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Old 28th November 2023 | 14:57
  #310 (permalink)  
safetypee
 
Joined: Dec 2002
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From: UK
Learning from everyday work - The best time to learn

Re "… no incident… " #270, this is a view of safety based on outcome.

Alternatively, considering 'safe' as minimising the risk of harm - future harm, then as argued at #250, night visuals have higher risk than daytime, and similarly visual separation for closely spaced runways more than IFR ILS approaches.

One's view of this depends on judgement, context, experience, knowledge, and the way that these come together in our thinking.

The ATC procedure is an accepted operation (aircraft, operators, ATC, FAA; as a system), however this does not preclude different risk assessments and SOPs to manage risk. The industry encourages this, it is a core aspect of safety management.

The operator's SOP requires ATC adjustment, which in this particular situation and time, resulted in a mismatch in requirements; the need for a (higher risk) night visual approach/sepatation vs a (lower risk) ILS approach. This situation was compounded by minimum fuel - time available for crew and ATC.

This mismatch is an opportunity to learn; not from an after the fact (with hindsight) apportioning of blame, but to reconsider the levels of risk in such scenarios, and the actual or inferred responsibilities.
One way is to conduct a 'Pre-mortem', a debated, justifiable 'what if' before an event:

What are the respective hazards, how best managed.
Is the level of risk minimised - are there better safety options.
Who holds the responsibility for these judgements (everyone); is this responsibility acknowledged, exercised (how), or mistakenly delegated to others.
What might be improved.

Learning from everyday work - The best time to learn.

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