Highly educational report on Swedish military crash
"The INTRODUCER"
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Highly educational report on Swedish military crash
I read the report and feel that there were operational & equipment issues that could lower efficiency, it is sad when this leads to a single persons death.
There are numerous points that sprang to mind whilst reading report, all helmets had damage & none appeared to be within the Manufacturers recommendation? how many of us in the commercial world have helmets that are old, damaged , or plain don't fit?.
The lack of reflective patches on immersion suits, the failure of personal Epirbs etc is a lesson to us all.
I have said for years instrument panels were drawn by artists rather than a user, perhaps it is me but the layout of most is designed to confuse.
I am not saying even if all items had worked 100% the outcome would have been different, just find it sad that people who put their life on the line for others have to use inferior equipment,
There are numerous points that sprang to mind whilst reading report, all helmets had damage & none appeared to be within the Manufacturers recommendation? how many of us in the commercial world have helmets that are old, damaged , or plain don't fit?.
The lack of reflective patches on immersion suits, the failure of personal Epirbs etc is a lesson to us all.
I have said for years instrument panels were drawn by artists rather than a user, perhaps it is me but the layout of most is designed to confuse.
I am not saying even if all items had worked 100% the outcome would have been different, just find it sad that people who put their life on the line for others have to use inferior equipment,
This is one of the more interesting reports that has been issued for a number of years - the reason? The lack of evidence resulting from an accident at night, without close eyewitnesses (in one case earwitness) and an absence of of Flight Recorders (the subject of earlier recommendations).
In the absence of operational and technical data, the investigators were limited to the post mortem and forensic analysis that they do so well. Because there was a lack of direct evidence, the investigators spent a great deal of time looking at the (lack of) operational, training and mangement procedures that were the inevitable precursors to this accident - the so-called 'Latent Conditions'.
The conclusions reached in this report have a much wider reach than this single accident, or the Swedish Military. The current emphasis on Safety Managent Systems and Risk Analysis demands that operators take a look at their present operations/procedures and identify and remove/mitigate existing hazards.
More, there is a need for Change Management to ensure that the identification of hazards is a dynamic (continuous improvement) and not static (once only) process. One particularly congent observation was that changes in management/systems does not lead immediately to accidents (although it might lead to instant improvement by culture change). Hence the observation by Wiegman and Shappell in their HFACS papers that the latent conditions need not manifest themselves for weeks, months or even years.
If you are pushed for time start with Chapter 2.14 but be sure to read all of it eventually.
Jim
In the absence of operational and technical data, the investigators were limited to the post mortem and forensic analysis that they do so well. Because there was a lack of direct evidence, the investigators spent a great deal of time looking at the (lack of) operational, training and mangement procedures that were the inevitable precursors to this accident - the so-called 'Latent Conditions'.
The conclusions reached in this report have a much wider reach than this single accident, or the Swedish Military. The current emphasis on Safety Managent Systems and Risk Analysis demands that operators take a look at their present operations/procedures and identify and remove/mitigate existing hazards.
More, there is a need for Change Management to ensure that the identification of hazards is a dynamic (continuous improvement) and not static (once only) process. One particularly congent observation was that changes in management/systems does not lead immediately to accidents (although it might lead to instant improvement by culture change). Hence the observation by Wiegman and Shappell in their HFACS papers that the latent conditions need not manifest themselves for weeks, months or even years.
If you are pushed for time start with Chapter 2.14 but be sure to read all of it eventually.
Jim
