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by colechristensen
1748 days ago
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Complex systems and aerospace particularly are dominated by little things. Failure or near misses are never single cause, those are all designed for. When fails to happen it is almost always a conspiracy of serval things out put together any one of which would have mostly prevented the incident. There is a lot that practices involving life critical complex systems can teach other fields. |
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Four hopefully independent things went wrong here: three computer failures plus less-than-documented braking performance. Additionally, there were at least two aggravating circumstances: wet conditions and a tailwind landing. Part of the investigation is to find out if there was a fourth or fifth system failure (poor pilot reaction time? Rubber level on the runway unacceptable? Either is plausible, but far from indicated by the report so far).
One extra thing going wrong here, in the wrong direction (anything that impaired braking or pilot reaction time) would likely have led to loss of life. Investigating near misses like this, and not only being exercised once five things go wrong and a hundred people die, is a sign of a healthy safety culture.