PPRuNe Forums - View Single Post - SQ006 final report out 26/4/02
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Old 27th Apr 2002, 05:58
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Four Seven Eleven
 
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Accidents don't just "happen", they are caused by actions of real human beings.
I would take issue with this. To state that accidents are 'caused by the actions of real human beings' is an overly simplistic and blame oriented approach to accident investigation.

It would be more accurate to say that 'accidents arise from a compex interaction between people, systems, procedures, equipment, environment etc.'

I have not read the SQ006 reports, nor do I have any detailed knowledge of the accident, but it would seem that factors such as: crew familiarity, currency of documents, aerodrome design, weather, company policies, ATS procedures, design of runway and taxiway lighting systems, traffic, communications and a host of other factor would or may have contributed to this accident.

It requires careful and skilled analysis - not always possible in a highly charged and politicised environment - to determine which of these factors can be changed and controlled to prevent future accidents.

To attribute a single 'cause' to any accident risks rendering the investigation useless. To attempt to attribute 'blame' is, to my mind, a totally pointless exercise. 'Blame' is normally associated with crimes or negligent acts. These are not within the scope of profesional aviation safety investigators.

It is this 'no-blame' approach which has led pilots to agree to the use of levels of 'surveillence' (FDR, CVR etc) in their workplace, which would be almost unthinkable in any other. (Can you imagine working in an office where your every word and action was recorded? (Yes, security cameras are the exception, but they are normally used in action against criminal 'intruders', not the company employees.)

Hopefully the lessons of this accident will be learned and passed on to others.
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