At 10:40 PM 3/14/97 -0500, you wrote:
>Neil,
> Paul Russell, Boeing Safety Office, did a nice piece of work on "error
>chains" a couple of years ago. As I remember his presentation, he addresses
>errors as variables being present or not present, kind of like holes in swiss
>cheese, the pieces of cheese being each individual's performance. What I
>liked about it is that events(performance) are directly linked to an
>individuals Situational Awareness. Crews like the concept in that if you make
>and error the variables can be altered by correcting the error made.
>Recovery. It reminds crews that mistakes made are not unalterable events or
>links in an error chain. The error chain is really what the accident
>investigation board witnesses. The mishap crew is unaware of such a chain
>but aware of their own performance, or lack of performance. CRM enhances
>this mode of check and balances, let's think this out together with all
>involved feeding the captain information.
>Have Fun Fly Safe
>Charlie
>
>