PJ, #548 “
we must explain things” … and the other questions.
This is a normal human desire; however, if we are unable to describe the overall operational system due to its complexity (man, machine, and environment), nor define the interactions, we will always face an uncertain future.
In these terms AF447 is unexplainable. Self-satisfaction will find whatever we choose to look for (root cause), we only fix what we find, thus avoiding repetition of the last accident, but providing little benefit for avoiding other accidents.
At best we must continue to ask questions, particularly by considering the widest range of possible contributions. In an accident there are many contributory items (at that time, in that situation) all are required, yet the absence of any one could prevent it. Thus our thoughts about potential contributions provide opportunity for safety activity.
Some considerations relating to AF447 :-
Loss of Airspeed (LoA) simulator training; did the FOs handle the aircraft during this session or was it a Capt only exercise? Did the LoA simulation degrade the control laws?
Are FOs given opportunity to decide on a course of action for avoiding weather, or is this always deferred to the Capt? Not a CRM view of a Capt stating a course of action and then seeking FO confirmation, but mentoring – “look at this situation, what would you do”, then discuss the reasoning and judgement, thereby learning and exercising skills of thought.
There are several new safety initiatives which could supplement current safety activities.
Amalberti requires that we must avoid ‘the big one’, but without great detail of how to. He also notes that continuing improvements in the current safety methods must avoid upsetting the delicate balance and creating ‘new’ accidents; yet many recent accidents could have been created – automation, reduced training, commercial pressure, SOP culture.
‘Resilience’ provides some practical suggestions; a continuous process of adapting to changing situations with an alternative view of human performance. Although Resilience does not provide a solution (it cannot – as above), it does stress the need for activity – safety is what is done. By continuing to ask questions, reviewing normal operations we might find indicators as to why accidents have occurred, but of greater importance aspects which can be improved to avoid the next (big) one.
The flight operational side of our industry shows signs of lagging in these activities compared with Eurocontrol, or are we too constrained – regulatory or self inflicted.
‘Systems Thinking for Safety’.