Germanwings, 9/11 and the Law of Unintended Consequences

Much of the media coverage around the Germanwings air disaster has – controversially – centred around the mental health of the co-pilot who steered the airbus and its 150 passengers to its doom.

However, many observers have also wondered whether the changes made to how airliner cockpits were reinforced and locked in the wake of the 9/11 attacks might have unwittingly played a part in this latest air disaster.

We asked James Jameson, VP of product strategy at risk management software platform Rivo, about the issues raised by the tragedy – though we’re clear that he’s not commenting on it directly – about the difficult decisions facing the aviation industry and how to factor in the law of unintended consequences when making changes to security procedures and safeguards.

IFSEC Global: In light of the Germanwings disaster, how important is it to be mindful of the law of unintended consequences when changing security measures to reduce perceived risks?

James Jameson: Organisations set out to create procedures to manage risk with the best intentions in mind and more often than not driven by a major incident. Yet often the bigger picture is overlooked for short-term fixes that have devastating effects.

Fail-safe measures often need mitigating themselves: mitigating the mitigation. But where?

When mitigations are irreversible or so extreme that they’re almost if not impossible to override should they be misused, there should be due process and authority in place to ensure warning signs are raised as the policy is being formulated and ultimately alternative mitigations enabled for that ‘mitigation of the mitigation’ – or dual procedures as they are often known.

There are often multiple methods to implement the same policy. The example of locking security doors from one side only could be alternatively managed by dual biometric capability from both sides or remotely from the ground.

We know the technology is there so this becomes a case of having the drivers in place to make everyone do it so that airlines can use expensive safety mechanisms without it adversely impacting their ability to compete, and this is often where the role of the regulator comes in.

IG: What kind of measures could the aviation industry take to reassure the general public and enhance security and safety in aviation?

JJ: Flying is cheaper and safer than ever. The aviation industry are arguably the most advanced in terms of industrial safety and security regulation maturity and, in general, regulation full stop next to financial services.

That’s down to the simple fact that the risks involved are high impact. Yet risk management and regulation including safety and security is always iterative.

Things happen, we learn, we improve. What we have seen here is what risk analysts call a black swan event: something that happens and takes everyone by surprise and it’s not until afterwards with better clarity of hindsight that the event and risk of future, similar events occurring can be rationalised and managed.

Black swan events are hard to predict and high profile and in their very nature ‘outliers’. One of the first areas of weakness the relevant authorities such as CAA will look at will be the vetting and make-up of the flight deck crew.

Airlines already adhere to strict rules and regulations regarding training and job-ready fitness so an area of focus for regulators and airlines will be number of flight deck crew at any given time.

A number of airlines such as Virgin and Qantas have already changed procedures in the wake of the Germanwings tragedy to ensure if a pilot of two leaves the flight deck, that a crew replacement will be made.

That won’t eliminate the risk by itself, however, and the holistic view must be taken into account. What failsafes can be put in place in the case of a third crew member being overpowered?

What technology is available to allow the cockpit door to be secured against everyone except the pilot who has visited the toilet?  What remote intervention technology can be put in place to override pilot control from the ground?

These are questions that many will be focusing in on to avoid this happening again and to provide assurance to the public that the risks are being properly accounted for.

Google are betting their money on zero-pilot cars – how far is the aviation industry going to be behind that vision? I wouldn’t imagine that far.

IG: Not that far at all as this BBC story from 2013 shows…

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