PPRuNe Forums - View Single Post - AS332L2 Ditching off Shetland: 23rd August 2013
Old 26th Nov 2013, 07:43
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Mars
 
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In previous posts on this thread there were attempts to attribute the cause of the L2 accident too simplistically. A passage from pages 103/4 of the recently issued report "Operational Use of Flight Path Management Systems" puts forward a much more enlightened viewpoint:

Data are collected primarily about “front line” operations. Attempts to diagnose safety-related problems in analyses and investigations are dominated by categorizing events as due to “pilot error” and “controller error,” and the WG found this is no different when addressing flight path management and use of automated systems. The persistence of this attitude reduces the ability to understand the factors that create the conditions for, or lead to, these errors (Woods et al., 2010). One class of latent or underlying factors is that of organizational factors related to organizational culture, including policy, procedures and economic pressures. Another class of latent factors relates to effects of complexity - increases in the degree and kinds of interdependencies across factors (including tighter coupling of systems). Unfortunately, very little information about these classes of latent factors is gathered at all (what is gathered is not done so in a consistent way), and little of the available data is utilized to assess the effects of such factors.
I think that most of us would subscribe to the view that "...organizational culture, including policy, procedures and economic pressures..." were issues that have to be examined when determining how to prevent other such accidents in the future.

Mars
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