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Causal Capital ~ The Knowledge Capital Specialists

You only hear about tragedies

When it comes to those outside the circles of risk management, they only hear about the tragedies. What would be deemed newsworthy is generally only something materially significant, even though it is often only transitory. If an event is not spectacular enough or if it lacks 'Paparazzi Potential', very few people pay that much attention at all.

This is not the way uncertainty unfolds. A class of randomness that is generally persistent for what it's worth and this fleeting social focus is not the way a competent risk management department should operate.

In the world of risk management, we run a concept known as Propagation Error or Knock-On Effects, that is and to put it simply; one thing can lead to another. Even small things can make a positive or negative difference, and then there is just plain luck as we shall see. However, one has to be paying attention beyond mass consumption of media banter if they are ever going to grasp how Propagation Error plays out ~ we'll come back to that shortly as well.

On Wednesday the 3rd of August, Emirates crash-landed its Boeing 777-300 EK521 flight from Trivandrum to Dubai in what ended up being a catastrophe for firefighters on runway 12L (left), see Figure 1. There was a complete hull loss for the airline and a challenging but well-managed escape for 282 passengers and 18 crew. Deep respect must be given to Jassim Essa Al-Baloushi who lost his life battling the aftermath of the disaster.

What ensues after tragedies of this magnitude and 'you only hear about tragedies' is the speculative reasoning, the criticism of who did what and more often than not, who didn't do what they were supposed to do. The OMG statements litter the headlines for a while and then society transitions onto something else. We usually finish up with the media pumping out social reassurance that flying is the safest form of travel, but take note; these things are much more complex than what one would expect from nothing more than basic observation of a simple statistic.

Figure 1 | EK521 Hull Loss in Dubai

If one was to count the number of aircraft that have landed in Dubai Airport since the beginning of time, well since Dubai Airport opened, perhaps all airports across the world, why just focus on Dubai but if we were to compare this volume of traffic against the number of catastrophes; most people would perceive many aircraft incidents to be nothing more than a statistical anomaly.

Remember ... You only hear about the tragedies but what about those incidents further away from a propagation error's ending point?

As it happens (Figure 4) the world has endured 1250 reported potential 'Dubai Like Catastrophes' this year alone but only those watching will be aware of this fact.

Figure 2 | SQ368 Catches Fire in Singapore (Sourced by passenger video)

If you take a look at Figure 2, we are can see that Singapore Airlines has been generous enough to put on an exciting firework display for passengers on a flight only two hours into its mission but unlike EK521 in Dubai, no passengers were evacuated. We must hope that Singapore's wonderful reputation for service prevailed and passengers or in this case guinea pigs to propagation error were served tea and coffee as they pass time recording the incident from the comfort of their aircraft seats.

SQ368 was a poorly managed but lucky catastrophe that didn't 'eventualize', while EK521 was a well managed and unlucky catastrophe that found its way to a propagation error's finishing point.

Figure 3 | EK512 BLEVE (Sourced by random spectator recording)

What we do know as is evidenced in Figure 3, is that airplanes can suffer from BLEVE events [LINK]. A BLEVE is a most dangerous outcome from any accident and requires a very carefully planned risk response.

It seems logical from the perspective of aviation engineering to load jet fuel and liquid weight into wing compartments of an aircraft. During normal flight operation this structure will act as a stabilizing factor for many important functions of flight but this logic also has a dark corner because it creates a massive hazard further down the propagation error chain. When a fire is present, BLEVE may no longer remain a latent hazard of aircraft travel.

Let's be explicit for a moment. EK512's BLEVE provided enough energy to blow the entire left wing section off the aircraft, several stories high into the sky and the shock wave / fireball is more than likely the cause for the firefighter's tragic death. SQ368 was quite simply 'plane lucky', pun intended.

Data Analysis

Civil Aviation does two things right from a risk management perspective to make it 'relatively safe' and we do have to be real here, any situation that may result in a BLEVE outcome is far from inherently safe. Firstly, civil aviation makes a concerted effort to standardize its operating environment including the tactical response to anomalies. Secondly, civil aviation takes the acknowledgement as well as the recording of incidents seriously and one of the best sources of Aviation Incidents can be discovered by perusing the pages within Aviation Herald [LINK].

Figure 4 | Risk Assessment of Incident Data [Aviation Herald]

In the schematic shown in figure 4, we mapped the Aviation Herald news feed to a factor capture algorithm so that we can perform numerical analysis on aviation incident data. The resulting reports and pivot tables gives us great insight into the multiple factors that drive propagation error.

The EK512-BLEVE outcome has many potential propagation pathways including; Wind Shear + Flap Configuration or Gear Failure or Hydraulic Faults and over this year alone, there have been many potentially compromising situations for aircraft all over the world but remember, those away from risk management only hear about the tragedies.

What a comprehensive incident reporting system does for risk management is to improve the survival rate for those facing impending doom. Fundamentally it helps staff prepare for and respond to catastrophes so that they can maximize their outcome horizon. The professional and ethical actions of the Emirates flight crew, including the challenged evacuation of the aircraft and the shouting of "Leave your bags behind, jump jump jump" saved the lives of all those on board. These people deserve awards for the way in which they responded to this incident, especially as the event unfolded across its propagation pathway so rapidly.

"The professional and ethical actions of the Emirates flight crew saved the lives of all those on board."

Incident Management

The importance of having a comprehensive incident management and analytics system is so fundamentally critical to effective risk management that I would go as far to say that any risk management framework is incomplete without it.

Figure 5 | Civil Aviation Incidents by type

If you are a risk manager wanting to understand what factors propagate error and how to respond to them, an incident reporting system should be your best tool of choice. If you want to disarm commercial politics and enable a strong risk management culture, formal incident reporting will take you to that end.

In the case of civil aviation we can be nearly sure of one thing. Given we have an average number of 173 incidents per month and event numbers are so huddled around the mean that it is difficult to find any significant deviation, we can be expecting our next tragedy anytime now. Two days after the Dubai case, we have it and another Boeing 737-400 overrun its runway approach, this time in Milan [LINK].

Remember airline travel is safe, that's what they say, we just don't see the tragedies in everyday life.

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