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Thomas pfp
Thomas
@aviationdoctor.eth
In aviation safety, we use James Reason’s “Swiss cheese” model to describe the successive layers of organizational defenses against human errors (which, themselves, form the overwhelming majority of errors). 1/
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Thomas pfp
Thomas
@aviationdoctor.eth
The idea is that each layer of the model is meant to catch a certain type of error, such that it is extremely unlikely that a failure will propagate through the weaknesses in every successive layer (the “holes”) and lead to a catastrophic outcome. 2/
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Thomas
@aviationdoctor.eth
That’s why you often hear that aviation accidents have multiple causal factors; it takes a combination of failures to cause a crash. 3/
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Thomas
@aviationdoctor.eth
It is by multiplying all these successive low probabilities of “successful failure” that we get to the current >6 sigma (in six sigma parlance) level of aviation safety, or roughly 0.03 accident for every one million flight sectors. 4/
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Thomas
@aviationdoctor.eth
Now, constantly reading reports that glorify entrepreneurial success stories has made me think deeper about survivorship bias, and how the media (especially social media) magnifies success and either hides or minimizes errors. 5/
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Thomas
@aviationdoctor.eth
Elon can get away with a cheeky tweet about Starship’s “rapid unscheduled assembly”, laugh it off, and move on. More generally, successful founders attract strong audiences online, but rarely do we hear honest accounts of the many more founders who failed. 6/
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Thomas
@aviationdoctor.eth
By over-indexing on successes, we are not taking the opportunity to learn from mistakes. Whereas in a safety-critical industry like aviation, nuclear, or pharma, we make sure to investigate and analyze every near-miss, incident, or accident, not to apportion blame but so we can learn from them and avoid reoccurrence (a “just culture” approach). 7/
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Thomas pfp
Thomas
@aviationdoctor.eth
That’s why I’m proposing to invert and repurpose James Reason’s model. Instead of seeing its layers as artificial defenses against errors, I think of them as natural obstacles to success. What are the typical factors trips up entrepreneurs and founders? Personal competence? Access to capital? Market timing? Poor PMF? Lack of a support network? 8/
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