safetypee;
An excellent, thoughtful and thought-provoking post, thank you and thank you for the links.
In safety work it is not always easy to learn how, where and when to place one's "focus". We can "tune in" varying "causes" according to our models of this and that, and even lend to such models' details a taxonomy which can at once legitimate such approaches and even explain but also carry the potential to limit such approaches unintentionally, a sort of "auto-immune" disease of process, as it were.
The generic issues here are the failures to learn from previous and often unrelated events, and in judging the risks associated with the identified threats current state of knowledge or application of knowledge.
Yes, I think so. Interestingly, this describes some of the system characteristics now known to have occurred prior to 9/11, and, as we are slowly learning, prior to the 2008 financial and to a certain extent, social meltdown in the U.S.
franzl;
Quote:
Clandestino
even the best pilots can underperform occasionally
Tat is a very true statement.
Itīs astonishing how reading thousands of pages on the various AF447 threads could lead to the conclusion, that only this very unfortunate AF447 crew was able to do such mistakes, all others being skygods and unfailable, and therefore thoughts about an improvement of systems, of the machine man interface is not necessary and a waste of time.
First, I know from a few "first-hand" experiences in a number of types including the A330 and A340 that there is no such thing as infallibility in the cockpit. I have plenty of colleagues who can say the same thing. Anyone who does high-risk work (doctors/nurses/engineers/pilots) will have things which he/she has done that keep them awake at night. It is testimony to the success of processes in place which provide redundancy and resiliency in mitigating systems that the accident rate is what it is.
Anyone who flies and is contributing to this discussion knows this very same thing but that sense of someone's approach can't always come through in just a post or two.
If comments default to blame or dissing a crew, the contributor hasn't flown long enough, they are living an illusion informed only by ego, or they aren't a pilot.
Rather than agreeing or disagreeing then, I would like to recognize that over the life of eight or so threads on this accident, that while we have some responses which seem to do this they always seem to fade away while those who do this work (flying transports, engineering safety systems, etc) on a regular basis do have and do provide broader perspectives. Most know that "blaming this crew" doesn't cut it and dooms any responses to pedantic repetitions of the notion of "primary causes", leaving us to chase down, focus upon and fix "the cause" while waiting for the next cause. The simplest example is, "the accident occurred while approaching runway 31L so we won't use "runway 31L" anymore. I thought the ETTO presentation was worth examining in this light. And as many have clarified, focusing on the crew is not the same thing as blaming the crew.
In this, the BEA "Human Factors" group have a Herculean task.