Revisiting the Aviation Safety vs. Networking discussion

David Hiers hiersd at
Mon Dec 28 09:05:55 CST 2009

In general, it seems that a field has to be aware that it can kill (or
has killed) an embarrassing number of people before its members accept
the need for controls such as processes and checklists.

Here's a couple if incidents in which gruesome, public loss of life
was necessary to for thought to triumph over ego:

Doctors took forever to get over their bad selves and adopt the
process of handwashing:

Pilots discover humility and the value of checklists in managing complexity:

Reactor-rats, wing-wipers, barber-surgeons, and rocket-jockeys now
recognize that the best and brightest among us, polished with state of
the art education and training, ruthlessly drilled in the
fundamentals, and armed with the best processes and checklists, are
just barely good enough to have even-money odds when dealing with
everything the world can throw at them.

I suppose that once us packet-pushers kill enough people, the
economics of lost market share, falling stock prices, and embarrassed
CxOs on CNN will push us in that direction.   Until then, however,
Anarchy and Heroics ( sing
their siren song.


On Sat, Dec 26, 2009 at 4:24 PM, Robert Boyle <robert at> wrote:
> At 02:08 AM 12/25/2009, Scott Howard wrote:
>> On Thu, Dec 24, 2009 at 6:27 PM, George Bonser <gbonser at> wrote:
>> > So you can put a lot of process around changes in advance but there
>> > isn't quite as much to manage incidents that strike out of the clear
>> > blue.  Too much process at that point could impede progress in clearing
>> > the issue.  Capt. Sullenberger did not need to fill out an incident
>> > report, bring up a conference bridge, and give a detailed description of
>> > what was happening with his plane, the status of all subsystems, and his
>> > proposed plan of action (subject to consensus of those on the conference
>> > bridge) and get approval for deviation from his initial flight plan
>> > before he took the required actions to land the plane as best as he
>> > could under the circumstances.
>> "*mayday mayday mayday. **Cactus fifteen thirty nine hit birds, we've lost
>> thrust (in/on) both engines we're turning back towards LaGuardia*" - Capt.
>> Sullenberger
>> Not exactly "detailed", but he definitely initiated an "incident report"
>> (the mayday), gave a "description of what was happening with his plane",
>> the
>> "status of [the relevant] subsystems", and his proposed plan of action -
>> even in the order you've asked for!
>> His actions were then "subject to the consensus of those on the conference
>> bridge" (ie, ATC) who could have denied his actions if they believed they
>> would have made the situation worse (ie, if what they were proposing would
>> have had them on a collision course with another plane). In this case, the
>> conference bridge gave approval for his course of action ("*ok uh, you
>> need
>> to return to LaGuardia? turn left heading of uh two two zero.*" - ATC)
> Once he declared an emergency, he had the right of way over all other
> traffic. ATC would move anyone in his way out of the way.
> Under <>U.S.
> <>FAA FAR 91.3, "Responsibility and
> authority of the pilot in command", the FAA declares:[2]
>   * (a) The pilot in command of an aircraft is directly responsible for, and
> is the final authority as to, the operation of that aircraft.
>   * (b) In an in-flight emergency requiring immediate action, the pilot in
> command may deviate from any rule of this part to the extent required to
> meet that emergency.
>   * (c) Each pilot in command who deviates from a rule under paragraph (b)
> of this section shall, upon the request of the Administrator, send a written
> report of that deviation to the Administrator.
> Just because we have checklists doesn't mean we can't think on our feet and
> handle situations not contemplated in checklists, but checklists and
> procedures exist to ensure we don't forget something we need to remember.
> They aren't a substitute for creativity and logical thought. They are an aid
> to it to ensure a minimum of creative thinking is needed to solve problems
> which shouldn't exist in the first place.
> -Robert
> "Well done is better than well said." - Benjamin Franklin

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