Don’t Move The Cheese

"Who Moved My Cheese?" is a fun book written in 1998 by Spencer Johnson to demonstrate how we deal with unexpected change. In the aviation world, change is inevitable, yet the only cheese we often talk about is the Swiss Cheese Model when it comes to accidents and incidents. That kind of cheese changes our mood entirely. Still, there are some similarities between the two.

The theory of the Swiss Cheese Model is that multiple factors often align in order to allow accidents or incidents to occur. These factors, whether it's fatigue, mechanical error, weather, communication, or planning, are each continual moving targets of opportunity—or disaster, as the case might be. Ideally, we like to line these factors up in our favor so that nothing bad ever happens. But sometimes, someone or something moves our cheese. Sometimes, we even do it ourselves.

Perhaps if we understood that moving one factor, or "cheese," would so catastrophically impact another, we would think a little harder about the action. If we feel we need to move our own cheese by reducing crew rest, trying to push through weather, not completing proper pre-flights, or not conducting proper crew coordination, we increase our risk more and more. We sometimes move the cheese into a far riskier position from which we may not recover.

It's true that only one cheese out of place can cause fatalities in aviation, but more often than not, there are multiple factors identified in each accident report. And unfortunately, we aren't always afforded the luxury of dealing with one factor at time as flying is a very complex task and occasionally demands that we balance many responsibilities at once.

The good news is that there are many tools available to assist aircrews in the form of automation, training, crew coordination, and even our own commitment to safety. We can argue that our own commitment to maintaining safety is perhaps the most important part. This means we have to commit ourselves to keeping each block of cheese safely in place. Proper rest, proper procedures, proper communication, and thorough planning are all required elements for safety.

While we often accept some degree of risk in our daily lives, often simply on our drive to work, we must recognize each time we move a piece of cheese into a dangerous position. Speeding, texting while driving, or allowing other distractions might be a factor in the car; however, in aviation, there are different and even more numerous threats. As aircrew members, we must be cognizant of moving not only our own, but other people's cheese as well because in effect, we often unknowingly change the environment for the worse. Unexpected changes are often the cause of aviation accidents. We certainly can't always control how weather chooses to move its own block of cheese, but we can affect how we react to the change and what decisions we make behind the controls. Recognizing the changes, the significance of the changes, and seeking immediate mitigations with appropriately conservative judgement might just be the difference between making it home or making it on the news.

Fly safe. Fly smart. And don’t move the cheese.