"my Observations And Comments About The Accident"
"If the world were perfect, it wouldn't be"
"Yogi" Berra
Ataps': did you update your observations with the hindsight of the evidence that was rather skillfully derived by the AAI's?
(Peter is correct, the investigation techniques were advanced by the efforts of those involved in this investigation).
Would love to operate in a world that humans don't suffer from human constraints and where machines don't break down, and where computers don't suffer BSOD's. But that is going to have to be in another universe. In this one, we have "the germans in charge of law and order, the british in charge of cooking (and car electrics), the french in charge of personal hygiene... etc, and the Italians in charge of maintenance..." (apologies to all).
AA965 [oops... 587 was bigfoot....or how we learn about certification issues after the event, thanks zee] had 2 nominally performing humans (3 if the ATCO is included...) acting in a standard routine and didn't need much for the round bit to go pear shaped. What may be considered rash or wilful disregard later is often hard to distinguish pre accident from being expedient, and "applied initiative" at work.
Expectancy was a significant issue with the FMS-NDB issue, and it occurred at a tragically inopportune time with a crew that were at a low arousal state, in high risk conditions. That the crew didn't recognise that they had multiple SA errors starting to compound again confirms that they were human. (as was the software developer who released the NDB that was not consistent with ARINC standards... the same for the people who considered that the QMS of the NDB was adequate...).
" The future ain't what it used to be "
Yogi
If Peter's Risks Digest methodology is not to your liking, perhaps you may be interested in looking at risk as considered by Erik Holnagel (if there is some discomfort with Reason's simple model of causation), or at least consider SA matters in general as well described by Mica Endsley. As contributory factors, I believe if anything that the AA[965] investigation could have followed further down the path of causation, to highlight opportunities for reinforcing systemic weaknesses. (Vaughn or McDonald can also give some insight to how technology retains flaws, against the best intentions of those entrusted with it's implementation).
After Annex 13, and all other processes are complete, it is always the intent of this industry to avoid repetitive failings. Civil tort law has different priorities, and does not in itself lend to avoidance of repetition. If it did, my computer screen wouldn't regularly go to BSOD.
"It's deja vu all over again"
Yogi
regards.
FDR
Last edited by fdr; 18th Jan 2011 at 04:08.
Reason: 965 not 587, Dooh! thanks Zee.