FDMII, we are looking in the same direction
If we consider the many different views in this thread as parts of the same safety issue, then we could reconsider the operational continuum with a wider perspective. We should refrain from focussing on isolated problems, or with the hindsight of the last accident; Dekker - all viewpoints (ref).
If the industry adopts this way of thinking, then ‘the problem’ becomes which views might offer an adequate solution, given that there is no ideal in time, money, (automaton, training) or with assurance of human behaviour (training).
- Regulation and training may be seen to be the quicker to implement, but perhaps the least effective, particularly without changing automation or the operational environment.
- New automation could help, but this is neither a quick process or low cost; and we must consider the existing ‘grandfather rights’ aircraft still in-service (B737 AMS Rad Alt, MD80 MAD TOCW accidents).
- Changes to the operating environment could affect commerce – we may not be able to reduce workload by going back to the old ways. However, it might be possible to adjust the current operational environment to reduce complexity and workload, e.g. the way we implement SOPs, reduce overburdening call outs, and simplify flightpath procedures.
The diagrams below (Amalberti, Cook, Rasmussen) provide a high level view of ‘the problem'. If we can understand the contribution of the pressurising influences on accidents – excursions beyond the safety margins, then we might better focus our safety improvements.
- What social contributions influenced crew behaviour in QZ8501; everyday we might switch a computer (automation) Off then On to rectify a fault. We have acquired Ctrl-Alt-Del mentality.
- What were the commercial–environmental-social contributions in AF447; we like (need) direct routing, we have better WXR thus we might cut CBs closer than in previous operations, but the industry ‘overlooked’ ice crystals. Or did the regulator see the human as a hazard in need of (UAS) training opposed to the human as an asset who could avoid CBs if this were to be the focus of training – avoidance vs recovery.
- What regulatory training influences were there in Cogan; ice related tail-stall (not a realistic hazard, if at all, in that aircraft) where the training involved a film, no hands-on to reinforce knowledge that there would not be a stick shake – nor that tail stall did involve aerodynamic wing stall and thus conventional recovery action did not apply.
‘The problem’ could be clarified by positioning these accidents on the diagrams, then consider viable defences and how might we continue to operate closer to the margins to safety, yet recover from inevitable excursions into the safety space which is always reducing due to the operational workload, economic, technological, and social pressures.
Refs:
In the system view of human factors, who is accountable for failure and success? Note the concluding pages.
Also see:
Managing the Unexpected and
Safety Differently (read the summary).
Amalberti.
The paradoxes of almost totally safe transportation systems 2001.
Cook, Rasmussen.
Going Solid 2005.