Investigating aircraft and other accidents for more than 30 years, I have read several works on their cause and prevention. Omar Malik's work portended to be a more practical one - his background as a Royal Air Force flight instructor and British Airways captain with 12 years' experience in accident investigation, focusing on accident prevention, were indications that this fellow might know what he was talking about (helped by his strong education background, which includes a doctorate in aviation security).
Malik's main thrust is how to control risk, and to give us a working understanding of risk, he describes the world of risks, their geneses and relationships, and presents laws, lists, tables and concepts which, although sensible, are daunting in their number and interrelationships. In his defence, every book I have read in this area contains many lists and terms, so perhaps it comes with the subject. In this work, however, I found myself wishing for a separate glossary in order to avoid returning to prior pages to remind myself of what a particular concept meant. An index would have been helpful.
All the information is prologue for what Malik calls "Failure Path Analysis" which, at first reading, is similar to the "Swiss cheese" theory of accident causation, depicted in hundreds of works by showing several separated pieces, adjusted so that some of their random holes align with an arrow through them, the point being that when these holes (in other words, events) align, an accident happens. Similarly, Malik says that most failures occur when a number of deficiencies lying dormant become operative, creating a "failure path" through all preventative efforts. But here he ploughs new ground when he turns it around and looks for what would have prevented the accident rather than what caused it - "Possible Opportunities to Prevent Loss" or PO2PL, a process that identifies failure points within the system and traces the path through them. It is a fundamental alteration of the Swiss cheese model.
Via discussion of many of the best-known aviation disasters of the 20th century (including the loss of the Space Shuttle Challenger, the Black Hawk shootdown in Iraq and a number of catastrophic failures involving the de Havilland Comet) and other non-aviation tragedies, Malik points out not only the failures that produced the terrible results but also the failures in the post-accident investigations that constitute missed opportunities to prevent future horrors. He blames this, in part, on non-independent bureaucracies' ineptness and unwillingness to think beyond their own inherent viewpoints, augmented by a healthy portion of CYA, or Covering Your Ass. With sharp insight, he notes that one of the necessities of accident investigation is closure, which often pinpoints a simple, singular cause of an accident, such as the failure of a person or a component. But the failure of a system of operation, or elements thereof, is too nebulous to enable closure. In my experience, systems (in other words, organisations) are much more difficult to alter - institutions are highly resistant to change, even after tragedies.
The Grown-Ups' Book of Risk makes a number of other excellent points, centred on Malik's core point that the world is and will remain a dangerous place, and one that constantly presents new risks and alters the ones already here. One example is that the introduction of a new safety measure itself creates risk, because it is new, adding another layer of complexity to an operation, and because safety measures themselves can produce complacency.
Malik deserves praise for many of his insights, especially his scepticism on investigative findings of "operator error" that often should more accurately be attributed to system flaws, management choices, or equipment design defects - not to mention the failure of governmental regulators and regulations. Amen.
Simply stated, this is a worthy book. As I read it, I thought of many acquaintances in the aviation safety field who I would hope would read it. Safety is big business in aviation now, with alphabetised systems aplenty. Malik brings the focus back home to where it belongs - to us, the human component.
As Malik points out, perhaps this self-published work does not contain enough scientifically defined terms to merit inclusion in academic journals. That may well be a flaw to some, but those people aren't in the cockpit. I'll take his "common sense" approach to accident prevention. That is a term with which I, and others who fly and operate in this hazardous world, can live.
The Grown-Ups' Book of Risk
By Omar Malik
New Insight Press, 338pp, £12.99
Published 1 November 2008