Abstract
The origins of disaster are complex. Systems-thinking offers the best chance of identifying contributory factors. Two disasters are discussed with reference to actor-network theory (ANT) which, thanks to its ‘principle of generalised symmetry’, supports holistic, high-fidelity analysis. It is suggested that the 2014 Malaysia Airlines Flight MH17 disaster originated in a mélange of factors, from cognitive bias to the economic organisation of commercial aviation. There are overheads associated with the methodology. Systems-thinking-informed investigations are intellectually demanding. Further, they are potentially time-consuming and costly. Liberal terms of reference are a prerequisite. Vested interests that seek to constrain, obstruct or undermine the investigation must be challenged. During the early stages of his investigation into the 1989 Dryden aircraft accident, The Honourable Mr Justice Virgil P. Moshansky and his team were subjected to what he later described as intimidation. Because of the inevitable clamour for answers, systems-thinking-informed investigations may be unpopular with politicians, constituents, managements, shareholders, regulators, journalists (whose disaster coverage can be hyperbolic) and other interested parties. Lead investigators must be politically shrewd and emotionally resilient.
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Notes
- 1.
Denialism and blamism “have strong psychological ‘drivers’” (Reason 2013) and operate at both the individual, organisational and societal level.
- 2.
Other proxy wars include the 1950s and 1960s Vietnam War between Asian communist powers like China and Western powers like the United States and Australia (Ambrose 1985).
- 3.
Predicted/expected behaviours are described in, for example, system blueprints, operations manuals and organisation charts.
- 4.
By the end of 2014, falling oil prices and Ukraine-related Western sanctions had weakened the Rouble significantly. During the year the currency had lost over 50 % of its value against the US Dollar. At the beginning of 2014, Russians needed thirty Roubles to buy one US Dollar. By the end of the year they needed eighty. On December 17, 2014, the Daily Mail's Hugo Duncan quoted the Deputy Governor of Russia’s Central Bank as saying: “The situation is critical”.
- 5.
Sometimes referred to by Ukrainian separatists and Russians as Novorossiya, the Donbass includes the Donetsk and Luhansk oblasts of Ukraine. The separatist uprising commenced on 6 April, 2014.
- 6.
The tables are reproduced in Appendix 1 exactly as they appeared in the Levada Centre and Kiev International Institute of Sociology research report (2014).
- 7.
Two Russia Today (RT) journalists, Liz Wahl and Sarah Firth, resigned over what they claimed was biased coverage by their Russian employer of the Ukrainian crisis. Firth claimed RT showed a “total disrespect to the facts” (Saul 2014). Liz Wahl, who resigned live on air, claimed RT’s coverage was “whitewashed” (Saul 2014).
- 8.
Imperial ambitions persist on the fractious continent of Europe. Buffer states like Ukraine are under the greatest pressure. Will Europe ever be truly modern? Will it forever be a prisoner of its chaotic and bloody past?
- 9.
Although most of the downed machines were helicopters or ground-attack aircraft, larger machines, like the twin-engined Antonov 30 and four-engined Ilyushin 76 strategic transport were also destroyed.
- 10.
And, possibly, the fact that MH17 had drifted 3.6 nautical miles north of airway L980’s centreline. An aircraft not on centreline may have looked suspicious to a SAM missile crew, although deviations for weather are not uncommon.
- 11.
Some military aircraft, like the Fairchild Republic single-seat A-10 ‘Warthog’ ground-attack aircraft, can survive shrapnel. The A-10 demonstrated “incredible resilience” during the First Gulf War: “Some Warthogs returned from battle with as much as 20 ft. of wing missing, tails shot off, and gaping holes in the fuselage” (Funding Universe 2014). Unlike the 777, the A-10 is unpressurised. Consequently, there is no risk of an explosive decompression.
- 12.
According to former staff member at the US Joint Chiefs of Staff, retired airline pilot and Embry-Riddle Aeronautical University academic, Professor Kees Rietsema (cited in Halsey 2014): “Airliners overfly conflicted areas all the time”.
- 13.
Robert Crandall (cited in Petzinger 1995), Chief Executive Officer (CEO) of American Airlines, argued that aviation is “intensely, vigorously, bitterly, savagely competitive”. Cost reduction is a key objective of most airlines (Lawton 2002; Massachusetts Institute of Technology 2011; Franke and John 2011).
- 14.
Johnson (1986) describes Sakhalin and Kamchatka as “perhaps the most dangerous part of the world’s surface”.
- 15.
Aping Reagan’s unsubtle approach to foreign policy, President George H W Bush talked about a multi-nation ‘Axis of Evil’. Like father, like son: Following the 2001 World Trade Centre attacks. President George W Bush told the world community: “Either you are with us, or you are with the terrorists”. Some thought it unwise for the United States to conduct bilateral relations on the basis of how a country reacted to the attacks. Discriminating friend from foe with such a calculus was possibly a mistake.
- 16.
Of course, hindsight is always 20-20 (perfect).
- 17.
SpaceShipTwo is a 60 ft. long, air-launched reusable space vehicle that is boosted to the edge of space at circa 2500 miles per hour. Its flight profile resembles that of North American’s X-15 aircraft, the first air-launched reusable space vehicle.
- 18.
On his Virgin web log, Branson described Rutan as a “genius aerospace engineer” (Branson 2014).
- 19.
- 20.
The feathering system requires two actions. First, a lever must be moved to the ‘unlock’ position. Then a handle must be moved to the ‘feather’ position.
- 21.
Tom Wolfe described the dangers of flying at the edge of space in his celebrated 1979 book The Right Stuff. Wolfe described the experiences of many of the USA's military test pilots, including those who flew the rocket-powered North American X-15, an aircraft capable of flying at Mach 6.7 at an altitude of 67 miles (354,000 ft.). Death was an expected overhead of test flying exotic machines at speed at high-altitude. SpaceShipTwo’s apogee is 68 miles.
- 22.
In July, 2007, an explosion at Scaled Composites killed three and injured three more. The explosion occurred during testing of SpaceShipTwo’s hybrid rocket motor. The California Occupational Safety and Health Administration (COSHA) suggested a lax safety culture may have contributed to the accident. According to Rhian (2013): “The findings in [the COSHA] report highlight concerns that have been raised regarding the manner in which a number of the commercial start-up companies conduct their business”. Following the loss of SpaceShipTwo and questions about the 2007 deaths and injuries, Virgin Galactic said: “[A]n industrial accident with tragic consequences during a nitrous cold flow test … clearly has no bearing on the events of last week” (cited in Ensor and Mendick 2014). If the NTSB finds that the 2014 accident resulted partly or wholly from a lax safety culture at main contractor Scaled Composites then, clearly, the 2007 accident would have a bearing.
- 23.
Virgin Galactic has a backlog of over 700 passengers, each of whom has paid circa $250,000 to be carried to the edge of space.
- 24.
In the parlance of actor-network theory, this singular triumph would have ‘bent space around itself’ (see Callon and Latour 1981), creating a supportive network of media attention, enthusiasts, sympathetic investors, reliable funding and new ideas. The SpaceShipOne actor-network boosted confidence in the embryonic commercial manned space flight industry.
- 25.
The fifteen-year Apollo programme, that put twelve men on the moon, cost $109 billion in 2010 dollars. At its peak the programme employed 400,000 and required the support of 20,000 contracting firms and universities. According to NASA: “Only the building of the Panama Canal rivalled the Apollo programme’s size … only the Manhattan Project was comparable in a wartime setting”. The cost of the Shuttle programme was circa $200 billion in 2010 dollars. Each Shuttle mission cost about $1.4 billion (Lafleur 2010). By November, 2014, the SpaceShipTwo programme had cost $1 billion (£626 million). The programme employed around four hundred engineers.
- 26.
Prior to the rationalisation of the commercial spaceflight industry, launch companies had to deal with seventeen US Government agencies.
- 27.
In 2014, Northern Ireland’s budget for the retrospective investigation of murders committed during the Troubles was cut, delaying inquiries and undermining public confidence. The Police ombudsman commented: “The reduction in budget has undermined our ability to deal with the past”.
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Appendices
Appendix 1
What do you think about the political future of the Donbass (Donetsk, Lugansk regions)? Which of the following versions would you prefer?
According to residents of Russia Aug.14, Levada—Centre | According to residents of Ukraine Sep.14, DI + KIIS | |
|---|---|---|
For Donbass to remain a part of Ukraine on the same terms as before the crisis | 6 | 45 |
For Donbass to remain a part of Ukraine but receive greater independence from Kyiv | 18 | 32 |
For Donbass to become an independent state | 40 | 7 |
For Donbass to become a part of the Russian Federation | 21 | 5 |
It is difficult to say | 16 | 10 |
Do you agree with the view that Russia actively supports pro-Russian-oriented forces in eastern Ukraine?
According to residents of Russia August 14, Levada—Centre | According to residents of Ukraine September 14, DI + KIIS | |
|---|---|---|
Definitely yes | 12 | 49 |
Mostly yes | 38 | 25 |
Mostly no | 22 | 8 |
Definitely not | 8 | 7 |
It is difficult to say | 20 | 11 |
Do you think that Russia bears responsibility for the bloodshed, death of people [sic] in eastern Ukraine?
According to residents of Russia August 14, Levada—Centre | According to residents of Ukraine September 14, DI + KIIS | |
|---|---|---|
Definitely yes | 5 | 44 |
Mostly yes | 12 | 19 |
Mostly no | 25 | 10 |
Definitely not | 50 | 17 |
It is difficult to say | 8 | 10 |
Do you agree with the view that there is a war between Russia and Ukraine?
According to residents of Russia August 14, Levada—Centre | According to residents of Ukraine September 14, DI + KIIS | |
|---|---|---|
Yes | 26 | 70 |
No | 59 | 19 |
It is difficult to say | 15 | 11 |
Appendix 2
Aircraft destroyed | ||
|---|---|---|
Date | Aircraft | Specification and role |
16/07/14 | Sukhoi Su-25M1 | Single-seat, twin-engined ground-attack |
16/07/14 | Sukhoi Su-25M1 | Single-seat, twin-engined ground-attack |
14/07/14 | Antonov 26 | Twin-turboprop transport |
12/07/14 | Mil Mi-24 | Helicopter gunship |
02/07/14 | Sukhoi Su-25M1 | Single-seat, twin-engined ground-attack |
02/07/14 | Sukhoi Su-24 | Twin-seat, twin-engined supersonic strike |
01/07/14 | Sukhoi Su-25UB | Single-seat, twin-engined ground-attack |
24/06/14 | Mil Mi-8TV | Twin-engined transport helicopter |
21/06/14 | Mil Mi-8T | Twin-engined transport helicopter |
14/06/14 | Ilyushin 76MD | Four-jet strategic transport |
06/06/14 | Antonov 30 | Twin-turboprop photographic reconnaissance aircraft |
05/06/14 | Mil Mi-8 | Twin-engined transport helicopter |
04/06/14 | Mil Mi-24RhR | Helicopter gunship |
04/06/14 | Mil Mi-24VP | Helicopter gunship |
04/06/14 | Mil Mi-24VP | Helicopter gunship |
04/06/14 | Mil Mi-24VP | Helicopter gunship |
03/06/14 | Mil Mi-24VP | Helicopter gunship |
29/05/14 | Mil Mi-8MT | Twin-engined transport helicopter |
05/05/14 | Mil Mi-24P | Helicopter gunship |
02/05/14 | Mil Mi-8MT | Twin-engined transport helicopter |
02/05/14 | Mil Mi-24P | Helicopter gunship |
02/05/14 | Mil Mi-24P | Helicopter gunship |
25/04/14 | Mil Mi-8 | Twin-engined transport helicopter |
22/04/14 | Antonov An-30B | Twin-turboprop photographic reconnaissance aircraft |
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Bennett, S.A. (2016). The Benefits of a Systems-Thinking Approach to Accident Investigation. In: Masys, A. (eds) Applications of Systems Thinking and Soft Operations Research in Managing Complexity. Advanced Sciences and Technologies for Security Applications. Springer, Cham. https://doi.org/10.1007/978-3-319-21106-0_10
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