Go Back  PPRuNe Forums > PPRuNe Worldwide > The Pacific: General Aviation & Questions
Reload this Page >

Are there lessons to be learned today from "old" accidents

The Pacific: General Aviation & Questions The place for students, instructors and charter guys in Oz, NZ and the rest of Oceania.

Are there lessons to be learned today from "old" accidents

Old 20th Dec 2009, 12:55
  #1 (permalink)  
Thread Starter
Join Date: Jun 2000
Location: Australia
Posts: 3,979
Lessons from past accidents to the current pilot generation

It is generally accepted that the number of serious accidents to aircraft has reduced over the past 25 years. The reasons for this are varied but would include increased reliability of aero-engines and better navigation equipment.

In terms of Australian accidents the usual culprits are in GA while at the same time there have been very few serious large RPT accidents in Australia. This leads to an earlier subject in PPRuNe pages which discussed seemingly general discontent with the flight safety content of the official ATSB/CASA publication Flight Safety Australia and what measures are needed by the editorial staff to make the FSA magazine more interesting to read - like the former Aviation Safety Digest of yore.

This reader has been researching more than one hundred Air Safety Digests and coming across countless thoroughly informative accident reports involving local GA including PNG - as well as heavy aircraft overseas operators. These reports were included regularly in ASD because of their relevance to Australian flight operations. In turn the journalistic style of the then editor was largely responsible for the popularity of the magazine.

It's a fair bet that most of the current generation of pilots in Australia were not born when the first ASD was published, and are therefore denied the opportunity to learn from these accidents of long ago. Yet, the cause of those accidents are as relevant to the study of flight safety today as they were all those years ago. And I am not talking about the last flight of the Hindenberg airship.. For those saying, Huh? - just Google it.

There is a tendency for the current editorial staff of FSA to treat "old" accidents as not worthy of re-publication to the present generation. Instead, we are served an unending proliferation of advertisements leavened with amateur pilot articles or personal stories with maybe an occasional overseas event. Mind you, no shortage of CRM and TEM ad nauseum. A new course needs to be charted.

In one copy of Air Safety Digest (ASD) I found an NTSB report on an overseas accident reproduced in a well written shortened version covering two pages of text and a couple of sketches. After reading that report I sat back and came to the conclusion that it had a far greater flight safety message that ten FSA magazines put together.

It was about a Boeing 707 accident in USA where, at V1 and max take off weight, a loud noise like an explosion was heard in the cockpit, prompting the captain to abort the take off just after the call of V1. It turned out that the first officer's sliding window had popped open and the combined noise of the engines and high airspeed was enough to scare the captain into an unwise decision. Despite maximum braking and full reverse thrust on all engines the 707 over-ran the 4442 metre length runway and caught fire. The 186 people on board managed to escape.

The investigation found that due to an undetected defect in the braking system, only six of the eight brakes were operating. Hence, in addition to aborting after V1, the captain was not to know the aircraft braking capability was already fatally compromised.

There were several lessons to be learned from that accident and Boeing in later years addressed one of them. That was if a cockpit window becomes unlocked after 80 knots on the take off run, it is insufficient reason alone to abort. That advice is now incorporated in the appropriate Boeing manuals.

Personally, I believe that selected accidents from the past, such as the event described here, should be re-published for the present pilot generation to study and learn from. The editorial staff of FSA apparently disagree. Whether the selected accident occured in 1959 or 2009 should not matter. It is the applicability to the current generation of pilots that is important.

Your comments for and against the publication of early accidents would be appreciated and I am sure will be read by the staff of Flight Safety Australia.

Last edited by Centaurus; 20th Dec 2009 at 13:28.
Centaurus is offline  
Old 20th Dec 2009, 14:23
  #2 (permalink)  
Join Date: Aug 2006
Location: On the move
Posts: 939
I would rayher learn from others mistakes than my own ie know what the cause was before experiencing it myself . Watching the TV series has been a big eye opener from simple tape and insects to severe engine failures .
ab33t is offline  
Old 20th Dec 2009, 15:11
  #3 (permalink)  
Join Date: Aug 2004
Location: Melbourne, Australia
Posts: 8,109
With respect, I suggest that there are no old accidents, all are worth studying.

We continue to make exactly the same errors, aided and abetted by better technology, with exactly the same outcomes.

I'm beginning to think that the current rag is politically correct. I'm also of the opinion that perhaps the reason the articles are oriented towards GA pilots is because the current culture of CASA would not encourage commercial pilots to provide examples of learning from mistakes.
Sunfish is offline  
Old 20th Dec 2009, 19:17
  #4 (permalink)  
Join Date: Mar 2008
Location: Australia
Posts: 149
Agreed, the study of past accidents is helpful, but alone is not the answer. It is easy to read about an accident and say I won't do that because look what happened. It is harder to look at ones own discipline and change the way we think.

For instance, why is it that in Australia there is still a large number of fuel related incidents/accident every year. There are plenty of digests still around about these kinds of accidents but still it happens.

In closing, my belief is that digests are only helpful if we ask ourselves, How can I reduce the risk of that happening to me, rather than, I won't do that if it happens to me?

To all have a very MERRY XMAS, FLY SAFELY and HAVE FUN.
Zoomy is offline  
Old 20th Dec 2009, 20:26
  #5 (permalink)  
Join Date: May 2006
Posts: 399
"Safety" is a word written in blood.
slamer. is offline  
Old 20th Dec 2009, 21:15
  #6 (permalink)  
Join Date: Jul 2000
Location: London
Posts: 1,263
We make the same mistakes because we are the same humans.
4Greens is offline  
Old 20th Dec 2009, 23:24
  #7 (permalink)  
Join Date: Dec 2001
Location: YMML
Posts: 2,496
Agree here. My goal is to never make it into a crash comic. Agree also the new FSA is somewhat sanitised. Agree also also that Mac Job had the right stuff.
OZBUSDRIVER is offline  
Old 20th Dec 2009, 23:58
  #8 (permalink)  
Join Date: Dec 2005
Location: Oz
Posts: 468
Lessons from past accidents to the current pilot generation

Probably the most obvious lesson (missed by piliaks,skulls and governments) is that you cannot legislate safety.

Many have tried, all have failed.

If they had been successful nobody would be killed on our roads!

The other lesson would seem to be that accidents continue to happen. This is inspite of many eminent people (Reason, Lee etc) teaching us why and how we fail as "the human machine"

FSA is a damaged brand, best dumped and a new start made.

tipsy2 is offline  
Old 21st Dec 2009, 00:58
  #9 (permalink)  

Join Date: May 2003
Location: Enroute
Posts: 624
The systems have changed,, but people stay the same.

Any accident is worth reading - there are lessons from all.

What Can You Learn from Accident Reports?

by Gerry Binnema, Civil Aviation Safety Inspector, System Safety, Pacific Region, Civil Aviation, Transport Canada

A lot of people who work in aviation like to read accident reports. The reports serve as good reminders that aviation can be dangerous and that we always need to be vigilant. But if we were all being completely honest, sometimes we read them because it makes us feel smugly superior to the people who messed up. So, how much do we really learn from reading accident reports? Surprisingly, there has been very little research to see if accident reports actually have any positive effect on the people reading them. It seems very obvious that accident reports would be helpful, but there are a number of things that interfere with our ability to learn lessons from them.

Our brains process information and organize it before it is presented to our conscious attention. This processing follows certain relatively predictable patterns, which serve to help us understand the world around us. However, this processing can also distort our view of things, as information gets processed in such a way as to protect our self-esteem and our confidence. The patterns of processing that are very relevant to our understanding of accident reports are hindsight bias, attribution error, and invulnerability.

Readers will recall Heather Parker’s series of articles on the "new view" in the past three issues of the Aviation Safety Letter (ASL). In these articles, she described hindsight bias and attribution error. These concepts also apply when we are reading accident reports. By way of a brief review, hindsight bias refers to our tendency to look back at events and believe the events should have been predictable beforehand. A classic example of hindsight bias is the Monday-morning critique of the weekend’s sporting events by armchair athletes. The coach should have anticipated the other team’s strategy. They should have known that the goalie would get re-injured if they put him in so soon. In reality, as we try to anticipate what will happen next, there are many different potential outcomes and we make the best decision we can with the information that we have available. As we read an accident report, we already know how the flight ends, and so we tend to judge all the decisions that led up to the accident with hindsight bias, believing that the pilot should have known better.
Attribution error refers to our tendency to overestimate the contribution of personal factors when we observe other people’s errors. This means that when we see other people making a mistake, we tend to believe that their errors are a result of their own inadequacies (ignorance, incompetence, laziness), rather than a result of situational factors. Even when a situation arises over which the pilot had no control, we still tend to believe that they were at fault for allowing themselves to get into that situation.

Invulnerability refers to our tendency to believe that bad things will not happen to us. Of course, there are hazards all around us, so in order to enjoy life we suppress our fear and deny the possibility that anything will happen. But an unrealistic sense of invulnerability actually places us in danger. Young people, especially males, have higher levels of invulnerability, and this can be observed in the number of accidental injuries and deaths among young males. A strong sense of invulnerability will prevent us from taking the lessons of an accident report to heart.

In combination, these three factors make it easy to read an accident report and learn very little. It would be almost natural to believe that the pilot should have known better, that their errors were caused by their own ignorance or incompetence, and that this kind of thing could never happen to you.

I recently had an opportunity to conduct some research to see if accident reports were having an impact on readers. Eighty-nine college aviation students participated in the study by completing a questionnaire, and then six weeks later reading an accident report and completing another questionnaire. The questionnaire was intended to measure invulnerability and attribution error.

The participants’ responses to the questions on invulnerability showed very clearly that they did not believe they could be in an accident. The participants also clearly demonstrated a willingness to place the entire responsibility for an accident on the pilot, even when a number of situational factors contributed to the accident. However, the most interesting finding was that there was a remarkably consistent, but small, decrease in the measures of invulnerability immediately after reading an accident report. This means that reading an accident report does have an impact on the reader and does help to make a pilot think about their vulnerability to an accident.

The participants read one of two accident reports. One was a typical accident report format, while the other was written in a narrative format, describing the unfolding events from the pilot’s perspective. Both report formats achieved the same level of change in invulnerability. However, the latter format was able to build sympathy for the pilot so that participants who read this style of report were more likely to believe that they could commit the same errors and be in a similar type of accident.
This is good news for those of us who read a lot of accident reports. It really does give us a more realistic sense of the fact that we could be in an accident if the wrong set of circumstances hit us. In addition, earlier research (see http://psy.otago.ac.nz/cogerg/Rememb...ses%20Past.pdf) conducted in New Zealand, and repeated here in Canada, demonstrates that we do recall lessons from accident reports while in flight. However, in order to make the most of these lessons, we need to keep some things in mind. Here are some practical suggestions for reading accident reports:

• Be aware of the fact that hindsight bias and attribution error do alter your perspective on an accident. As you read a report, think about how the unfolding events might have appeared to the pilot. Think about the decisions the pilot made, and try to ignore the fact that they resulted in an accident. Could you have made the same decisions? What circumstances might have led you to those decisions?

• Be aware of the fact that the majority of people have an unrealistically optimistic belief about the probability that they will be in an accident. Ask yourself if you are really being as cautious as you should be.

• Finally, as you read an accident report, remember that the pilot’s actions made sense to them at the time. If you cannot make sense of the actions, you do not understand the situation as the pilot understood it. Try to step into the pilot’s shoes and see if you can build sympathy for their predicament. Could you fall into the same trap? Could some external pressures or stresses cause you to behave in this way?

• If we all use this kind of strategy as we read accident reports, we are more likely to learn valuable lessons from them, and this may prove to be the critical piece of information in some future decision you need to make. In the next issue, I will look at how to apply these same ideas to the way organizations think
Jet_A_Knight is offline  
Old 21st Dec 2009, 01:58
  #10 (permalink)  
Join Date: Jun 2001
Location: Victoria
Age: 58
Posts: 984
Have a look at the books written by Macarthur Job (spelling?).
The accidents I refer to are from the 30's to the post-WW2 period. After reading those very well written articles, I occasionally think that maybe we haven't learnt as much as we should.
Perhaps these books should be compulsory reading when studying for a license.
Captain Sand Dune is offline  
Old 21st Dec 2009, 03:06
  #11 (permalink)  
Join Date: May 2006
Location: Canada
Posts: 67
I have neither the time to make all the errors already made that resulted in those " old" incident/accident reports, nor the skills required to get myself safely out of all of the different situations that arose from the sequence of events that led up to those reports being written. Little snippets of "hangar chatter" about those "close calls" have stopped many of us from lining up the last couple of holes in the cheese slices. Even when an incident report is 50 years old, reading it may just place a small paragraph in the library of our minds that comes to the fore when it's needed.
Or is learning about ones craft no longer fashionable?
Codger is offline  
Old 21st Dec 2009, 04:12
  #12 (permalink)  
Join Date: Feb 2009
Location: dans un cercle dont le centre est eveywhere et circumfernce n'est nulle part
Posts: 2,606
Those who cannot learn from history are doomed to repeat it.

The Australian Aviation Safety Digest is a vital, part history of our aviation heritage. The stratagy by which it's non availability to all by the current safety authorities is a proof of their lack of a safety strategy.
Frank Arouet is offline  
Old 21st Dec 2009, 04:20
  #13 (permalink)  
Man Bilong Balus long PNG
Join Date: Apr 2002
Location: Now stewing on the fact that due to this Gottverdammt Covid-19 curse I am not returning to Japan this year, or going anywhere for that matter! So just continuing the search for that bad bottle of Red!
Age: 65
Posts: 2,582
The Australian Aviation Safety Digest is a vital, part history of our aviation heritage. The strategy by which it's non availability to all by the current safety authorities is a proof of their lack of a safety strategy.
Well put Frank! If the producers of the FSA magazine wish to have their publication taken as anything other than the pathetic joke that it currently is, then serious consideration should be given to reprint a couple of reports from old editions of the ASD in each future edition of FSA.

Though I would prefer a return to the ASD format in its entirety!
Pinky the pilot is offline  
Old 21st Dec 2009, 06:20
  #14 (permalink)  
Join Date: Jul 2000
Location: London
Posts: 1,263
Readers may rember the Sioux city complete loss of hydraulics accident. Having studied that I decided that if faced with a similar situation I would practice a great deal more before trying a landing. Also, if available, probably a calm sea water landing. Plenty of runway, no line up problems and little chance of fire.

Botany Bay in Sydney would be ideal; lots of rescue and facilities available.

That is how one can learn from reading accident reports. Fortunately I never had to try it out
4Greens is offline  
Old 21st Dec 2009, 08:05
  #15 (permalink)  
Join Date: Mar 2003
Location: NSW Australia
Posts: 2,407

Probably the most obvious lesson (missed by piliaks,skulls and governments) is that you cannot legislate safety.
Obviously you don't understand. ICAO and now CASA have made safety compulsory.

Much in the same way as Operators must have an operations manual to conduct operations,

safe operations must have a safety management manual to be safe according to the Civil Aviation Safety authority.

If you fail to understand this, comrade, you will be sent to Siberia for re-education.

...oh hang on... you're already in Tropical Siberia...
Horatio Leafblower is offline  
Old 21st Dec 2009, 09:58
  #16 (permalink)  
Join Date: Jul 2007
Location: in the classroom of life
Age: 51
Posts: 6,876
Bring back the old crash comic younger folk like me ( ) have not seen enough of them.

The newer articles seem to be watered down, or made politically correct or just simply do not call a spade a spade.

Jabawocky is offline  
Old 21st Dec 2009, 10:23
  #17 (permalink)  
Join Date: May 2002
Location: Permanently lost
Posts: 1,784
One of my favourite adages in aviation is: "Learn from the mistakes of others because you won't live long enough to make them all yourself". It is something I take quite seriously.

When I started flight training the ASD was delivered to all licence holders. I read it cover to cover and recall that it pointed the finger in no small measure at the culprit(s). Now days, the reports are not so pointed and tend to look at the multitude of reasons that an aircraft wound up in the position that it did. That is an improvement.

To give an example from a far from perfect memory, I remember the report on the BAC 1-11 that came apart in storms on a domestic flight in the USA. The cause, as stated in the ASD, was the pilots proceeded into a storm. What was overlooked in that report was that the pilots had come out of piston aircraft and were using the same technique to run a storm line. That crash led to huge modifications in the training of pilots transitioning onto jets.

However, quibbles aside, I did read the ASD avidly and I now tend to throw the FSA in the bin, often unread.
PLovett is offline  
Old 22nd Dec 2009, 03:37
  #18 (permalink)  
Join Date: Jun 2008
Location: South Pacific
Posts: 851
Morbid, I know, but I too have a 'Christmas' story. A long while back I was tasked to go interstate in a Baron to Canberra on Christmas Eve to pick up a young recently married Customs officer who had been involved in a fatal accident. Seems he had not long moved into a new house on the outskirts, and riding home on his scooter had come off where the gravel road started and cracked his temple on a rock. Was met at the airport by the hearse early on Christmas morning, we squeezed the coffin in and got away. Home by lunchtime, my girlfriend couldn't understand why we did it, but the parents who picked up the coffin had the saddest Christmas ever, and I still think of it at this time. Take care out there, - in the sky, and on the road..
frigatebird is offline  
Old 22nd Dec 2009, 06:04
  #19 (permalink)  
Join Date: Dec 2005
Location: Oz
Posts: 468

Just because CASA says so doesn't make it happen (or right).

One day somebody will take them to court for false advertising for they cannot be accused of being an Authority on Safe, Civil Aviation. They are regulators, nothing more, nothing less (quite a bit less actually). As we all know, being 100% compliant does not necessarily ensure safety. That though does not fit the CASA spin.

I too have a near complete collection of the ASD, even the mention of FSA in the same breath is an insult to the ASD, Mac and his colleagues that produced it.

tipsy2 is offline  

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off

Thread Tools
Search this Thread

Contact Us - Archive - Advertising - Cookie Policy - Privacy Statement - Terms of Service - Do Not Sell My Personal Information

Copyright © 2018 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.