Active Failures of the National Airspace System (NAS)

31 Jan 25:

Dr. James Reason's Swiss Cheese model is often used as a visual model to show how active failures work their way through the latent risk holes in defensive layers (controls) of a system.

(Image Credit: Unknown)

In the case of the recent midair collision over the Potomac, the holes in the National Airspace System (NAS) cheese were big enough to fly a Sikorsky Blackhawk through...

Investigators will quickly determine the Who What When Where and How of what happened in this tragic mishap. Now we must ask, Why? And keep asking, so that we can create solutions that eliminate the multiple severe hazards that exist within the NAS in latent form, in order to keep this from happening again.

Fly Smart

"Clark" Kent

PS: The 2 dimensional, static sliced cheese model gets us thinking about the challenge, while in reality all of the cheese is melted together as a fondue and moving through space and time.