Accidents - CBLFs vs God

[Safeware]

In response to John Farley's input on the Typhoon:
I nearly agree. I would just delete 'almost'. This is because God does not design, manufacture, maintain or operate aeroplanes - only your CBLFs do that. Therefore all accidents (in some way) can be traced back to people.

If anybody can come up with a case not covered by the above please take me to task on a new thread.

Wouldn't a) Windshear and b) Lightning strike cover such cases?

Or would it be argued that it is the inability of CBLFs to deal with these elements of nature that is the trace back to people?

s/w

[Pontius Navigator]

You could argue that a lightning strike, while clearly an act of God, only occurs because the aircraft is there.

The DC9, many years ago, was not allowed to fly whenever there was a risk of a strike. OTOH in a Nimrod we got struck several times in the space of an hour but carried on with the mission. Had we not been tasked, or had the pilot decided that night IMC without radar was too dicey then we could have avoided the lightning.

As for windshear, is this not now forecast? If there is a forecast what do we do? Usually we train to handle the event rather than avoid it. When the training is inadequate or the sheer too violent was this really an act of God?

I am not saying that unless we don't fly we will eventually crash just that there are circumstances that at first sight appear as AOG but were actually avoidable. One that spings to mind was a Transall that launched with Red airfields everywhere. Ultimately training got them out of the cr*p.

[Safety_Helmut]

Bigtop, Tigs2 et al

I am not a pilot, but I am an engineer, who has also studied and read on the subject of system safety engineering for some years now. So when the Typhoon thread moved onto the subject of accident causation I became quite interested. I feel that some of the comments should give anyone with a professional interest in military aviation cause for concern.

I personally feel quite alarmed that someone who claims to “train people on AIB’s (sic)” can then go on to state: “80 % of accidents are, these days, caused by carbon based life forms - because of the swing in technology. The 80% figure can never be reduced.”

This cause me concern on two separate, but closely related issues. The first being that we put so much down to ‘human factors’, without the proper recognition that we have presented our crews with inadequate interfaces. The second concern is the apparent presumption that we are any good at accident investigation in the military.

Some of the comments appear to show a fundamentally narrow view of why accidents happen. The complex systems we are able to deploy now, place the operators at such a level of abstraction that maintaining an understanding, or model of reality, becomes very difficult. A very good paper (open source) by a former member of the DASC suggests that we cannot hope to significantly reduce our accident rates until we properly understand the accident sequence, and to do this we must understand that the accident sequence begins not when the engineer makes a mistake or the jockey climbs aboard, but during design and development.

Safeware, good thread !

Safety_Helmut

[buoy15]

Windshear, Clear Air Turbulence, Lightning Strikes ?

Surely an act of weather or nature ?

Unless of course your submitting an insurance claim - then an Act of God, so no dosh!

Bloggs, what are these goats doing above this cloud ?

[Two's in]

A pedant writes -

All weather related phenomena are to some degree predictable and hence a risk assessment can be made. Of course there are variables, and of course the model is hard to define, but it comes down to basic risk management. As Pontius says, weather related events occur because the aircraft is there.

Some CBLF made a judgement call that despite, or because of, the forecast meteorological conditions, he/she would expose the aircraft to the risk. When it doesn't work, and there is a smoking hole in the ground, there is always a Human Factors decision in the chain that got them to the scene of the accident first.

As for AIB's, after the first few they have a dreadful note of predictability and inevitability about them. I don't disagree that we have some jolly clever systems, that left alone, might prevent some accidents, but a Human Factors dig on an AIB covers a vast spectrum of reasons why Bloggs knew better/felt sharper/ignored the warnings/didn't see the caption/didn't get the briefing updated/went lower than Authorised/didn't get a jump the night before/missed breakfast/pi$$ed of the CO etc. etc. (We've all seen the movie).

Most pilots can truly understand the notion of a cold sweat running down your back, feet off the pedals because your legs are shaking so much and thinking - Jesus H, we nearly died because I just did something monumentally stupid, and all the smart stuff in the world won't save you on the day, unless you get at least one jump ahead of your error prone Human Brain.

[Pontius Navigator]

Safety_Helmut,

I think that the reference to CBLF was not restricted to the twin wing master race.

You said "we put so much down to ‘human factors’, without the proper recognition that we have presented our crews with inadequate interfaces.""

I hope that the 'we' here is a CBLF and not a plane built by robots.

"apparent presumption that we are any good at accident investigation in the military." CBLFs again.

" the operators at such a level of abstraction that maintaining an understanding, or model of reality, becomes very difficult. "

Ah. CBLFs again. Then a CBLF decided that one man and a computer was better than 2 men and a computer.

"the accident sequence begins not when the engineer makes a mistake or the jockey climbs aboard, but during design and development."

This is still a human factors event then. Man builds 'em. man crashes 'em.

[John Farley]

Thanks Safeware for the new thread.

The met events you mention (in my view) represent known risks to aviation. If the circumstances make them likely to happen then people (crews) can choose to avoid them by diverting, changing their route, holding and so on. If the crews decide to take the risk because they feel it is negligible or managable then that is a people decision and if it turns out to be wrong…….

Please understand I am not trying to suggest that any one group of people (designers, builders, maintainers, operators, accountants etc) are to blame more or less than others My simple point is that without people there would be no aviation and so in the end all accidents can be traced back to a human decision/mistake/lack of skill or whatever.

JF

[Safeware]

John et al,

I put my 2 thoughts up because they were the only areas that I could see that, given a (seemingly) 'straight run', that a curved-ball could come at you that you had no control over. I accept that man now has better understanding of such 'acts of God' and can predict them with great(er) accuracy. Ignoring / belittling the risk is certainly a human failure, but (and I'm not a met man or aircrew) unexpected changes in weather do occur which may catch people out. Who is cause and who is contributor then?

On the other hand, it's all the pilot's fault because he decided to go flying :) :)

s/w

[Art Field]

In spite of great advances in forcasting it can never be that all aircraft threatening weather generated dangers can be avoided, indeed it would be a foolish designer, engineer or aviator who assumed that to be so. If caught in such conditions the only variable left, since aircraft strength, control and engine response etc, are already fixed factors, will be the skill of the pilot. Is it possible to train to cope with such variables beyond advice to get out of the condition as best as you can?.

Two totally unexpected and unforcast examples come to mind. In one a heavy VC10 got airborne out of Goose Bay and almost immediately was hit by a violent downdraft from which the very experienced pilot just managed to avoid the ground. In another a Victor, transitting the UK at high level, well above any cloud layer, with absolutely no pre-warning turbulence, suddenly and violently dropped 3000ft before control could be regained. The aircraft required a thorough airframe check on recovery. On both of these events aircraft handling well outside of the norm was required.

[Rhys S. Negative]

No-one has yet mentioned the little feathered aviators (admittedly still carbon-based), which have led to the loss of a number of Harriers and other aircraft...

It is up to the designers to provide protection of vulnerable areas of the machine, but there still needs to be a big hole so that the air can get to the engine; and airfield management to keep the grass at optimum length and employ the birdscarers, but once outside the ATZ...?

Moving on from there, there have been mid-air collisions between aircraft where post-accident reconstruction of flight paths and cockpit geometry showed that the chances of either pilot seeing the other aircraft were virtually negligible. Do we CBLFs really need to be super-human to avoid all possible pitfalls?

Rhys.

[Pontius Navigator]

The invisible aircraft syndrome where both aircraft cannot be detected by the brain before collision is of course the result of:

1. two aircraft permitted in the same piece of sky

2. aircraft fitted with inadequate or no collision avoidance equipment given that their speed capability would permit the collision unseen

3. at night as for 1 above

So it all hinges back to CBLF whether in the cockpit (not designed by higher authority for the job now in hand) or on the ground in creating the rules of the air.

If the collision was a red-blue one then we may blame the politicians for not setting up mutual protection schemes.

And so on.