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Old 18th Jan 2010, 01:51
  #488 (permalink)  
alf5071h
 
Join Date: Jul 2003
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The discussion has drifted into ‘mechanistic and reductionist thinking’, where evidence from one context is applied to another or used to pursue a cause and effect solution unsuitable for highly complex situations. This tends to restrict a much needed wider view of the world, a wider view of aviation safety, a wider view of accidents, and thereby an opportunity to learn from the misfortunes of others.

Many would argue ‘wait for the report’, but accident investigations rarely are able to identify all aspects or contributions to the ‘cause’. Sometimes evidence is un available, insufficient or unreliable to draw conclusions from, or in many cases such as with human error, it remains unknown even to the perpetrators of ‘unsafe acts’.

Thus, there is merit in exchanging informed speculation, where similar issues can be aired, what if’s explored, and best practices exchanged. These may not relate directly to this accident, but might just avoid another – the primary aim of any formal investigation.

As an example, there was an exchange of the pros and cons of using HUD. If in this accident the lateral transition from an offset LOC in restricted visibility due to heavy rain, and with a tailwind which might have equated to an additional 1.5 deg ‘air-mass’ flight-path, perhaps the pilot was experiencing high workload in a restricted timeframe. This might not be determined beyond supposition by an investigation. More likely other pilots could comment on similar experiences, good or bad, not just quoting a HUD ‘sales’ pitch, but providing first-hand examples with reasoned argument; there may be something which we can learn, so that we might continue to operate safely.

This forum should not degenerate into a ‘bad apple’ – person (or organisation) model of safety, this can only conclude with blame which contributes nothing.
We have to look at the wider issues in complex scenarios often encountered in modern operations.
This forum should be generating a learning culture, lest such an accident might happen to us, irrespective of what statistics or self opinion might indicate.
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