lomapaseo;
I am rarely cynical but always skeptical. This may be one of my cynical moments where optimism is defeated by experience.
That said up front, I fully agree that the lesson(s) is(are) important. The difficulty is, and this is an issue not limited to aviation, many times, "learning the lesson" is set aside in favour of those other factors.
Today it is almost trite to state it, but I have always been and remain, deeply mistrustful of corporate interests and therefore of corporate governance in all its forms, private and public whether intentional or through inability or plain incompetence. This stance has proven correct but requires an ameliorating clarification. I think that true malfeasance such as cutting corners with knowledge of increased risk, something Diane Vaughan called, "amoral calculation", was rare if it occured at all. Accidents occur when people are doing exactly what they think is the right thing, under the best of intentions and a "clear" understanding. That is the lesson here, not this SOP or that MEL procedure but in the "Not Learning", (I know you know this but I am speaking broadly here, not "in response"). In fact, some who are writing now regarding the "meta-themes" being discussed on a number of different threads on PPRuNe are turning from "training, experience, pay, fatigue" to the larger issues of "why accidents?" and finding it in the "not learning"; it is not found in intentional avoidance of solutons however they may be conceived. I think the notion of "Special Interests" captures far too narrow a field of vision to be helpful in resolving complexity and the addressing of risk and the very notion of "accident".
I think the upcoming ISASI conference will have something on this.
This April, 2003
article from AW&ST states very well, what I mean:
Echoes of Challenger
Evidence is growing that NASA failure to fully implement lessons from the earlier accident played a key role in the loss of Columbia.
The Columbia accident investigation board is beginning to embrace assertions that the same management loopholes and flaws that resulted in the Challenger accident 17 years ago also played key roles in the Columbia tragedy.
Such findings would mean that in effect similar NASA program deficiencies are directly culpable in the death of 14 astronauts and the loss of two shuttle orbiters worth $4 billion.
Experts last week told the board that "the problems that existed at the time of the Challenger accident have not been fixed"--sobering testimony likely to cause further heartbreak at NASA, especially in the Astronaut Office and among the families of the U.S. and Israeli crewmembers lost on STS-107.
What that assessment indicates is that not only could the Columbia accident have been prevented, but that the Challenger management findings made years ago provided ample direction on how to avoid the Columbia tragedy. Board Chairman Adm. (ret.) Harold Gehman said the group recommendations will address serious changes needed in NASA management and culture while being mindful not to violate "the law of unintended consequences."
"Despite all the resources and all the insights the Challenger Presidential Commission found in 1986--these problems still remain," said Diane Vaughan, an associate professor of sociology at Boston College.
Vaughan spent nine years studying the decision processes that led to the Challenger accident and is now advising the Columbia board. Her findings on safety process flaws have been used by many sectors of U.S. industry and U.S. Navy nuclear safety experts.
Vaughan noted that former astronaut Sally K. Ride, a member of both the Challenger and Columbia accident boards, cited growing concern about the similarities between decision processes in the two accidents, saying earlier this month, "I think Im hearing an echo here." Vaughan said when you find patterns that repeat over time--despite changes in personnel--systemic problems remain in the organization. "The echoes mean that the changes post-Challenger did not go far enough. The contributing causes in the organizational system were not fixed."
In both cases, the hardware involved--Challenger booster O-rings and Columbia external tank foam--had repeatedly exhibited anomalous behavior that was treated as a maintenance issue rather than a fatal flaw before the respective accidents (AW&ST Feb. 10, p. 22).
Vaughan described the situation where anomalous data become acceptable as an "incremental descent into poor judgment . . . the normalization of deviance."
AW&ST April 28, 2003
re your comment,
[FONT='Verdana','sans-serif']Never have I seen an investigation where we actually believe more than 90% of what we think we know. [/FONT]
Yes. Many even now must be contemplating what will be said in the AF447 "Final" Report...