Get out of the airplane to close the holes in the Swiss cheese
The Swiss Cheese Theory is used to illustrate how holes in different layers in a system have to align for an accident to occur. Closing one of the lined-up holes is sufficient to prevent bad things to happen. Experts still disagree about how many layers there are in aviation but that’s not relevant – all what we need it to maintain at least one closed. Some are not directly under pilot’s control. Weather, other traffic, technical failures, mistakes from other parners like maintenance, ATC, issues with passengers are all out of control. But one single layer can make the difference, and we always control some of them. Always. Even catastrophic airframe failures don’t happen in a snap.
While we’re always smarter in the aftermath of an accident than before, it’s our job as pilots to make what it takes to avoid negative things to happen. When discussin such things I always feel like I’m repeating the same old tips again and again:
- Know your priorities: aviate – navigate – communicate
- Have personal minimums to determine between what’s legal and what’s reasonable
- Act before it’s to late – and if you feel things go bad on approach, go around. In worst case, it will hurt your ego
Is there a real difference between the moment where we make decisions in the cockpit and the time we read an accident report and discuss about a safety ? I don’t think the confined space of a cockpit turns us into idiots or makes us act like cowboys. Having our own life at stake shall be a sufficient motivation to make us think better. So what ? Is the excitment or stress of flying so high that we can’t we remember these simple things and apply them ? I’m aware that the answer to this question is… yes.
As Patrick pointed in two posts, one about airborne and one about ground situations, the first thing to do when situation goes wrong is to take time. The first linked post above contains an excellent quote from John King: “there’s no problem you can’t make worse by going too fast”. Personally, my response to stress tends to be a quick reaction. My Instructor was good enough to sometimes let me react so, just to make me experience first hand how bad this can be. After that, he gave me a simple tip: get out of the airplane.
Not literraly, though. Just stop thinking, take a deep breath, project my mind somewhere else for a couple of seconds, and come back relaxed, with a wider perspective. This helped me a lot, and I know accept and understand that there are no situations where 10 seconds of thinking can make a real difference. Even at 200 feet above ground descending at 500 feet per minute, the impact is 30 seconds away.
Accident causes are always found minutes, if not hours before their occurence. This “get out of the plane” technique makes sense at any moment. From weather analysis to in flight route update, taking a step back and look at the big picture can really make a difference. Play the “what if” game when you’ve time is fine, but not sufficient. It’s exactly when you feel like there’s not time left to think or react that you should do it. What if you continue this approach which looks bad ? What if the pass at the end of this narrow valley is not clear of clouds ? Would something else than your ego or planning be impacted if you turn around now ?
Trust me, these questions are much easier to answer when you’re not in the airplane. So get out, think, and come back.







2 Comments, Comment or Ping
Sylvia
To my mind, personal minimums is critical. It is too easy to just “keep going” in hopes of finding a solutions, whilst losing options because you continued.
Oct 2nd, 2009
Julien
A perfect illustration of holes in the Swiss Cheese lining up can be found in this real story published on the AOPA website.
Root problem: fuel cap not properly secured let fuel out of wing tanks in flight due to siphoning (since pressure is lower on the top side of a wing, fuel is sucked out if the fuel cap does not provide a good enough seal)
Layers of cheese:
- Pilot didn’t trust his fuel gauges but rather relied on the estimated amount of fuel left computed by the fuel computers based on indications from the fuel flow meter.
- When the engine eventually stopped, the airplane had drifted too far from the shore of Lake Michigan to glide to land
- The pilot didn’t know how to swim and subsequently drowned.
Sad story, and a fatality that could have been avoided if any of the three layers above had been aligned a different way.
Oct 3rd, 2009
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