledge that you had done
a lousy job of flight planning?" Most of them say no, and yes, some have
admitted they have begun a flight knowing they were not prepared to fly.
So my question of the day is "How do you know you are in an Error Chain?"
Greg Deen
Raytheon