PPRuNe Forums - View Single Post - AF 447 Thread No. 12
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Old 27th Sep 2014, 03:22
  #452 (permalink)  
Cool Guys
 
Join Date: Mar 2010
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For any accident/incident/problem there is a root cause, and if that root cause is found and fixed the issue will be resolved and will not happen again. Aircraft accident investigation is particularly good at this. In some cases the root cause cannot be found so we investigate the contributory factors and the chain of events (effects) resulting from the original issue and we implement counter measures for these. Contributory factors can be minimised or eliminated and any effects can be minimised by introducing containment/redundancy/contingency measures into the system. Depending on the severity and nature of the issue this may be a legitimate, complete handling. The 787 battery issue is a contentious example of this. In the case of AF 477 the root cause of the PFs decision to pull rather than “do nothing” has not been identified however some contributory factors have been identified and some counter measures have been introduced.

Recently in this thread there has been 2 lines of discussions, one regarding the root cause and the other contributory factors. A couple of days ago some pilots were discussing contributory factors such as the user interface, PIO and cognitive bias. A poster then got on his high horse and demanded the root cause be found and a perfect solution implemented. Since then the root cause has been the topic of discussion. This is a valid topic but rather than allowing demands for a perfect solution to drown all else, in the absence of a root cause being found we can and must address these contributory factors. It is a very challenging task to find the root cause of a human decision during a time of stress. With our present level of understanding of the human mind it may take us 20 years to understand why the PF pulled rather than “did nothing”, we may never understand. However the contributory factors and effects can be identified and understood better. There can be many possible effects and contributory factors so a full handling can get quite complex.

The posts a couple of days ago were suggesting (from my understanding) the PF was overloaded due to PIO and the PNF was confused because he did not know what the PF was doing. This would appear to be one possible scenario which has tangible and more easily obtainable resolutions but it seems to have been discounted in the process of a quest to discover the root cause.
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