Fourth, error classification systems typically try to lead investigators further up the causal pathway, in search of more distal contributors to the failure that occurred. The intention is consistent with the organizational extension of the Fitts and Jones '47 premise (see Maurino et al., 1995) but classification systems quickly turn it into re-runs of The Bad Apple Theory. For example, Shappell & Wiegmann (2001) explain that "it is not uncommon for accident investigators to interview the pilot's friends, colleagues, and supervisors after a fatal crash only to find out that they 'knew it would happen to him some day'." (p. 73) HFACS suggests that if supervisors do not catch these ill components before they kill themselves, then the supervisors are to blame as well. In these kinds of judgments the hindsight bias reigns supreme (see also Kern, 1999). Many sources show how we construct plausible, linear stories of how failure came about once we know the outcome (e.g. Starbuck & Milliken, 1988), which includes making the participants look bad enough to fit the bad outcome they were involved in (Reason, 1997). Such reactions to failure make after-the-fact data mining of personal shortcomings—real or imagined—not just counterproductive (sponsoring The Bad Apple Theory) but actually untrustworthy. Fitts' and Jones' legacy says that we must try to see how people—supervisors and others—interpreted the world from their position on the inside; why it made sense for them to continue certain practices given their knowledge, focus of attention and competing goals. The error classification systems do nothing to elucidate any of this, instead stopping when they have found the next responsible human up the causal pathway. "Human error", by any other label and by any other human, continues to be the conclusion of an investigation, not the starting point. This is the old view of human error, re-inventing human error under the guise of supervisory shortcomings and organizational deficiencies. HFACS contains such lists of "unsafe supervision" that can putatively account for problems that occur at the sharp end of practice. For example, unsafe supervision includes "failure to provide guidance, failure to provide oversight, failure to provide training, failure to provide correct data, inadequate opportunity for crew rest" and so forth (Shappell & Wiegmann, 2001, p. 73). This is nothing more than a parade of judgments: judgments of what supervisors failed to do, not explanations of why they did what they did, or why that perhaps made sense given the resources and constraints that governed their work. Instead of explaining a human error problem, HFACS simply re-locates it, shoving it higher up, and with it the blame and judgments for failure. Substituting supervisory failure or organizational failure for operator failure is meaningless and explains nothing. It sustains the fundamental attribution error, merely directing its misconstrued notion elsewhere, away from front-line operators.
In conclusion, classification of errors is not analysis of errors. Categorization of errors cannot double as understanding of errors. Error classification systems may in fact reinforce and entrench the misconceptions, biases and errors that we always risk making in our dealings with failure, while giving us the illusion we have actually embraced the new view to human error. The step from classifying errors to pursuing culprits appears a small one, and as counterproductive as ever. In aviation, we have seen The Bad Apple Theory at work and now we see it being re-treaded around the wheels of supposed progress on safety. Yet we have seen the procedural straightjacketing, technology-touting, culprit-extraditing, train-and-blame approach be applied, and invariably stumble and fall. We should not need to see this again. For what we have found is that it is a dead end. There is no progress on safety in the old view of human error. People create safety
We can make progress on safety once we acknowledge that people themselves create it, and we begin to understand how. Safety is not inherently built into systems or introduced via isolated technical or procedural fixes. Safety is something that people create, at all levels of an operational organization (e.g. AMA, 1998; Sanne, 1999). Safety (and failure) is the emergent property of entire systems of people and technologies who invest in their awareness of potential pathways to breakdown and devise strategies that help forestall failure. The decision of an entire airline to no longer accept NDB approaches (Non-Directional Beacon approaches to a runway, in which the aircraft has no vertical guidance and rather imprecise lateral guidance) (Collins, 2001) is one example of such a strategy; the reluctance of airlines and/or pilots to agree on LASHO—Land And Hold Short Operations—which put them at risk of traveling across an intersecting runway that is in use, is another. In both cases, goal conflicts are evident (production pressures versus protection against known or possible pathways to failure). In both, the trade-off is in favor of safety. In resource-constrained systems, however, safety does not always prevail. RVSM (Reduced Vertical Separation Minima) for example, which will make aircraft fly closer together vertically, will be introduced and adhered to, mostly on the back of promises from isolated technical fixes that would make aircraft altitude holding and reporting more reliable. But at a systems level RVSM tightens coupling and reduces slack, contributing to the risk of interactive trouble, rapid deterioration and difficult recovery (Perrow, 1984). Another way to create safety that is gaining a foothold in the aviation industry is the automation policy, first advocated by Wiener (e.g. 1989) but still not adopted by many airlines. Automation policies are meant to reduce the risk of coordination breakdowns across highly automated flight decks, their aim being to match the level of automation (high, e.g. VNAV (Vertical Navigation, done by the Flight Management System); medium, e.g. heading select; or low, e.g. manual flight with flight director) with human roles (pilot flying versus pilot not-flying) and cockpit system display formats (e.g. map versus raw data) (e.g. Goteman, 1999). This is meant to maximize redundancy and opportunities for double-checking, capitalizing on the strengths of available flightdeck resources, both human and machine. When failure succeeds
People are not perfect creators of safety. There are patterns, or mechanisms, by which their creation of safety can break down—mechanisms, in other words, by which failure succeeds. Take the case of a DC-9 that got caught in windshear while trying to go around from an approach to Charlotte, NC, in 1994 (NTSB, 1995). Charlotte is a case where people are in a double bind: first, things are too ambiguous for effective feedforward. Not much later things are changing too quickly for effective feedback. While approaching the airport, the situation is too unpredictable, the data too ambiguous, for effective feedforward. In other words, there is insufficient evidence for breaking off the approach (as feedforward to deal with the perceived threat). However, once inside the situation, things change too rapidly for effective feedback. The microburst creates changes in winds and airspeeds that are difficult to manage, especially for a crew whose training never covered a windshear encounter on approach or in such otherwise smooth conditions. Charlotte is not the only pattern by which the creation of safety breaks down; it is not the only mechanism by which failure succeeds. For progress on safety we should de-emphasize the construction of cause—in error classification methods or any other investigation of failure. Once we acknowledge the complexity of failure, and once we acknowledge that safety and failure are emerging properties of systems that try to succeed, the selection of causes—either for failure or for success—becomes highly limited, selective, exclusive and pointless. Instead of constructing causes, we should try to document and learn from patterns of failure. What are the mechanisms by which failure succeeds? Can we already sketch some? What patterns of breakdown in people's creation of safety do we already know about? Charlotte—too ambiguous for feed forward, too dynamic for effective feedback—is one mechanism by which people's investments in safety are outwitted by a rapidly changing world. Understanding the mechanism means becoming able to retard it or block it, by reducing the mechanism's inherent coupling; by disambiguating the data that fuels its progression from the inside. The contours of many other patterns, or mechanisms of failure, are beginning to stand out from thick descriptions of accidents in aerospace, including the normalization of deviance (Vaughan, 1996), the going sour progression (Sarter & Woods, 1997), practical drift (Snook, 2000) and plan continuation (Orasanu et al., in press). Investing further in these and other insights will represent progress on safety. There is no efficient, quick road to understanding human error, as error classification methods make us believe. Their destination will be an illusion, a retread of the old view. Similarly, there is no quick safety fix, as the punishment of culprits would make us believe, for systems that pursue multiple competing goals in a resource constrained, uncertain world. There is, however, percentage in opening the black box of human performance—understanding how people make the systems they operate so successful, and capturing the patterns by which their successes are defeated. Acknowledgements
The work for this paper was supported by a grant from the Swedish Flight Safety Directorate and its Director Mr. Arne Axelsson.
Well, you can either accept that the buck stops nowhere, and nobody is responsible, or, as many people do, accept the opinion of Sir Geoffery Roberts, a very experienced aviator and Airline administrator. He is quoted as saying,
"I say quite flatly, the main cause was the fact a pilot failed to locate himself in relation to ground features and flew his aircraft into the side of a mountain".
...Or you may like to think a little more deeply and consider the statement from the privy council appeal, where they said
Quote:
The Royal Commission Report convincingly clears Captain Collins and First Officer Cassin of any suggestion that negligence on their part had in any way contributed to the disaster. That is unchallenged.
Hey DD.
If that finding is unchallenged, then plz explain why so many professional aviators have a problem with the findings? Their Lordships had no aviation training, and had to rely on third parties for perspective. In an aircraft under my command, the onus is on me to ensure the passengers I carry arrive at their destination. Or at least arrive. Somewhere.
As for causal factors, I have no doubt that there was a deal of contribution the the accident by AirNZ. It would be totally unreasonable to suggest otherwise, but as a professional, I must also accept my responsibility as P-i-C to ensure the safe conduct of my flight. There were laid down procedures for a letdown to McMurdo - these were not followed.
There were distractions on the flight deck, these were not ignored. And, of course, there were commercial pressures to ensure the "punters" got what they paid for. HOWEVER, these two factors should be not be a consideration when YOU are in charge of an aircraft. Company SOP's are there for a reason. You have to have a damn good reason to ignore them. I didn't see (or hear) of one good reason from any of the written submissions or the verbal transcript that suggested otherwise. What other pilots did on the run should have had absolutely no bearing on what happened on the day. Unfortunately, mindset determined what would happen, not professional dictum.
Any pilot who suggests he is beyond reproach, is one to avoid flying with. We are only human, and as such are prone to making errors. But when we do err, lets accept that it was our responsibilty to be the final stopgap. If you can't accept that as a condition of your employment, perhaps you should be looking elsewhere. It doesn't matter what a judge or jury determines, it is about accepting responsibility. I daresay if Jim had have lived, he would have accepted that. It was the sort of person he was.
400R
DD...yeah, well mate...the privy council doesnt live in the world I live in ......a bold statement to think these blokes were experienced aviation individuals??? in what fields are we talking about???....as suggested ...3rd parties provided info so that they were able to give/pass judgement.....
The combination of 400,s and Brians arguments is where I feel we must find common ground,this is not the first incident of this kind and it certainly wont be the last.....
I constantly try to find reasoning in decisions I make,some worthy of extra training,some absolutly brilliant,more so the first than the last......but at least I,m critical of myself and of no other......
the bottom line ....as PIC ....dont pass the buck,you are an will be responsible for the conduct of your flight,if your not up to it,dont take it,and as 400 stated and I believe this,Jim would have found himself accountable whether it was is cockup or not....that is the PIC,S resonsibilty....
thats the other problem inherant in aviation....it can never be a combination of people and problems,someone has to be the scapegoat....we need to nail "someone"....one individual has to be responsible.In case,s like this,it is just not the case
Brian,great reading mate,actually copied it and fwded to several people in my Ops dept for reading...if you dont mind......PB
Last edited by pakeha-boy : 24th October 2006 at 21:06.
Justice Mahon's royal commission of inquiry into the 1979 Erebus crash has changed the way many of the world's transport accident inquiries are handled, says retired investigator Ron Chippindale.
Mr Chippindale, who was among those who received a special service medal this week for their work on Erebus after the DC10 crash which killed 257 people, said the broad approach taken by Justice Mahon had since been adopted internationally.
Justice Mahon's inquiry pointed the finger at Air New Zealand management rather than the DC10 pilots. A section looking at possible airline management issues contributing to accidents is now included in all International Civil Aviation Organisation accident inquiries.
Mr Chippindale said that, at the time of his inquiry, the objective was to sift through the information and come to a proximate conclusion as to the probable cause - the last critical error that made the crash inevitable. He found the probable cause was the captain's decision to continue flying at a low level toward an area of poor visibility when the crew were uncertain of their position.
Justice Mahon disagreed with the investigator's approach, of attempting to find a single cause. This had long since been discarded by the legal profession. He set the pattern for allocating a number of causes without giving priority to any particular one.
Though that had now been taken up overseas, Mr Chippindale said he still took issue with Justice Mahon's exoneration of the pilots. He instead blamed the airline for changing the computer flight coordinates without telling the pilots, and the optical illusion of a "whiteout", which made it look as though they were flying over flat ice when, in fact, the ground was rising quickly.
Mr Chippindale said the pilots had instructions not to descend unless the air was "gin clear". "They had practised that in the simulator and they had written instructions to that effect.
" Had they stayed above minimum safe altitude the accident wouldn't have happened. That's called airmanship.
"They were down at just under 1500 feet at high speed and not sure of their position. In my opinion that was inexcusable." Though the airline had changed flight coordinates without telling the pilots, he wondered whether they had coordinates in the first place. "We examined the briefing which was shoddy, pathetic and hopeless. If they (the pilots) had maintained the minimum safe altitude, the wrong coordinates would not have made a difference."
Judge Mahon came to a different conclusion about the written instructions, saying that Air New Zealand had not objected to other flights going to low altitude and that the airline had therefore condoned it.
"He omitted to mention that all the other aircraft had descended in clear conditions, where this one descended through a gap in the cloud and that made a critical difference," Mr Chippindale said. "Just because a lot of people get away with going up a one way street in the wrong direction doesn't mean it's allowed."
Still begs the question, Even if they were in the position where they thought they were, following the track they thought they were on, why could they not see a 12,000ft mountain that they knew, or should have known was some 40 miles away, this in an area of renown brilliant visibility in excess of 100 miles. Sector whiteout, it would appear, explains why they never saw this mountain, but if they had never, as no one else at the time had, heard of sector white out how do you explain a descent without even wondering why they could not see this mountain.??
How can anyone not agree with Mr. Chippindales findings??
Having spent the last hour reading this whole thread I feel inclined to align myself with prospector & co.
I believe that there were many factors leading to the crash but at the end of the day I can't go past the fact that the SOP's mandated no descent below FL160 unless VMC and no descent below 6000' ....period.
When I read John Kings book a few months back on the crash, one pilot who had conducted a previous flight testified that although he had unlimited visibility, and although he was an ex strike pilot with plenty of low level experience, and although he dearly wanted to, when McMurdo ATC invited him to do a low run down the strip he declined and remained at 6000'. If that chap was PiC of flight 901 would the accident have happened? I don't believe so.That is not a dig at J Collins...just what I believe to be most likely.
Jim C had his flight plan mucked up, he didn't know that, but he did know that it was a new environment for the whole crew and that he expected VHF contact earlier, and radar contact earlier, and TACAN reception, and he also knew the SOPs for letting down.
Lots of people made mistakes, Collins' mistake is easy to take a shot at. No one person is totally to blame. Many people carry a share of the blame.
I have always felt that the crew were made scapegoats in this accident, however having read 400Rulz posts on the subject, I have changed my view on the cause of this accident somewhat to acknowledge that the crew were the last line of defence in preventing this accident, however I still steadfastly stick to the view that ANZ must share responsibility in this accident.
I note the relevant comments about the Privvy Council having little or no aviation experience, however I also note that Sir Geoffrey Roberts may have had a bias in ANZ's favour.
Brian Abraham that is valuable information that we should all reflect on for a long long time. Probably the most valuable post I have ever seen on here.
On Sept 11th 2001? I was in Adelaide, watching those aircraft fly into the WT Centre. I had flown down to hear Professor James Reason speak at a breakfast meeting the following morning. (the only time I ever got a free feed from CASA. I had to fly 3000 km to get it.)
I remember very clearly that James Reason said emphatically and repetitively that the "blame game" was counter productive, and it is obviously damaging. It fixes nothing.
From another source, I remember the saying "I don't care who is to blame, I want to know who is going to fix it, and how"
We have to decide whether we are going on a witch hunt to find a politically convenient outcome of an investigation, or if we are genuinely trying to improve safety by finding the traps that the players fell into, and fixing them. This has been known since 1947, and it has been denied since 1947. It is being denied today. I heard a saying today "the fools are in charge, but the wise men are shouting louder".
Did Capt Collins know he was going to fly into a mountain? Of course not. He had a reputation as a competent, reliable, stable pilot, so we can reasonably assume that he considered what he was doing was safe. And when faced with information that challenged that safety he took steps to climb out. Too late. I think the CVR backs up that.
There is much evidence that Capt Collins was tricked by false information, and lack of essential knowledge about whiteout and visual tricks in that region.
It has been said that he descended below the level allowed by SOP's. It also appears that he had a long history as a safe, responsible pilot. Why then did he descend lower than the SOP'S permitted? Did he know the SOP's?.
Does this tell us something about the credibility of the SOP's
Powerful forces are involved. Air NZ was a government owned airline, and the regulator was the govt, and a large English insurance company, all had much deeper pockets than the pilots could ever have. The legal and financial possibilities were frightening.
Mr Chippendale did what he thought was right, and it was a convenient outcome for many. It followed the normal pattern of accident investigation, but was it right?
The other pilots and the Judge did not think so, and the final outcome was decided by their lordships in another country. A country where the big insurance company lived.
Many things could have been done better
but the NZ people are not silly and they quietly re-organised things. Today most of the people who were involved at the time of the Erebus crash have long gone. I had great respect for the head of the navigation section who stood up in court and said "I did it wrong". Air NZ is not a newcomer. They have been operating (earlier as TEAL) for more than half a century.
But the inappropriate, simplistic, military style administration system still prevails, in our society, and the knowledge which has been available to us since 1947 is still denied.
It's convenient for our administrators that way. That's why we have to have independent legal systems to pull them into line sometimes. Checks and balances.
And Air NZ operates today as a safe, respected airline, as it should, because someone challenged the system.
One day I got the "phone call from hell".
It was ASA, and the voice said "one of your aeroplanes has had an engine failure at Woop Woop and has landed on the road. Do you want me to call the police, or will you do it?"
After I had stared at the wall for about a minute I phoned the refueller at Woop Woop and asked him to provide a vehicle, and go out and look after the pilot and passengers until I could get another aeroplane to pick them up. (refuellers know everything, and control the resources out there). Then I phoned the LAME who looked after that aeroplane.
Within five minutes I got a call from the Woop Woop refueller to say"they put AVTUR in that aeroplane". It had a piston engine and should have had AVGAS. The LAME was pleased to hear this news, but I was not.
So this is a simple case isn't it? The pilot stuffed up. So you sack him, and get on with the work. Problem solved. Isn't it? Or is it?
That's not what happened. When the pilot got back to base, I shook his hand, and thanked him for saving the aeroplane and passengers. I told him to take a week off work, and that his job was safe.
Then I talked to the Woop Woop refueller and found a couple of things I did not expect. The avtur drums and the avgas drums were stored in close proximity, in the the same compound. I remember the old drums used to have large areas of bright colour as well as small lettering to indicate what grade of fuel they contained. This company painted all of the drums the same colour, and the small identifying lettering was a different colour for each grade. One layer of the swiss cheese had been removed. But the one I did not expect in Australia was THE REFUELLERS COULD NOT READ!!!
The Woop Woop refueller agreed to make sure the different types of fuel were stored at different sites, and to be more carefull allocating labour. He was normally present himself, but was not on this occasion). He built more fences.
I talked to our ever helpful FOI and he promised to speak to the fuel company about more prominent labeling on fuel drums.
Sure, the pilot could have done it better. Couldn't we all? He had had a very valuable lesson (one you cannot buy) and did lot's of good work for me before going on to bigger and better things with my recommendation and support.
Let him who is without sin throw the first stone.
Had I just sacked the pilot, the trap would still be out there for others, and no-one would know. This would have been the simplistic, military style convenient pseudo solution that is too common in aviation. And it would have adversely affected one of the industry's better pilots.
A much better outlook was described in 1947, and is still being denied.
Re your distinction between the work of Chippendale and Mahon - I suggest they were both right, because they were looking for different things. Chippendale was correct in stating that the actions of the pilots placed the aircraft in a situation where it suffered CFIT - and that is CFIT - it was not a person in Auckland who disconnected the A/P and descended the a/c to 1600'. So he was looking at the actual actions in the immediate lead-up to the impact. That's understandable, he was a copper.
However Mahon then looked at why the crew thought it was ok to act as they did - that is, what they (as competent, experienced aviators) were thinking - and he found that there was background to it which did stretch back to Auckland.
One was looking at 'what has happened'? - an a/c hit a mountain; the other was looking at 'what caused the a/c to be in a position to hit the mountain?' - human factors and the ol' chain...
They were both right. In their own way. According to their own culture and standards. But thank god for Gordon Vette and the courts, and in particular Justice Mahon.
From memory in the accident report there were 5 factors required by Air NZ SOPs for you to descend below the MSA. You needed all 5, not a couple, not near enough, and they descended without all 5. And yes, the captain has the final authority to operate the aircraft as he sees fit but the SOPs are what the AOC is legally based on in a court of law. When you add in the fact that the US military did an awful lot of training to operate in that environment and had pretty strong reservations about Air NZ doing what they were doing. It was crazy to think that widebody longhaul anywhere else on the Air NZ network could prepare you for VFR polar ops. There were so many holes lined up the second someone in marketing first suggested "let's do antartica" it doesn't bare thinking about.
Bushy Quote........"But thank god for Gordon Vette and the courts, and in particular Justice Mahon".
yeah mate!! well said...at least he was an advocate for the pilots....he took a lot of strife....but a very interesting and smart fella.....met him quite a few years back,briefly as I recognised him from photos,.......last I heard he was not doing well....anyone know
Anybody know if the TVNZ docudrama "Erebus-The Aftermath" is available as video tape or DVD ?
13370khz,
How did you go? Any favourable responses?
I have been trying (in vain) for several years to obtain a copy of this (award winning) TV docu-drama. I vaguely recall watching it on TV here in Australia as a youngster, probably around 1988 when it was released. I have since contacted the Australian Broadcasting Commission, who have said that they don't have the rights to this series. I've also contacted the TV station in NZ that screened it, as well as the NZ Film Commission, but have similarly had no success. It is almost as if there has been some type of intervention to prevent it from ever being released commercially (even on a small scale).
Now what would Justice Mahon have thought of this......
Erebus article censor found at Air NZ
By JOHN HENZELL - The Press | Tuesday, 21 August 2007
An Air New Zealand computer was used to sanitise an online encyclopaedia article to make the airline look less culpable for its part in New Zealand's worst peacetime disaster.
An article about the 1979 Erebus crash on Wikipedia, an internet encyclopaedia able to be edited by users, was altered to state "pilots are divided to this day as to whether the responsibility ... should rest with the pilot or the flight planning department" over the deaths of 257 passengers and crew.
The alteration, which has since been deleted, was identified this month as coming from a computer using the Air New Zealand server.
An Air New Zealand spokeswoman said the company was investigating the allegation.
But Cabinet minister Jim Anderton said that, if true, the change was "outrageous (and) entirely erroneous".
It was a case of the airline – now 80 per cent owned by the Government – trying to rewrite history to make itself look better.
The airline's computers were implicated through a programme devised by self-described American "destructive technologist" Virgil Griffith to identify the computer systems used by those who made alterations to Wikipedia.
Computer experts contacted by The Press also tracked the altered entry back to Air New Zealand's computer server.
Anderton has previously called on the Government to make a formal declaration that Captain Jim Collins and co-pilot Greg Cassin were not to blame for the crash.
He said yesterday that to suggest there was disagreement over blame for the Erebus crash was unjustifiable and wrong.
Maria Collins, the widow of Jim Collins, said yesterday that it was of little importance what Wikipedia said about the crash.
"Whether Wikpedia says one thing or another and who wrote it or authorised it – so much has been written that is incorrect that I have stopped jumping up and down," she said.
The Wikipedia alteration left unchanged the findings by Justice Peter Mahon's Royal Commission that Air New Zealand executives had been behind an "orchestrated litany of lies" to cover up the cause of the accident, including disposing evidence and engaging in subterfuge.
It also made no change to the assertion that Mahon's findings remained, even though the Privy Council overturned the result because he had exceeded his powers and denied the airline a fair hearing.
Anderton said the alteration suggested that Air New Zealand remained sensitive to allegations of blame for the Erebus crash.
He said pilots' associations in New Zealand and internationally had endorsed Mahon's findings and the only dissent by pilots over the fault was from those who had a "vested interest" in upholding the original accident report overturned by the Royal Commission.
New Zealand Airline Pilots Association president Mark Rammell said there was no division among pilots.
"Justice Mahon's finding, that was the official finding of the Royal Commission and that was accepted in Parliament," Rammell said.
"Our pilots are completely happy with that finding, that it was not pilot error."
"New Zealand Airline Pilots Association president Mark Rammell said there was no division among pilots."
Just reading this thread and others from other forums, it is patently obvious that there is much division among many pilots from many backgrounds.
As for the opinion of Mr Anderton, it is just that, his opinion, based upon what aviation knowledge or experience?. It is of as much value in determining blame as the Townsville refuellers opinion.
Last edited by prospector : 22nd January 2008 at 09:13.
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