Originally Posted by
alf5071h
The history of aviation safety has been built on learning from events involving technical failure - structure, engine, aerodynamics, etc. Human misjudgements reflected the knowledge existing at that time; we learnt, adding knowledge, improving experience - safer.
In this instance (737 Max) the technical knowledge was available; the issue is not of human misjudgement, but of human failure - violation of the principles embedded in the process of design, certification, and regulatory oversight.
The industry’s surprise was that these events did not involve technical failure (although initially thought most likely), but of the ‘failure’ of the humans in the process. Initial reactions, typical of self-denial, sought to blame those nearest to the accident, pilots, maintenance, which only masked the fundamental factors.
One viewpoint is that the violation was deliberate, people knowingly set out to deceive; if so the law will judge.
Alternatively the violation was influenced by ‘environmental’ factors; commercial pressure, faster, better, cheaper, government objectives; normal pressures in the world environment requiring management: - self-management, awareness of personal behaviour and influence on others.
Thus the immensity of the surprise; human failure, not technical.
With technical failure trust can be restored because it is possible to demonstrate that technical aspects have been improved.
However, in this instance the human aspects have to be demonstrated to be ‘improved’, world wide trust re-established, recognition of the falsehood of self generated illusion of being the best - manufacturing or safety oversight, and that the culture which resulted in violation is itself wrong.
Such realisation will take time - how long, has this ever been encountered before? These events will change aviation, a change which requires management, but within a world which is changing even more quickly, and where the greatest ‘environmental’ pressure is time itself.
Aviation has to slow down, balance the pace of certification and regulation with safety. It is not possible to be faster, better, cheaper, all of the time; some aspects have to give way, it must not be safety or the processes which aim to achieve that.
But who judges these, and in a situation where previous measures of being ‘the best’ are broken. First rebuild and calibrate the measuring device - ourselves - an issue without solution, but one which might be contained.
Many thanks for that lucid expose of where the industry finds itself. I’ve said many times here that fixing MCAS or anything else will not resolve the issues of human performance esp. pilots, but including design n certification.
We are at a crossroads as serious as climate change with similar lag times/inertia issues.
We are about to train 500,000 pilots over next 25/years. To what standard one wonders?
30 years ago a BA cartoonist drew a sketch of two pilots with no control column and a hammer. .behind them was a glass case with a control column. On the glass it said “ break glass and remove in an emergency and fit to hole in floor” ! He had it spot on.
Cheers
R Guy