AF 447 Thread No. 11

[PEI_3721]

J.O. ‘It’, AF447 should not happen again; as you say there are fixes, and the industry rarely suffers the exact same accident.
Did it change enough for AF447, yes; for future safety, I doubt it.
The critical lesson is how difficult it is to identify the significant contributing factors and the conditions by which these line up – what is significant.

Attributing cause or identifying the ‘holes’ which previously had lined up, suffers hindsight bias.
Humans are biased; it’s easier to blame someone or something than understand the underlying issues. Blame – blame culture, does not help learning.

What the industry might learn is a reminder that accidents can happen from very rare events, and with hindsight there are indicators – precursors, which if understood earlier and managed, might prevent an accident. We cannot succeed in all cases, but we might learn how to prevent the initial events escalating.

Safety is like a boat, they all leak. The art of safety is to identify the large holes, plug them, and ensure that you can bail faster than the residual leaks. But this assumes you understand what is meant by a hole or a significant leak.

We might not be able to identify all aspects, but we could identify and change the process of how ‘holes’ line up; i.e. how we think about safety, anticipate, monitor, respond, and learn; both individually and as an organization.