There is a high potential for catastrophic failures in the dynamic and complex world of aviation operations. Yet catastrophes are avoided on a daily basis due to processes and procedures that work correctly. Even when errors occur, the likelihood of a catastrophic failure due to cascading errors is extremely remote. That’s the good news.
Now the bad news. When cascading errors do occur, with little or no mitigation, the probability of a catastrophic event becomes more likely (as in James Reason’s Swiss cheese model). Catastrophes are typically the end stage of a series of failures that may have been latent in the system for a long period of time, perhaps years. Catastrophes typically are not the result of one errant individual; instead, that individual may just be the “trigger puller” for an accident that was waiting to happen. In many cases, accident precursors can be traced back to poor management decisions at the highest levels of the organization.
By definition, a hig…
