Originally Posted by
Chronus
Yes of course human factors have been a significant factor in many air accidents. Sydney Dekker is one of the authorities on the subject. A most interesting and revealing talk by him was :
The human factor: Pursuing success and averting drift into failure - Sidney Dekker - DDD Europe 2018.
It may be found at :
https://www.youtube.com/watch?v=9fwJ9xgvu3A
Here is an extract from Handbook of Human Factors in Air Transportation Systems
edited by Steven James Landry
Page 337-" Human Error" Is a Judgment, contributed by Cees Jan Meeuwis and Sydney W.A. Dekker.
"
Judging behaviour to be Human Error stands in the way of learning from failure. "
So far as blame is concerned let it be a judge sitting in his court decide. For those who are engaged in aviation at all levels, it must be the learning from failure that they must be concerned with.
Nice film, pretty tough crowd but interesting and yet again furious agreement. I've not been advocating blame. I'm suggesting the process of investigation takes too long (timeliness is surely important if we are intending to learn from all of this?) , its distribution is not certain (so who learns what?), the mechanism and forum for learning is poorly developed (so you learn, but do I learn?), indeed if we refocus on aviation it isn't even clear that any actions suggested from the investigator are implemented by the regulator (rules and guidance developed from the past in a format that may consider what works or does not?) ...and what role for the regulator? (i.e. aviation is not the dutch town square model and all these AOC holders are not happy to highlight their failures... they absolutely are counting the risk free!!).
We can have a philosophical debate about if any of that is a good thing but if we are putting the armour where there are no holes, to use the jingoistic phase of the film, it surely validates the fact that focus on who was paying what to whom doesn't really matter. The aircraft was likely capable of flight in the conditions found and on the basis of the autopilots ability to automate the phase of flight this pilot [via evidence of his ratings] was not formally able to do, and perhaps not actually able to do given the outcome. So if we are looking at this from a purely scientific perspective we might suggest - throw all those EASA, FAA, CAA rule in the bin. Can you get the aircraft in the air? OK good. So for the middle bit read the hell out of that autopilot manual and learn that....Then you can at least have the accident on landing in Cardiff..
UK aviation currently has a no rules area. The sub 70kgs SSDR. You don't need a licence, the aircraft doesn't need registration, I've no idea if that category has a lot of accidents...Arh but hang on now I'm counting failure. Indeed now I think about it that's what the AAIB is doing. Isn't that what court cases do? Lets be honest we are going to reflect attitudes that seem to suggest a successful outcome. Yes we don't want to crash.... but now having crashed what are we going to do then? Take Shoreham. I remember when Shoreham happened the great cry even from the CAA, from BADA and the AAIB report all mention X death free airshows since... Good grief in the final report there are tables to the ying yangs on failure and that is before all of the formal rules and regulations that get quoted. In reporting this accident aren't many of the safety recommendations reflecting existing rules and regulations? and indeed here there seems a different of opinion between two national bodies, the CAA and AAIB as reflected here, which in themselves seem to suggest that the aims and aspirations are somewhat confused. Be lucky.
Safety Recommendation 2016-042: It is recommended that the Civil Aviation Authority publish a list of occurrences at flying displays, such as ‘stop calls’, that should be reported to it, and seek to have this list included in documentation relevant to Regulation (EU) No 376/2014.
The CAA responded as follows: ‘The CAA does not accept this recommendation.
The CAA is developing a positive reporting culture - a Just Culture – for the air display community. Within the air display sector the CAA believes that this is the most effective way to identify and address potential safety issues before they lead to accidents. In support of this, from April this year the CAA required all event organisers and FDDs to submit, within seven days, a post-air display report to the CAA. This report must include what went well at the display, as well as information on any lapses or breaches from the required standards. Pilots must also report any aspect of their display that could have caused a significant safety risk. The CAA will record all this information. Key information will be shared with the civil air display community through briefings, the pre- and post-season seminars that the CAA jointly hosts with BADA1 and the MAA, and the annual seminar that the CAA organises for DAEs.’
The AAIB has categorised the response to Safety Recommendation 2016-042 as ‘Partially adequate – closed’.
Safety Recommendation 2016-043: It is recommended that the Civil Aviation Authority introduce a process to immediately suspend the Display Authorisation of a pilot whose competence is in doubt, pending investigation of the occurrence and if appropriate re-evaluation by a Display Authorisation Evaluator who was not involved in its issue or renewal.
The CAA responded as follows: ‘The CAA accepts this recommendation. In its final report of its Review of UK Civil Air Displays, published in April 2016, the CAA announced that where a stop is called because an FDD, or member of the Flight Control Committee, has reason to doubt the fitness or competence of a pilot that pilot will be subject to a provisional suspension of their display authorisation pending an investigation by the CAA of the circumstances leading to the stop being called. In its investigation, the CAA will determine whether the suspension of the display authorisation should be withdrawn or further regulatory enforcement action taken against the pilot concerned.’
The AAIB has categorised the response to Safety Recommendation 2016-043 as ‘Adequate – closed’.
Safety Recommendation 2016-044: It is recommended that the Civil Aviation Authority establish and publish target safety indicators for United Kingdom civil display flying.
Following the publication of FACTOR F4/2016 Issue 2, the CAA’s response is as follows: ‘The CAA will undertake a study to identify and publish meaningful safety indicators for civil display flying. The CAA will conclude this study and publish safety indicators by September 2017.’
The AAIB has categorised the response to Safety Recommendation 2016-044 as ‘Adequate – closed’.