BLACK SWAN LESSONS

摘要

It was once believed that all swans were white. No one considered the possibility of black swans until a Dutch explorer discovered them in Australia in 1697. That is the nature of a Black Swan event: It's rare, has an extreme impact and is predictable in retrospect.Let's examine three Black Swan events in aviation. There is much we can learn from how professional aviators handled, and mishandled, their black swans.Four minutes after departing Singapore's Changi airport in November 2010, Qa-ntas Flight 32, an Airbus 380 and the world's largest passenger aircraft, suffered a catastrophic failure of the number two engine, the inboard engine on the left wing, while climbing through 7000 feet. A turbine disc disintegrated and destroyed the engine, damaged the nacelle, punctured the wing, and caused fuel system leaks. One hydraulic system and the anti-lock braking system failed. The flaps were damaged as were the controls for the number one engine. In all, 21 of the aircraft's 22 systems were affected. About 65 percent of the aircraft's roll control was lost. A crash was in the offing and the deciding factors were on the flight deck.