PPRuNe Forums - View Single Post - Air India Express' landing woes continue..
Old 18th Nov 2011, 10:17
  #27 (permalink)  
fdr
 
Join Date: Jun 2001
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@FBW:

Hi. admittedly there are some groups that are much more efficient at entering retrograde habits, but it is hardly the unique character of the sub continent, they are just rather efficient in that regard.

Recall that NASA forgot everything they had learnt from the Apollo 1 fire, and repeated similar systemic failings for Challenger, then after a remarkable report on that disaster, where the administrator specifically states "he gets it...", they backslide into the same behaviour culminating in Columbia. Post Columbia, they "get it again..." Yeah, right.

Now that is mainly in regards to normalizing deviance, as postulated by Diane Vaughan, [the "z" is from the US..] but it also raises the observation by Feynman:

"For a successful technology, reality must take precedence over public relations, for nature cannot be fooled."

Roger that.
(I have used this many times, and I don't think it loses its fundamental truth by the fact that it is a fairly universal concept about hubris and the human condition).

Self delusion is a very human character trait. To consider it as being the sole domain on any one group is somewhat myopic, and potentially indicates an extent of delusion existing in the observer - observer bias in a rather off beat form.

Operationally, a system assumes that the problems have been overcome in a very short timespan, the "we get it...". After a very small sampling, we assume that the problem no longer exists, even if the behavioural traits are inherently risky. Risk doesn't equate to an immediate disaster, it just makes one more likely in the time domain. Added to this, the "just bad luck, could happen to anyone..." fatalistic outlook just makes it easy to assume that the system status is a "was always thus" condition.

Failure apparently is an option, and the aviation industry is staring down the barrel of escalation of the rate of catastrophic events, as we have allowed the competency of flight dynamics to be dictated by bean counters, and as a "profession" the majority of us (professional flight crew) have been at best laissez faire as to the decay, or at worst supporting it actively by providing the pavlovian response to the self interest that is inherent in providing DFO's/Chief Pilots and similar post holders charged with maintaining (or upholding? sounds like Dick Turpin...) standards.

"The people in the US as well as the courts of justice see the world as the result of individual failures. They think that if you find the individual responsible, you would solve the problems. But the problem is that if you take the responsible people out, new ones will take the job and social factors will just reproduce the behaviours and replicate the problems. America is a culture where individual achievement is everything. We consider that if you don’t achieve, you are responsible for your own failure. So looking beyond individual responsibility, to seeing what’s going on in the social context, how it works, what are the beliefs, the common culture, the political economy, etc.. is something we sociologists believe explains human behavior. So it is important to target the real root causes when things go wrong, whether we are talking about relationships, shuttle accidents, or terrorist attacks.We want to know why people make the décisions that they do. When it comes to organization mistake, misconduct, or disaster, the blame usually goes to low level workers and middle managers. Blaming them works for the organization. It deflects attention from top administrators who make major décisions about goals and resources that affect organization cultures, and falls upon workers, affected their actions. I call this « the trickle down effect ». To show the connection between élite actions, as they affect organizations and harmful outcomes shifts our understanding of what to do about the dark side of organization. And this at the core of public sociology. [Even if] it happens to be demonstrated « by accidents »."
Vaughan interview, California Management Review, Vol 39, N°2, Winter 1997

Theres a message in there for management, and for the public that entrust their safety in the systems that we have developed so far.

This is not even close to being a rant... There are some topics about ethics in aviation I would dearly love to expand on, but it certainly would become uncomfortable to many organisations.

The Merlot is starting to age, better get back to it.

Fly safe, and look after each other.

There is no contest between ones soft body parts and 500Kt impacts to the earth (5.9742 x 10^24 kgs), barely leaves a dent....

kind regards,

FDR,

Last edited by fdr; 18th Nov 2011 at 11:12.
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