Maybe.
randomness is the way of the universe, and patterns that we are genetically programmed to search for, as are our SMS systems a la Doc 9859 AN/474 and our most revered teachings by the maters of linear causation, and of tasty cheese repurposing, Emmentaler, Gouda etc... The sad fact is the universe is stochastic, it doesn't follow much in a linear fashion, and while we put emphaisis on the past being a predictor of the future, well, that only is true to a limited extent. Ukraine shootdown didn't predict a B772ER loss 6 months later; 447 didnt glean much about it's future from 358, or 4590. 587 didn't gain much from 585, or 427. We are great at matrix, QA checklists and other accoutrements of the advanced safety systems we have developed, and they just ain't so.
Our safety would be better served by enhancing SA increasing displays and alerting systems, and teaching crews more on recognition of SA loss, and SA recovery techniques.
It is slightly specious, but Niels Bohr's comment " "Those who are not shocked when they first come across quantum theory cannot possibly have understood it." sums up the difference between a linear causation as ICAO, FAA, etc espouse, vs functional resonance and stochastic system behaviour, which is how the world really is.
Change doesn't have to be expensive; my jets use systems that were old when Armstong was kicking sand in a far off sandpit, yet my iPad, which gives head down synthetic vision with terrain awareness, HITS, and 3D traffic vision is only acceptable to the extent that it doesn't interfere with... what, a black and white FMSCDU display?
odd world we live in.
PS: Swiss cheese says more about the CO2 bubble formation in a lactose product than it does safety. lining up of "holes" happens in storybooks, not the universe we inhabit in the myriad of the multiverse. If you imagine a wave-particle (LMAO! ) behaviour around a slit of your philosophy's linear model, then you start to approach the non-linear functions that occur in the universe. Imagine that your rules cause a change to the vector of your "hole piercer" problem, that is, when manglement raise another incessant policy change, they act to change the path of all, a "butterfly effect" if you must. The crew then cope with a new reality caused by the changes in the policy, but that affects all, not just one slice of predrilled pecorino or parmesan. Linear models make bureaucrats happy as it simplifies their ticking of box solutions, but it doesn't meaningfully alter the likelihood of a future calamity. Things have improved, training, systems, and alerting have improved; TCAS, weather forecasting, hardware reliability, nav system accuracy... etc, so things are getting better. CRM? sometimes, but we don't teach SA and we spend little time on developing NDM heuristics, in fact, we essentially suppress the conditions where new crew gain such heuristics.
Last edited by fdr; 23rd Nov 2021 at 07:36.
Reason: swiss cheese