Genghis the Engineer wrote:...the holes in the swiss cheese...
That's it, you're now on The List.
Sorry, but my hobby is writing papers for academic aeronautics journals. You have to expect the odd slip. I'll try not to do it again.
Welllllll, alright then. I'll let you off with twelve months probabtion if you join me in my campaign to eliminate that bl00dy hackneyed old phrase from the aviation lexicon, particularly the CRM syllabus. It's a flawed analogy anyway.
Have you ever seen a block of swiss cheese with a hole all the way through? No. So, take a block of swiss cheese. Slice it up and take each hole in a slice to be an error. Yes, if you line a few slices up there's a clear run through but if you replace the other slices the hole no longer runs all the way through. Translate this into errors and what you're saying is that if you make more errors an incident won't occur.
Flintstone wrote:Slice it up and take each hole in a slice to be an error. Yes, if you line a few slices up there's a clear run through but if you replace the other slices the hole no longer runs all the way through. Translate this into errors and what you're saying is that if you make more errors an incident won't occur.
Didn't think it through, did they?
You clearly misunderstand the analogy, which is probably why you reject it.
Each slice is a layer of process, equipment or procedure designed to prevent an accident.
Each hole is an error or oversight. There can be many holes in a slice, or no holes in a slice.
The more slices, the less likely to be an accident (so if you have five engineers checking a piece of work, it is less likely to have a failure than if two do).
The more holes per slice the more likely (so, if one engineer is partially sighted, another has faked his qualifications, another is dyslexic and drunk etc the more likely a failure.)
I don't really see what's wrong with the analogy, except that it's now boring (in the ennui sense, not drilling a hole through.)
I've only read the news reports, and the case is against an alleged dodgy instructor/examiner.
What would be the implications of successful prosecution? Would the pilot be deemed unqualified and hence impact on insurance payouts? Graham Hill and Colin McRae had irregularities in their paperwork which seriously affected their families finances, and AIUI relieved the insurance companies of a need to pay out in full.