Assuming that our industry has achieved the status of ‘a highly reliable (ultra-safe) system’, we should use alternative analyses of accidents to identify solutions.
Highly reliable systems are complex and lack predictability and thus may not respond to conventional methods of control – fixing safety problems.
Many posts, including those ‘blunt and off the mark’ comments use mechanistic thinking. This is based on ‘evidence’; it assumes that facts from one context applies in another (tech failures vs human failures), it assumes a linear relationship between cause and effect, and often results in statistical based solutions. Mix these together with weak understanding or failure / inability / reluctance to consider the human element, often results in biased viewpoints.
We must take wide ranging and alternative views. Consider the many contributions in this accident how they might link or interact with each other and modern flight operations. It is unlikely that we will be able to determine a precise outcome – neither the problems nor solutions, because the very nature of complexity prevents us from forecasting the result of safety activities.
By considering the contributing factors, links, and interactions, we can generate a framework for action – something to hang future safety improvements on. We might seek to improve / eliminate all of the contributions factors as no one issue can be proven to prevent future events, the analogy is adding cladding to the frame work and thereby strengthening the structure – safety.
However, this might be a weakness in thinking, often leading to a trade off between safety and economics – one or the other. This requires an alternative view – a culture where safety
and economic prosperity is developed jointly.
A complementary and very important aspect is to reconsider the many assumptions associated with the contributing factors.
The manufacturing and regulatory processes make assumptions about equipment reliability and warning system effectiveness; operationally the industry holds many assumptions about human performance – pilot and ATC, context dependent.
The industry (top-down and bottom-up) should re-evaluate these assumptions; are they still valid, has the operating environment changed, are ‘old aircraft’ designs applicable to new pilot training, and is the pilot (human performance / capability) changing – adapting, or failing to adapt to a new operating environment (all the arms of the SHEL model).
Much of the above was influenced by
Systems Thinking – “it enables people to see a bigger picture that makes more sense of their world”.
At least read the preface and summary; read them again in the context of aviation safety, and then again relating the issues to this accident.
“… difficulties are bounded problems, and individuals will know when they have found the solution. … with a mess there is rarely agreement about where the problem actually lies or where improvements can best be made, and they are subject to high levels of uncertainty.
Another difference between these classes of problem is that
when the problem is a difficulty an individual claiming to have the solution is an asset, but when the problem is a mess that individual is usually a large part of the problem!”
Also see
Revisiting safety and human factors paradigms to meet the safety challenges of ultra complex and safe systems.