An old accident -Pilot Error?

[Menen]

This from Pprune Aviation History and Nostalgia Forum:

Date: January 06, 1948
Time: ?
Location: Ruislip, England
Operator: British European Airways
Flight #: ?
Route: Renfrew - Northolt
AC Type: Vickers 610 Viking 1B
Registration: G-AHPK
cn / ln: 148
Aboard: 18 (passengers:14 crew:4)
Fatalities: 1 (passengers:0 crew:1)
Ground: 0
Summary: After two or three failed approaches, the plane struck trees and crashed into a field. Poor judgment on the part of the pilot attempting to land in VFR conditions in limited visibility and poor weather conditions and not diverting to another airport.


The Poms were certainly blunt with their assessment of the primary cause of the accident. None of this Swiss Cheese business and blaming everything else except the pilot.

Funny thing is that when accidents and incidents were written up in the old Australian Aviation Safety Digests, there was no shilly-shallying about and if pilot error was involved (that now forbidden phrase) the writer had no qualms about saying it. Readers could then learn from an accident, rather than now, where ATSB reports tip-toe around and readers are left to their own conclusions.

I am not saying this is right or wrong - merely pointing out the political correctness that has steadily infiltrated official accident reports over the years.

[Ultralights]

in VFR conditions in limited visibility and poor weather conditions and not diverting to another airport.

this make NO sence what so ever! poor weather and limited vis are NOT VFR conditions.

[the wizard of auz]

quick quick, spelling police, somebody.
the word sence makes no sense at all. :E
I hope that word doesn't get past your proof readers in the CD/DVD game. ;)

[Howard Hughes]

Could it be possible, that the science of accident investigation and subsequent reporting has actually improved since 1948?

Perhaps now that we can often identify the individual system or procedure which contributed to the accident, we are less inclined to simply write "Pilot Error".

As for the style of writing, I see nothing wrong with easing the pain and suffering of a dead pilots family, by leaving the reader to make up their own mind about the cause of an accident. I mean after all, are'nt we meant to be educated, analytical, professionals?;)

Cheers, HH.

:ok:

[Bizpax]

Anti-political correctness is running amok! We have actually progressed in the last 60 years because of a scientific understanding of how accidents occur.

In 1948, flying was feeling the wind in your hair and we were free and we killed lots of people! But now we have rules and regulations and procedures and back up systems and fail safe systems and redundancies and fancy fandangled accurate and reliable instruments and high performance aircraft, and most importantly, a recognition that the crucial decision that determines whether an accident will occur is often made well before the very last action taken. Yes, pilots makes errors but who pressured the guy to fly when the weather was setting in? Who didn't have alternative aerodrome procedures in place? Where was the technology to give the pilot the best knowledge possible of the terrain/weather/traffic?

Believe it or not, we safety scientists and engineers aren't just there to get in your way but there to transmit many many years of study and knowledge to produce the safest flying machines and conditions we can. And we have learned from Australia's aircraft accident investigators who are amongst the best in the world. And a revolution in technology is on the way now with the demise of radar and the rise of GNSS technologies. The idea is that human error ( at whatever phase of flight) can be better managed.

Yes, we all make errors but it ain't the full story by far and without an understanding of this we won't improve safety.

[glastar]

Menon, you are obviously new to the industry.
Many years ago when accident investigation was in its infancy the majority of accidents were put down to pilot error because the investigators did not have the technical expertise that we have today. Nothing was learnt from these judgements. I asked a question once to the experts at a technical symposium.[given that pilots don't set out to kill themselves, don't you think there maybe other causes, that my contribute to their decision making process leading to an accedent]. Fortunately these days with CRM taken seriously and much more educated and informed technical specialists in the accident investigation profession we now get to the contributing causes leading up to each accident and the lable PILOT ERROR is not often seen.
Unfortunately some pilots do not educate them seleves with all the available literature available these days and continue to fall into the same old traps. If you read an aviation safety digest from 40 Yeras ago and a recent one you will see the same old causes being repeated. Mabe in these cases you could lable it PILOT ERROR.

[Ultralights]

quick quick, spelling police, somebody the word sence makes no sense at all.
I hope that word doesn't get past your proof readers in the CD/DVD game

Yo! da shiznit!

I pay accountants and solicitors for that!



as for the topic, i belive it was Mt Erebus (quick speeling police check here) that the art of technical investigation took a turn away from the "pilot error" as the most likely cause of any incident, and begun looking at all aspects of the aircraft and Airlines operations as major contributing factors.

[Iakklat]

:O :O :O

[Kaptin M]

Can anyone give me an example where pilot error has NOT been cited as one of the contributory factors?

There are a lot more "tools" available to investigators in recent times - namely CVR's and FDR's - than there were back in the '40's and 50's.

By the same token, the statement made in Menen's opening postPoor judgment on the part of the pilot attempting to land in VFR conditions in limited visibility and poor weather conditions and not diverting to another airport.is pure speculation, and a personal opinion seemingly made without full knowledge of all the facts, eg. engine condition, fuel state, proximity and suitability of alternate airports, etc.

And a revolution in technology is on the way now with the demise of radar :confused: huh??? :confused:

[kellykelpie]

Menen,

Wasn't that you posting weasel words?

You are obviously a dinosaur.

To suggest that concluding an investigation with Pilot error actually prevents further accidents only shows that you have a lot to learn

[BOPralph]

Pilot error is almost always a contributory factor in an accident - yes. But does that make it the fault of the pilots - are they to blame?

We all make mistakes - but how tolerant is the way we operate and the system we operate in to the types of mistakes we make. Improve error management, and error tolerance, and we should make the world in which we work more resistant (but never immune) to adverse safety events.

Todays accident reports avoid apportioning blame. That does not prevent them identifying errors. The thing is to identify and correct or defend against the route cause of the errors.

[noooby]

KAPTIN M

DC-10 engine fell off on takeoff, plane rolled over, all dead. Pilots not blamed.
JAL 747 rear pressure bulkhead blow out. Pilots not blamed.
Sioux City DC-10 Turbine failure. Pilots not blamed.
If you want to go waaaaaaaaaay back, Bristol B170 Freighter, wing fell off near Christchurch. Pilot not blamed.

The only time pilots wear some of the blame, is when they contribute to the accident/incident. Of course, because of where they sit, and the job at hand, one would hope they were in some way responsible if no major pieces have fallen off. Otherwise they'd be asleep!! :)
Of course, the main reason for Accident Investigation, is not to find a Who, but a Why. Blame is not directed in an accident report, and nor should it be. Assigning blame just means that people won't be so forward with information the next time.
Just a thought

noooby