瑞士奶酪模型 Swiss Cheese Model.docxVIP

Accidents, Errors and Swiss CheeseOn Saturday, Asiana Airlines flight 214, a Boeing 777, crashed upon landing at San Francisco Airport. Through a combination of luck and robust aircraft design, only 2 people were killed; a surprising outcome given the photos of the wreckage. Unfortunately, many more were injured, a number in serious or critical condition. Intense speculation surrounds the cause of the crash, with theories ranging from pilot error to inoperative runway guidance systems to mechanical failure. What is known so far is that the plane made an abnormal final approach, striking it’s tail against a sea wall that precedes the runway. What’s unclear is why?The NTSB, the government body in charge of the investigation, has numerous experts on scene. Their process is methodical, sometimes taking years to establish a series of root causes and recommendations following a plane crash. In this case, the NTSB has a number of factors in its favor. The remaining pieces of the plane are immediately observable, unlike crashes that happen at sea. The black boxes have already been recovered. The crash happened in a populated area, with numerous eyewitnesses as well as video. The crew survived the crash and will be able to provide important information about the final fateful minutes of the flight.When accidents like Asiana 214 happen, people hunger for immediate and simplistic answers. Our need to feel secure fuels a desire for straightforward explanations that bring closure to mysteries. Our culture of real-time social media rapidly turns people into aviation experts, investigative sleuths and conspiracy theorists. Unfortunately, armchair speculation is rarely accurate, and ultimately the contributing factors of a crash can be diverse and complex.The intense media focus creates a false sense of insecurity, leading many to feel that commercial air travel is risky. In truth, aviation safety efforts have produced remarkable results — commercial air travel is an incredibly saf