PPRuNe Forums - View Single Post - Police helicopter crashes onto Glasgow pub: final AAIB report
Old 8th Nov 2015, 20:14
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SilsoeSid

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Join Date: Nov 2002
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Error Trap

Whether the switches were manually switched or their positions were the effects of the 100 G, will be a discussion that no doubt will continue to run; however there is, imho, action that should be taking place to prevent future inadvertent switching but isn't. In our aviation world this is clearly not safe practise;

How to blame less and learn more

... it pays to pause to look beneath the surface, to challenge the most reductionist narrative. This is what aviation, as an industry, does. When mistakes are made, investigations are conducted. A classic example comes from the 1940s where there was a series of seemingly inexplicable accidents involving B-17 bombers. Pilots were pressing the wrong switches. Instead of pressing the switch to lift the flaps, they were pressing the switch to lift the landing gear.

Should they have been penalised? Or censured? The industry commissioned an investigator to probe deeper. He found that the two switches were identical and side by side. Under the pressure of a difficult landing, pilots were pressing the wrong switch. It was an error trap, an indication that human error often emerges from deeper systemic factors. The industry responded not by sacking the pilots but by attaching a rubber wheel to the landing-gear switch and a small flap shape to the flaps control. The buttons now had an intuitive meaning, easily identified under pressure. Accidents of this kind disappeared overnight.

This is sometimes called forward accountability: the responsibility to learn lessons so that future people are not harmed by avoidable mistakes.

We have a yellow rubber cover for the 'sprung to off' Hyd Test switch to make it different from the others (FLM- do not operate the test switch while airborne), but over a year after the first detailed report came out S2/2014 mentioning the 'incorrect' fuel switch positioning, as far as I am aware, there has been no action taken to differentiate the two sets of switches.
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