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Old 19th Dec 2010, 10:50
  #447 (permalink)  
PBL
 
Join Date: Sep 2000
Location: Bielefeld, Germany
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Safety Concerns,

I think there is a subtle point here. It is not just a matter of agreement or disagreement with a verdict.

About fourteen years ago, Jens Rasmussen wrote an article in which he introduced his Accimaps, which are causal graphs in which the factors are described broadly rather than in detail, and the factors are layered according to the "level" at which they operate: direct causal events; operational background; legal background; organisational factors; and so on. The ATSB currently uses Accimaps, for example in the Lockhardt River report. (They are like Why-Because Graphs, which are, though, more detailed and drawn somewhat more rigorously, but without the layering.). Rasmussen also introduced the phenomenon of "migration to the boundary" (MttB). People doing their jobs optimise the way they accomplish things, in order to achieve their immediate goals, until they come up against constraints (this is MttB). However, the optimisation criteria available or preferred by an individual worker (getting the perceived job done while, say, minimising effort and resources) are not necessarily the criteria to which the task was designed (say, overall safety measures designed in the light of external review of accidents and incidents). He suggested that MttB was by far the most common phenomenon involved in the accidents which they had been looking at (primarily for the Danish process industries, as I recall). Reference: Rasmussen, Risk Management in a Dynamic Society: A Modelling Problem, Safety Science 27(2/3):183-213, 1997.

So the phenomenon of a mechanic effecting a repair without quite the right material, using a material which he may well have thought was better, and which apparently his supervisor thought was OK, is a known phenomenon. Stuff like this is pervasive (MttB).

The question is then what should happen when such behavior contributes in a directly causal way, not just to an accident, but to a freak accident to an airplane with unusual TO constraints.

Compare. German laws of the road are written basically in order to apportion compensation when an accident occurs. That is indeed how the laws read: "This is to be done, and if this is not done, and an incident ensues, then the perpetrator carries x% of the responsibility/blame for the event" and that pays out directly in monetary terms. This is an odd system to those of us used to British or US road law. It means, for example, that you can ride the wrong way on a bicycle track, and if the police stop you, you are not guilty of any offence. After all, there has been no damage. However, there is a legal trick: the police are entitled to give you official advice on the traffic law, and this advice comes with a fee. It is called a "fee for warning".

Germany, for example, is well known as a place in which people get annoyed at you for travelling on the autobahn as slow as 130 kph, which is the maximum speed in France and well over the maximum speed in Britain. People really do travel at 180/200/well over 200 kph depending on the car (usually Mercedes, BMWs and Porsches travelling very fast). However, it is little known that if you are travelling over 130 kph and are involved in an accident, you automatically carry a proportion of the responsibility/blame depending on your speed.

I live in a village, on the outskirts of Bielefeld. There is a narrow main road which curves around the church mound. My road comes off it at right angles, and there are a dozen young kids and a dozen older, not very mobile people all living within about a 100m radius of this junction. A kindergarten, and the church hall, is about 200m up the road. Curves. Houses. Kids who play in the village square and around the road. Old people regularly crossing the road on what amounts to a blind curve (there is a mirror for one direction). There is nominally a 30kph speed limit, which is appropriate. And which is ignored. People regularly come by my house at 40-60 kph, despite that they must stop at the junction, where the road ends, in 50m.

There has not been an accident. The police won't set radar traps unless there is a "reason", meaning it has to be designated a hazardous area by the appropriate political group.

Somebody is going to be hurt, sometime, outside my front door.

So what is best to avoid accidents? The system we have at the moment, in which no responsibility/blame is attached unless there is a resulting accident, in which case the consequences come down heftily? Or a system in which everybody is held strictly to the appropriate speed limitation, which is regularly controlled?

I would suggest: the latter. Taylor may have been engaging in sloppy work, but I would guess he was also working to MttB. And the responsibility for setting the constraints against which MttB behavior strains lies with the company and the regulators. Holding Taylor responsible does not serve the longer-term interests of safety, because the accident was freak. Lessons learned should include a review of safety practices and the way in which a safety culture is promulgated in the concerned organisations, here Continental's maintenance procedures.

There are organisations in which individuals take personal responsibility for safety (and therefore for accidents), and which engage in safety-critical operations to a high level of reliability. They have been studied by Berkeley groups centered around the organisational sociologist Todd La Porte. Th results are that in these high-reliability organisations, the personal responsibility of the individual worker is reinforced by having each critical point in the operation observed and checked independently by three different people reporting along different lines of command. Commercial aviation maintenance organisations have one person, the supervisor, (supposedly) checking and then signing off. The limitations of this system are well-known; see for example the Lufthansa incident at Frankfurt in 2001 in which the captain's side stick was reverse-wired in roll and he almost scraped a wing when responding to a gust during TO: AG RVS - Computer-Related Incidents with Commercial Aircraft

Convicting Taylor focuses away from the lessons that accident investigators believe are there to be learned. I would argue that anything that focuses away from those is less than conducive to aviation safety. This is independent of whether one considers the conviction of Taylor to be "just" or not. It is a point about negative interference amongst processes for achieving socially-important goals: on the one hand, pervasive safety; on the other hand, individual responsibility for negligent action.

(BTW, I expressly disagree with Mike7777777's analogy of the Concorde accident with Chernobyl, Piper Alpha, and Deep Water Horizon. Those all involved multiple instances of direct mistakes, and pervasively poor safety practice. Whereas the only action that could remotely be called poor practice in the Concorde incident was Continental's repair, and even that involvement in the causal factors was arguably extremely improbable.)

PBL

Last edited by PBL; 19th Dec 2010 at 11:03.
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