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November 2018 Issue

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As someone whoís researched my share of aviation accident reports over the years, itís frustrating to dissect those reports and pick out the various missteps made and the points at which a change in direction, a precautionary landing or other mitigation would have altered the outcome. Loyal readers of this journal understand that aviation accidents arenít preordained and, instead, often result from a complex series of events occurring over time. Itís often called the accident chain, a term recognizing how these events are linked. Often, individual events occurring in an accident chain, by themselves, would not result in a new accident report. The accident chain concept has great value, but Iíve come to think of it as a trajectory instead of a chain.

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