Sunfish
8th Apr 2013, 06:43
I believe esteemed moderator Tailwheel is wrong about the minimal potential for a bad aviation accident in Australia as I will explain at the end of this essay. The masterful work by the Senate Committee on the Pel Air accident and the associated memorandum of understanding between CASA and the ATSB provides valuable pointers to what has happened and what may happen in future.
In the introduction to his masterful history of the origins of World War One "The Sleepwalkers" (2012) Christopher Clark observes that the questions of why and how an event took place are logically inseperable, but lead us in quite different directions. The question of how invites us to look closely at the sequences of interactions that produced certain outcomes. By contrast the question of why invites us to go in search of remote and categorical causes: poor training, commercial pressures, slovenly administration, laziness, etc. The why approach brings a certain analytical clarity, but it also has a distorting effect, because it creates the illusion of a steadily building causal pressure; factors piling on top of each other pushing down on the events, pilots become mere executors of forces long established and beyond their control.
Aircraft accidents happen because of a chain of events performed by rational actors who are capable of self reflection, acknowledge a range of options and form the best judgements they can on the basis of the information they had to hand. The why approach can only be made to carry any explanatory weight if they can be seen to have shaped the decisions that led to the accident.
A Bulgarian historian recently observed that "once we pose the question why, guilt becomes the focal point" and so it proved in the disgraceful saga of the Pel AIr accident, where the ATSB totally accepted the CASA line that all guilt and responsibility must fall upon the pilot and abandoned what I believe is its proper role of determining how the accident occurred.
The focus on how which is the morally correct position that the ATSB should be forced once again to take is not driven by the need to draw up a charge sheet against this or that individual but aims to identify the decisions taken and the reasoning or emotions behind them This does not mean that the question of responsibility is excluded entirely - the aim is to let the why grow out of the how and not as suggested by evidence in the case of Pel AIr the reverse where CASA drove ATSB to its preconceived conclusion that everything was the pilots fault and no further discussion is to be entered into, to the point where the aircrafts flight recorders - the best source of how the accident came about, still languish on the bottom of Norfolk Island lagoon.
The danger in allowing this situation to persist - a complaisant ATSB following the diktats of CASA and the Department Of Transport is this: The why argument - the CASA blame game implies that the causes of accidents are long term deterioration in safety systems among operators. This seems to me to be embodied in its approach to regulation - closing down operators on the basis that they pose "unacceptable risk". In other words that systemic risk is the enemy and that it is possible to map out a causal chain of why it was inevitable that an accident happened as opposed to the more useful how that the ATSB was supposed to investigate.
The danger in this is inherent in the idea that as Tailwheel believes a major aviation accident in Australia is "improbable" - accepting that there is no obvious chain of "inevitablity" associated with any accident as CASA would like us to believe. I instead incline to the belief that short term events and apparently logical short term decision making instead create the conditions where an accident self assembles very, very rapidly and the why model of accident history completely fails to explain this, moreover it provides absolutely no guidance as to what to do to prevent future chains of consequence from self assembling., only the how model of accident analysis, now spurned by the ATSB can do that.
Think of the 275 people on Emirates 407 out of Melbourne that came within an inch of disaster and then tell me again how "improbable" a major accident might be. And that little episode involved a few quick key strokes on a laptop computer. The ATSB needs to be granted its independence, if necessary from the Transport Department, otherwise we are going to have to re-learn the original reason for its independence the hard way.
In the introduction to his masterful history of the origins of World War One "The Sleepwalkers" (2012) Christopher Clark observes that the questions of why and how an event took place are logically inseperable, but lead us in quite different directions. The question of how invites us to look closely at the sequences of interactions that produced certain outcomes. By contrast the question of why invites us to go in search of remote and categorical causes: poor training, commercial pressures, slovenly administration, laziness, etc. The why approach brings a certain analytical clarity, but it also has a distorting effect, because it creates the illusion of a steadily building causal pressure; factors piling on top of each other pushing down on the events, pilots become mere executors of forces long established and beyond their control.
Aircraft accidents happen because of a chain of events performed by rational actors who are capable of self reflection, acknowledge a range of options and form the best judgements they can on the basis of the information they had to hand. The why approach can only be made to carry any explanatory weight if they can be seen to have shaped the decisions that led to the accident.
A Bulgarian historian recently observed that "once we pose the question why, guilt becomes the focal point" and so it proved in the disgraceful saga of the Pel AIr accident, where the ATSB totally accepted the CASA line that all guilt and responsibility must fall upon the pilot and abandoned what I believe is its proper role of determining how the accident occurred.
The focus on how which is the morally correct position that the ATSB should be forced once again to take is not driven by the need to draw up a charge sheet against this or that individual but aims to identify the decisions taken and the reasoning or emotions behind them This does not mean that the question of responsibility is excluded entirely - the aim is to let the why grow out of the how and not as suggested by evidence in the case of Pel AIr the reverse where CASA drove ATSB to its preconceived conclusion that everything was the pilots fault and no further discussion is to be entered into, to the point where the aircrafts flight recorders - the best source of how the accident came about, still languish on the bottom of Norfolk Island lagoon.
The danger in allowing this situation to persist - a complaisant ATSB following the diktats of CASA and the Department Of Transport is this: The why argument - the CASA blame game implies that the causes of accidents are long term deterioration in safety systems among operators. This seems to me to be embodied in its approach to regulation - closing down operators on the basis that they pose "unacceptable risk". In other words that systemic risk is the enemy and that it is possible to map out a causal chain of why it was inevitable that an accident happened as opposed to the more useful how that the ATSB was supposed to investigate.
The danger in this is inherent in the idea that as Tailwheel believes a major aviation accident in Australia is "improbable" - accepting that there is no obvious chain of "inevitablity" associated with any accident as CASA would like us to believe. I instead incline to the belief that short term events and apparently logical short term decision making instead create the conditions where an accident self assembles very, very rapidly and the why model of accident history completely fails to explain this, moreover it provides absolutely no guidance as to what to do to prevent future chains of consequence from self assembling., only the how model of accident analysis, now spurned by the ATSB can do that.
Think of the 275 people on Emirates 407 out of Melbourne that came within an inch of disaster and then tell me again how "improbable" a major accident might be. And that little episode involved a few quick key strokes on a laptop computer. The ATSB needs to be granted its independence, if necessary from the Transport Department, otherwise we are going to have to re-learn the original reason for its independence the hard way.