PPRuNe Forums - View Single Post - Air Asia Indonesia Lost Contact from Surabaya to Singapore
Old 31st Jan 2015, 01:44
  #2761 (permalink)  
bud leon
 
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xcitation:

The weather is just one hole in the swiss cheese.
Sorry to be pedantic, but in the swiss cheese model of accident causation weather is not a hole in the swiss cheese. Weather is a hazard. The slices of cheese are defences that sit between hazards and losses. A hole in the cheese is an inadequacy in part of the defence. Assuming weather was the primary hazard in this event, the defence layers might include aircraft design, AB FBW control philosophy, cockpit ergonomics, pilot training, pilot behavioural aspects, airline SOPs, crew resourcing, CRM, management behaviours, scheduling, maintenance, information provision and analysis, etc. Inadequacies in these defences are holes. When the inadequacies manifest at once, the holes line up. Some holes could be much bigger than others. This is only one conceptual model of accident causality. I make this point because it seems to be a much misunderstood model on this forum. But it is also a good argument against the people here who are speculating a single cause as the cause.
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