PPRuNe Forums - View Single Post - Hawker Hunter Crash at Shoreham Airshow
View Single Post
Old 4th Apr 2016, 11:38
  #1506 (permalink)  
alf5071h
 
Join Date: Jul 2003
Location: An Island Province
Posts: 1,257
Likes: 0
Received 1 Like on 1 Post
My experiences of lawyers in safety - accident investigation (not AAIB, but in support of them and investigations worldwide), was that the legal views before and after an accident differed significantly. Not a change amongst the same people, but in the roles undertaken by different groups.
Proactive advice, safety orientated, was invaluable; seeking to avoid accidents or understand and learn from events to improve safety; the classic, but not exactly the same view of separating investigation and law.
Reactive involvement was restrictive, cumbersome, and in rare instances devious to the point of influencing investigations.
These views reflect learning without blame – aviation safety, or alternatively punishment and retribution within the law. ‘Oil and water’, unfortunately the slippery oil was usually on top; thus you require a good detergent for a clean balanced view.

If AAIB reports are admissible (civil law), then why not allow 'anonymous' text of research / books, particularly for human factors to be considered.
Investigation reports are often restricted in identifying ‘real’ facts. The industry is increasingly safe and most accidents relate to human behaviour. There are few 'facts'; reports rarely speculate on human behaviour and even in nonfatal accidents pilots may not know why a particular course of action was taken – the subconscious mind.
Investigation reports will always be open to interpretation, not only individual experiences and expertise, but also as to how rules and regulatory advice is (should have been) interpreted – hindsight, after the fact.

Consider an accident similar to this thread. A pilot is cleared to 100ft for fly pasts, but the general rules require vertical manoeuvres to complete by 500ft; how might the rules be interpreted during an aerobatic sequence, transitioning from the vertical to a level flypast; what is complete.
Before an event this could be a matter of judgement, the regulatory process has accepted that the pilot is qualified, experienced, current, etc; but after an event - a failure of judgement where rules could be reinterpreted by investigators, regulators, and legal argument. I stress that the more reputable investigators are well versed in hindsight – regulators much less so; lawyers - may depend on objective / aviation context – human factors – but then I am biased.

Thus the ‘success’ of judgement is always after the fact, either error, blame, or a unique opportunity to learn because this involves the same mental process of judgement – the everyday method of learning.
The difference between before and after might only be a few feet in altitude; I suspect that there will be many ‘expert’ witnesses with such experience.

Other thoughts:-
“A just culture depends on who draws ‘the line’, not where the line is.” (Dekker)

http://www.safer.healthcare.ucla.edu...lPrimerDoc.pdf

The emperor’s new clothes.
alf5071h is offline