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Old 22nd June 2007 | 16:45
  #637 (permalink)  
Safety_Helmut
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Joined: Mar 2005
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From: Cambridge
Unfortunately it is rarely the snag or fault that you know about that will cause the accident.
History has shown us time and time again that accidents are almost never down to one single event, ie a snag or fault. The training that many of us on here have had from the RAF always emphasises a chain of events leading up to an accident, and there are often many oppurtunites to break that chain, and thus prevent an accident.

The accident we are discussing here, is the end consequence of a whole chain of events, which I suppose started with the original design concept. Decisions were made then which affected the outcome for XV230 and her crew. Many subsequent decisions and actions were undoubtedly part of that chain. Look up Rasmussen's Swiss Cheese Model for a good representation.

Another basic part of any safety management system is the analysis of incidents. Again, this is not unfamiliar territory for those in aviation. We are talking about a history of fuel leaks. They were there 10 years ago when I worked Nimrods. Incidents have also pointed to ignition sources in potential fuel leak areas. What has been done ? I wonder how comfortable the Nimrod IPT would be if asked to see the analyses following earlier incidents, and in particular the analysis that demonstrated that the risk had been reduced to acceptable levels.

Think of an iceberg, 90% below the waterline, analagous to incidents, 10% above the waterline, the accidents.

Safety_Helmut
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