Tightly-Coupled Systems, Airlines and Error

Great new Vanity Fair piece out on the 2006 in-air collision of two jets over Brazil. It is an alternately fascinating and harrowing look at technical systems, complexity, tight coupling and fragility in the context of a preventable accident. We are allowing an over-aggrandized sense of the precision with which we can safely operate human-centered systems to create new risks. Sound familiar?

I asked the Caiapós to consider that in all the sky above the forest only these two airplanes had been in flight. It was as if in a space the size of the Caiapó village—no, all the way out to the road—you had shot two arrows in opposing directions, and they had collided. What were the odds? In the past it never would have happened. Even if you had assigned them identical flight paths, the arrows would have passed some distance apart because of the inherent inaccuracies of flight. But now better feathers have been invented, and have become required equipment for the high-speed designs. As a result, the new arrows are extraordinarily accurate, which allows more of them to be shot around, but with increasing reliance on tightly coupled systems of control. The sky is just as big as it ever was, but the margin for error has shrunk. And when the systems fail? That is what happened over the Caiapós’ land. The paradox was precision. Mistakes were made, the Devil played, and two arrows touched nose to nose.

More here.