Accident investigation and PPRuNe (Discussion)
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...and is still needed, apropos his comments early last-year regarding SMS and the de-regulation of safety oversight in Canada: Safety cuts risk air disaster: Judge - Toronto Star, March, 2007
However, it seems like Transport Canada is implementing SMS as a replacement for the existing system, outsourcing its safety responsibilities, as it were. Indeed, this was the message from Merlin Preuss at CASS 2006... from memory (so don't call this a quote or anything)... that fiscal constraint at the regulatory level and the expansion of the aviation industry have made SMS a necessity. Basically, TC doesn't have enough money to accomplish all of the regulatory activities they are charged with carrying out.
However, this was the principal thrust of Judge Moshansky's conclusions following the Dryden inquiry: that the downsizing of government in the 80's (at least in Canada), aka "fiscal restraint", and at the same time de-regulation of the industry leading to an explosion of growth in necessary certification activities (everybody and his brother was opening a new airline at the time), led to a situation which allowed the Dryden accident to occur. Reading the Moshansky report is a real eye-opener.
Right now, based on the Dryden experience, it looks like we may be seeing the foundations being laid for a future accident, which with hindsight (like with almost every accident) everyone will say was preventable if only sufficient funds had been invested, etc.
SMS is not a bad thing, but I think it's being implemented for the wrong reasons, or rather some people are using it to further goals which are not necessarily safety-related.
Right now, based on the Dryden experience, it looks like we may be seeing the foundations being laid for a future accident, which with hindsight (like with almost every accident) everyone will say was preventable if only sufficient funds had been invested, etc.
Placing a commercial enterprise motivated only by profit in charge of "expensive" safety processes will inevitably put such processes (and resources) at risk in terms of financial support and focus.
The operation becomes one of patch-work, ad-hoc crisis-management activities instead of one guided by a properly implemented, correctly resourced and fully utilized SMS program. In large airline operations the problems multiply because communications of "expensive" priorities tends to be pushed out by stronger commercial, (cost-control) messages. Short-term commercial goals do not support long-term planning of safety programs which tend to cost a great deal of money but produce "nothing" in return that can be shown on a balance sheet. If for example safety data is "inconvenient", (ie, will result in demonstrable commercial losses if acted upon), that data can tend to be "set aside" or quietly forgotten in the daily pagaent where "next!", is all-important. Resourcing safety programs faces such internal opposition as you may know and box-ticking becomes the solution.
Such traditional approaches only prevent the second accident, as you mention in the quote above.
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Here's the irony. Corporations like to say that they are ultimately responsible to their shareholders, which is true to a certain degree (but that's a whole different discussion). Shareholders as individual people care about airline safety... nobody wants to die in an accident. But. Shareholders as investors start selling when profits go down. When enough people sell and not enough buy, the share price goes down (basic market forces). When share prices go down long enough, CEO's get the boot. Now it's true that CEO's don't ultimately decide everything that goes on in a corporation (the all-seeing, all-powerful CEO is mostly a myth), but they do set the tone. So when a CEO fears for his/her job, and decides that profits are more important, this sets the field for the rest of the organization; it filters and percolates down through the whole management structure, right down to the janitor. The corporation as a whole will therefore go to great lengths to keep share prices up, including trading safety for short-term commercial gain. Ultimately, it comes down to individual shareholders sending a mixed message: they say they want safe travel, but they aren't willing to pay for it, as shown by the action of selling when profits go down. What's a poor CEO to do?
What's a poor CEO to do?
What that CEO needs to do is to listen to hisher "canaries-in-the-mine" with an active, open ear.
S/he needs to know where the long-term risks to profit (and even the organization's mere existence) are, send out the message to employees first, that inappropriate risk will not be tolerated, enact a protective safety reporting policy that is responsive, accept that mistakes will be made but that they will be made on the side of caution not risk, educate the shareholders that while aviation is a business with risk associated with it that such risk is being robustly managed in a healthy, fully-supported manner (upon which s/he comprehends and can intelligently report) and finally invite the media in to show how well the organization is managing the business in all it's aspects and not just the eye-candy-for-shareholders-and-passengers side.
Truth plays well in today's corporate environment but few CEOs are willing to risk public displays of safety conciousness because of the perception of "protesting too much". In my view, honesty and dealing straight is a better strategy...up to a reasonable point. It's part of the business, but so is all the rest and rightly so.
Now....tall order I know, especially with the last point regarding the media. But in Canada, a newspaper series last year took the industry strongly to task for ignoring this aspect of the travel business. Airlines reaction was defensive, sometimes to the point of emotive rather than rational response and it made them look as though they were hiding things. The public is smart and deserve better.
So long as the message is, "cost is king and profit is first", employees and shareholders alike will assume that safety is being looked after under SMS and will prioritize accordingly until a very bad surprise awakens everyone to the truth. Unless awareness and then change in the form of balanced priorities occurs, that is the path we are on at present - it is only a matter of time.
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I agree.
Research has shown (see for example a book called "The Addictive Organization", can't remember the authors sorry) that organizations work in both the top-down sense (CEO setting the tone) as well as the bottom-up sense. What this means is that organizations will tend to reflect the personalities and goals of the people who make them up. So in order to change the way the organization deals with safety, it's necessary to change the way each person in the organization deals with safety. Eventually, this kind of change works it's way into the decision-making process and the SOPs of the company. This is why one of the major points of SMS is that safety is everyone's priority. SMS is more than a system to be implemented, it has to be a cultural change. I like to think of it as the difference being going on a diet to lose weight, and actually changing your eating and exercise habits. The first works short-term, but you eventually put the weight back on and worse... the second is a lifestyle change and the effects are almost permanent.
I've actually gone through the exercise of pointing out minor safety issues which were completely outside my realm of responsibility, all in the name of "safety is everyone's priority" and was pleasantly surprised to find that I got a positive response and thank you from the people I addressed my concerns to. I found it a very encouraging sign.
Research has shown (see for example a book called "The Addictive Organization", can't remember the authors sorry) that organizations work in both the top-down sense (CEO setting the tone) as well as the bottom-up sense. What this means is that organizations will tend to reflect the personalities and goals of the people who make them up. So in order to change the way the organization deals with safety, it's necessary to change the way each person in the organization deals with safety. Eventually, this kind of change works it's way into the decision-making process and the SOPs of the company. This is why one of the major points of SMS is that safety is everyone's priority. SMS is more than a system to be implemented, it has to be a cultural change. I like to think of it as the difference being going on a diet to lose weight, and actually changing your eating and exercise habits. The first works short-term, but you eventually put the weight back on and worse... the second is a lifestyle change and the effects are almost permanent.
I've actually gone through the exercise of pointing out minor safety issues which were completely outside my realm of responsibility, all in the name of "safety is everyone's priority" and was pleasantly surprised to find that I got a positive response and thank you from the people I addressed my concerns to. I found it a very encouraging sign.
Just a couple of coments relative to the new twist in this thread.
Typically an oversight body audits the safety process from time to time. Under Continued Airworthiness Part 39 its the likes of the FAA, CAA, etc. etc. The process must be acceptable to them, else you could lose yout TC.
Of course its true about bean counters, counting beans, but the safety process should have been adequately funded and staffed in the first place to pass it's audit.
Then we have the top dog or CEO. This guy really worries about public perception and getting hammered in both the board rooms and cocktail parties and when things go wrong he's worse then a sea captain in holding underlings accountable for safety. If there's any negative pressure against safety it's more likely to come from middle management if you can define that level.
Typically an oversight body audits the safety process from time to time. Under Continued Airworthiness Part 39 its the likes of the FAA, CAA, etc. etc. The process must be acceptable to them, else you could lose yout TC.
Of course its true about bean counters, counting beans, but the safety process should have been adequately funded and staffed in the first place to pass it's audit.
Then we have the top dog or CEO. This guy really worries about public perception and getting hammered in both the board rooms and cocktail parties and when things go wrong he's worse then a sea captain in holding underlings accountable for safety. If there's any negative pressure against safety it's more likely to come from middle management if you can define that level.
Typically an oversight body audits the safety process from time to time.
One of the major omissions in SMS is the process or at least the depth of process which investigates incidents and mishaps (thus lack of data or inaccurate data). These are the low level events which are often the precursors to more serious problems, but are rarely investigated in sufficient depth to identify the underlying contributor factors.
I cite the very good UK CAA (EASA) system of mandatory reporting (MOR). Again, my experience with several operators suggests that only a first level of investigation was used to close the report. This could be the reporters perception of the event (opportunity for flawed perception), that of the operator (opportunity for operational bias – keep the good name), or the safety/QA department – usually under time pressure or not equipped/experienced to undertake an in-depth analysis.
More surprising was the acceptance of this process by the CAA, where only rarely was there any follow up or questions to the manufacturer (aircraft or component) and apparently no independent investigation by the CAA; it was a data gathering system apparently without validation. Yet MORs were used as the basis for many safety initiatives; – flawed data?
There are similarities with ASRS, where the reward of immunity from punishment in the event of a transgression is often seen as immunity from investigation. Where there is some follow up, the process is also depends on the integrity/ability of reporter, who in keeping with human nature, may well provide reports/answers to match those expected by the question/industry e.g. altitude bust - ‘I was distracted’ – because that is an expected / acceptable answer without the difficulty of further explanation or deeper analysis.
Note the alleged erroneous safety assessment / report by NASA – they are involved with ASRS.
lomapaseo;
Yes, but "acceptable" must be a sufficently high standard and that is both a political decision as well as an operational safety one. For example, it is my belief that if an airline passes the IOSA process the issues raised by PEI_3721 as well as other issues still obtain and in my view safety is not fully served as per our expectations of what SMS is and what is accomplishes.
While the actual IOSA process is comprehensive in its structure the answers to the questions are, again in my view, not always the whole picture and where a thorough audit process is intended, a less-than-thorough one can result, where shortcomings are "noted" and changes and/or improvements made after the passing of the audit.
In short, while the structure of oversight is essentially an audit of documents and processes, examining that what actually happens within the airline is in accordance with the documentation is not part of the IOSA or TC process or is at best a surface examination. The details are left "in-house", and that is where the risk in SMS arises.
Under SMS, "everyone" is responsible for safety, which is complete nonsense and entirely impractical not to say a conflict of priorities. A flight operations manager simply does not become a safety "expert" or specialist overnight and is far more likely to default to old habits and priorities which are entirely cost and schedule-driven. Take for example, the complexities of implementing an FDA Program. Are line managers going to take such a project on? Not at all. If "everyone" is responsible for safety, where does the leadership come from to implement such fundamental programs? Where do the justifications for resourcing such programs come from and how do they survive when such audits accept box-tick FDA programs?
Perhaps the notion will mature but, like the MCPL notion, I think the accident rate will have to rise before the realities of these cost-control initiatives settle in to the statistics.
The process must be acceptable to them, else you could lose yout TC.
While the actual IOSA process is comprehensive in its structure the answers to the questions are, again in my view, not always the whole picture and where a thorough audit process is intended, a less-than-thorough one can result, where shortcomings are "noted" and changes and/or improvements made after the passing of the audit.
In short, while the structure of oversight is essentially an audit of documents and processes, examining that what actually happens within the airline is in accordance with the documentation is not part of the IOSA or TC process or is at best a surface examination. The details are left "in-house", and that is where the risk in SMS arises.
Under SMS, "everyone" is responsible for safety, which is complete nonsense and entirely impractical not to say a conflict of priorities. A flight operations manager simply does not become a safety "expert" or specialist overnight and is far more likely to default to old habits and priorities which are entirely cost and schedule-driven. Take for example, the complexities of implementing an FDA Program. Are line managers going to take such a project on? Not at all. If "everyone" is responsible for safety, where does the leadership come from to implement such fundamental programs? Where do the justifications for resourcing such programs come from and how do they survive when such audits accept box-tick FDA programs?
Perhaps the notion will mature but, like the MCPL notion, I think the accident rate will have to rise before the realities of these cost-control initiatives settle in to the statistics.
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The process of thinking about an accident has safety value; it can be equated to a safety audit on a specialist subject. This is also somewhat speculative, but can occur more quickly while the event is fresh in peoples minds (greater training effectiveness), and can be more proactive in looking ahead to avoid a similar accident, as opposed to a formal report of how to avoid the accident we have just had
I am all for immediate opinions on the possible causes of an accident because some of these may prove spot on. As a former aircraft accident investigator in the military many years ago, I had precious little effective training. I recall with embarrassment being sent to the scene of an accident armed with an old Poleroid camera, a note-book and bugger-all knowledge - in fact it was training on the job with a vengeance.
If Pprune and the internet been available in those days, I for one would be quickly scanning contributors posts to pick on a facet of the accident which had previously escaped me. As it was, with no CVR or FDR available then most of the time we made an educated guess on why a crash occurred.
Of course you may have to wear occasional uneducated points of view on Pprune pages but it takes only a quick scan to sort the difference between well thought-out discussions and the bogan element. Naturally the final accident report may prove some of us wrong - but I am sure most will be mighty close to the truth.
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PJ2:
I disagree in part with your statement here. I don't believe that the concept of everyone being responsible for safety is complete nonsense, nor do I see how it would necessarily be a conflict of priorities. While it's true that you can't expect anyone to become a safety expert overnight, why is it necessary to be an expert in order to make a legitimate contribution?
To make an analogy... I don't have to know the ins and outs of the city sanitation system to pick up a piece of stray trash and throw it in the trashcan. I could easily ignore the trash and let it accumulate, but if I've decided to make picking up the trash one of my priorities, no matter what I'm doing, then it can become second nature. On the other hand, relying solely on good samaritans to ensure a clean city is stupid.
I think what the concept of "safety culture" tries to avoid is the situation where people can tell themselves that it's okay to put aside the safety questions because there are "experts" in the system to take care of that.
Under SMS, "everyone" is responsible for safety, which is complete nonsense and entirely impractical not to say a conflict of priorities. A flight operations manager simply does not become a safety "expert" or specialist overnight and is far more likely to default to old habits and priorities which are entirely cost and schedule-driven. Take for example, the complexities of implementing an FDA Program. Are line managers going to take such a project on? Not at all. If "everyone" is responsible for safety, where does the leadership come from to implement such fundamental programs? Where do the justifications for resourcing such programs come from and how do they survive when such audits accept box-tick FDA programs?
To make an analogy... I don't have to know the ins and outs of the city sanitation system to pick up a piece of stray trash and throw it in the trashcan. I could easily ignore the trash and let it accumulate, but if I've decided to make picking up the trash one of my priorities, no matter what I'm doing, then it can become second nature. On the other hand, relying solely on good samaritans to ensure a clean city is stupid.
I think what the concept of "safety culture" tries to avoid is the situation where people can tell themselves that it's okay to put aside the safety questions because there are "experts" in the system to take care of that.
krujje:
Sorry, not communicating very well - my fault. "Everyone responsible for safety" doesn't exclude specialists of course, the assumption being that within the culture where everyone contributes and has a responsibility to make sure oneself and others don't "run with knives". I know you're aware but for the sake of discussion, many, including "the top", assume that safety is not doing unsafe acts, period. If we just don't do things that are unsafe, we'll be okay. We know this is isn't what a safety culture is however, not, at least, a full and operating one.
None of us wish an accident ergo we will act safely; - it is upon that foundation that such 'first-level" thinking is based and so far as it goes, it works and "the streets will be clean", to extend your metaphor a bit.
However, again to extend the metaphor, the streets ought not to be trash-ridden in the first place because we all (should) have an ecological awareness which prevents us from trashing our nest.
In fact, carry it further, and there should be no "trash" to dispose of in the first place, (I really don't want to take this thread too far away - but ever taken all the packaging off the groceries you've just come home from and returned it all to the grocery store? Quite a reaction...).
Now we know that this is ideal and likely unachievable but we all agree it's a worthwhile goal.
Safety specialists and targeted safety programs such as ASRS, LOSA, FDA/FOQA, AQP and so on present an "ecology of mind" (a culture with an ethic, if you will) within the safety arena in much the same way that the extended metaphor would have non-polluted streets, (etc etc).
I realize this is simplistic and there are all manner of rabbit trails and yeah-but's that could be pursued, (some more worthwhile than others) but I would like to convey that I believe that while safety is "everyone's business", such is not exclusive of the need for specialists. The mistake in SMS design is, in my view, that it lets the regulator off the hook except for an audit/oversight role, (substantially less involvement, ostensibly due to the need to lower costs), an initially naive view of what safety is all about by operations managers who are not accustomed to stopping an operation in the same way that the guys in the cockpit might and are instead mission-oriented, and an airline where costs drive all decisions and then, where overt and imperative, safety considerations, if not too expensive, are taken into account.
The above is not intended to be a controversial statement to elicit response - this is a complex topic and not all can be said that needs saying in one sentence - I fully realize that such a black-and-white statement is not exactly how it works. Airlines have enormous interests in preventing an accident and by design, their daily operations reflect this deep concern in a thousand ways which are transparent to the user because they are "the culture". We are discussing safety within a period of metamorphosis - from traditional approaches like kicking tin, into "SMS-like" approaches which encourage the collection and examination of flight data and incident reports so that prevention, not investigation, becomes the goal.
What I meant by my foreshortened statement was, where safety is "everybody's business" and the airline assumes that such work as necessary to "make things safe" is being done, it becomes extremely difficult to implement complex and expensive safety programs because the justifications are, as is the case with safety, very difficult to specify in an economic model that requires specific definitions of the problem, targets, goals and a business case to defend the budget. "Everybody" can't just do that so it falls to a now-dwindling group of safety specialists to lobby for, create and implement programs like FDA. If management isn't onside and the CEO has no idea what "FDA" (or some other such pnemonic) means, then such programs are almost impossible to implement let alone actually use in daily operations.
I do not believe that SMS, as presently constituted and being enacted in Canada, will do this and instead will render the safety environment less, not more effective. Critical safety data such as DFDR and QAR (FDA) data is not protected in law in Canada (in the same way the CVR is) so while SMS requires the collection of information, it may, (not necessarily will) be "available" to the courts via the "public interest" route. That is not an SMS culture that adheres to "what" not "who" - we have already had a case where data has been used in a criminal case in Winnipeg. Also, the CVR of an accident aircraft was listened to by the families of victims. There are those who are today pursuing via the OSH process, flight data for their own narrow, industrial (not safety) purposes.
I hope I am wrong but it is far too early to tell.
I don't believe that the concept of everyone being responsible for safety is complete nonsense, nor do I see how it would necessarily be a conflict of priorities.
None of us wish an accident ergo we will act safely; - it is upon that foundation that such 'first-level" thinking is based and so far as it goes, it works and "the streets will be clean", to extend your metaphor a bit.
However, again to extend the metaphor, the streets ought not to be trash-ridden in the first place because we all (should) have an ecological awareness which prevents us from trashing our nest.
In fact, carry it further, and there should be no "trash" to dispose of in the first place, (I really don't want to take this thread too far away - but ever taken all the packaging off the groceries you've just come home from and returned it all to the grocery store? Quite a reaction...).
Now we know that this is ideal and likely unachievable but we all agree it's a worthwhile goal.
Safety specialists and targeted safety programs such as ASRS, LOSA, FDA/FOQA, AQP and so on present an "ecology of mind" (a culture with an ethic, if you will) within the safety arena in much the same way that the extended metaphor would have non-polluted streets, (etc etc).
I realize this is simplistic and there are all manner of rabbit trails and yeah-but's that could be pursued, (some more worthwhile than others) but I would like to convey that I believe that while safety is "everyone's business", such is not exclusive of the need for specialists. The mistake in SMS design is, in my view, that it lets the regulator off the hook except for an audit/oversight role, (substantially less involvement, ostensibly due to the need to lower costs), an initially naive view of what safety is all about by operations managers who are not accustomed to stopping an operation in the same way that the guys in the cockpit might and are instead mission-oriented, and an airline where costs drive all decisions and then, where overt and imperative, safety considerations, if not too expensive, are taken into account.
The above is not intended to be a controversial statement to elicit response - this is a complex topic and not all can be said that needs saying in one sentence - I fully realize that such a black-and-white statement is not exactly how it works. Airlines have enormous interests in preventing an accident and by design, their daily operations reflect this deep concern in a thousand ways which are transparent to the user because they are "the culture". We are discussing safety within a period of metamorphosis - from traditional approaches like kicking tin, into "SMS-like" approaches which encourage the collection and examination of flight data and incident reports so that prevention, not investigation, becomes the goal.
What I meant by my foreshortened statement was, where safety is "everybody's business" and the airline assumes that such work as necessary to "make things safe" is being done, it becomes extremely difficult to implement complex and expensive safety programs because the justifications are, as is the case with safety, very difficult to specify in an economic model that requires specific definitions of the problem, targets, goals and a business case to defend the budget. "Everybody" can't just do that so it falls to a now-dwindling group of safety specialists to lobby for, create and implement programs like FDA. If management isn't onside and the CEO has no idea what "FDA" (or some other such pnemonic) means, then such programs are almost impossible to implement let alone actually use in daily operations.
I do not believe that SMS, as presently constituted and being enacted in Canada, will do this and instead will render the safety environment less, not more effective. Critical safety data such as DFDR and QAR (FDA) data is not protected in law in Canada (in the same way the CVR is) so while SMS requires the collection of information, it may, (not necessarily will) be "available" to the courts via the "public interest" route. That is not an SMS culture that adheres to "what" not "who" - we have already had a case where data has been used in a criminal case in Winnipeg. Also, the CVR of an accident aircraft was listened to by the families of victims. There are those who are today pursuing via the OSH process, flight data for their own narrow, industrial (not safety) purposes.
I hope I am wrong but it is far too early to tell.
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I am also uncomfortable with the "everyone is responsible" mantra. resposnsibility balances with authority; you can't be considered responsible for something which you have not the authority to address. Safety (at least in the short term) is expensive - though the comment "if you think safety is expensive, try having an accident" is very true. So the people "responsible" for safety must also have the authority to make the necessary allocation and diversion of resources.
Everyone can - and should - contribute to safety.
But responsibility lies at the top - and even if they delegate the conduct to middle managers and safety specialist, they are STILL, IMHO, "responsible".
My fear with the "everyone is responsible" idea is that it dilutes the real responsibility. By analogy, the Chief Constable is responsible for the conduct of his force; rolling out a "we are all responsible for keeping the streets safe" campaign dilutes his responsibility not one iota.
Everyone can - and should - contribute to safety.
But responsibility lies at the top - and even if they delegate the conduct to middle managers and safety specialist, they are STILL, IMHO, "responsible".
My fear with the "everyone is responsible" idea is that it dilutes the real responsibility. By analogy, the Chief Constable is responsible for the conduct of his force; rolling out a "we are all responsible for keeping the streets safe" campaign dilutes his responsibility not one iota.
Moderator
The thread has a few comments about moderation and site policy ..
It may be useful to revisit some aspects of forum ethos -
(a) PPRuNe is ours, collectively, to enjoy subject to the fact that others, elsewhere, own and accept risks associated with the operation of the site
(b) the folk at the top of the totem pole set the underlying tone but moderators are given a pretty long leash in how individual forums are administered
(c) in Tech Log, the basic idea is for minimal active moderation. This can only work if the contributing folk maintain a reasonably high standard of personal integrity and general behaviour .. as is the norm for the forum
(d) personal attacks will be subject to edit or deletion. Where individuals raise complaint (and we have folk varying from thick-skinned to very sensitive) there often is no simple solution
(e) if posts get too far toward the conspiracist swamps, probably we will pull on the reins a little .. there are other places where such discussions might be more appropriate
(f) the moderators are mindful that there can be a fine line between moderation and dictatorship
(g) hopefully we don't fall into the trap of excessively fancying the professional expert's over the knowledgeable and competent amateur's opinion .. as most experts will acknowledge, while the average expert has made far more mistakes than the average amateur ... he/she generally hasn't had time to have made all possible mistakes ...
(h) if a thread is not interesting, or gets too far into the silly side of things, generally it will die a quick, quiet death as it sinks into the oblivion of the archives ...
(i) an overarching concern is that of education and the need for subjects to be revisited to address the needs of the continual turnover in new chum PPRuNers ...
I guess what the above all means is that we are never going to get it "right" ... we will just try to keep it working away to the general benefit of the readership .....
It may be useful to revisit some aspects of forum ethos -
(a) PPRuNe is ours, collectively, to enjoy subject to the fact that others, elsewhere, own and accept risks associated with the operation of the site
(b) the folk at the top of the totem pole set the underlying tone but moderators are given a pretty long leash in how individual forums are administered
(c) in Tech Log, the basic idea is for minimal active moderation. This can only work if the contributing folk maintain a reasonably high standard of personal integrity and general behaviour .. as is the norm for the forum
(d) personal attacks will be subject to edit or deletion. Where individuals raise complaint (and we have folk varying from thick-skinned to very sensitive) there often is no simple solution
(e) if posts get too far toward the conspiracist swamps, probably we will pull on the reins a little .. there are other places where such discussions might be more appropriate
(f) the moderators are mindful that there can be a fine line between moderation and dictatorship
(g) hopefully we don't fall into the trap of excessively fancying the professional expert's over the knowledgeable and competent amateur's opinion .. as most experts will acknowledge, while the average expert has made far more mistakes than the average amateur ... he/she generally hasn't had time to have made all possible mistakes ...
(h) if a thread is not interesting, or gets too far into the silly side of things, generally it will die a quick, quiet death as it sinks into the oblivion of the archives ...
(i) an overarching concern is that of education and the need for subjects to be revisited to address the needs of the continual turnover in new chum PPRuNers ...
I guess what the above all means is that we are never going to get it "right" ... we will just try to keep it working away to the general benefit of the readership .....
MFS re “Responsibility” #54. Like many words used in aviation they have several meanings often dependent on the context of use or the user’s perspective.
The top down view which you present is one view, which IMHO is often associated with blame and often follows accident investigation.
An alternative view that I favour is to use the word ‘accountability’. This can be applied in a similar way as responsibility, but accountability looks more to the future, what can / should be done before an event and thus avoids aspects of blame.
Accountability might better fit the view that everyone is accountable for safety.
We are accountable to ourselves for our thoughts and behaviour, both of which have strong associations with safety; pilots are accountable for the safety of their crew and the passengers, and as such contribute to the safety of the operation. This line of thought continues upwards through management, regulation, and government; thus this is a bottom up approach to safety.
Accountability is another way of encouraging ‘grass roots’ involvement in safety – individuals are empowered to ‘own’ procedures, to report errors, be a catalyst for change. The bottom up flow of safety information is an opportunity to remind those who have the power to change procedures, funding, even influence cultures. Management can be reminded of their accountability – their “responsibility” downward to the grass roots.
Many of the better accident reports represent an upward view.
We cannot sit back and expect that management will make us safe (you were not saying that), but often this is a view held in industry and thus the grass roots do not engage with safety, they do not contribute. Apply this view to you police analogy; yes we can do something, perhaps not much, but we should at least engaged with the problem; if we don’t then the potential for complacency, indiscipline, and lowering standards in aviation could be mapped to an analogy of a changing UK society, PC, and failing law and order; and how is that accident going to be investigated.
Thus it is an appropriate reminder for everyone to remember that they are accountable for safety before the incident/accident.
The top down view which you present is one view, which IMHO is often associated with blame and often follows accident investigation.
An alternative view that I favour is to use the word ‘accountability’. This can be applied in a similar way as responsibility, but accountability looks more to the future, what can / should be done before an event and thus avoids aspects of blame.
Accountability might better fit the view that everyone is accountable for safety.
We are accountable to ourselves for our thoughts and behaviour, both of which have strong associations with safety; pilots are accountable for the safety of their crew and the passengers, and as such contribute to the safety of the operation. This line of thought continues upwards through management, regulation, and government; thus this is a bottom up approach to safety.
Accountability is another way of encouraging ‘grass roots’ involvement in safety – individuals are empowered to ‘own’ procedures, to report errors, be a catalyst for change. The bottom up flow of safety information is an opportunity to remind those who have the power to change procedures, funding, even influence cultures. Management can be reminded of their accountability – their “responsibility” downward to the grass roots.
Many of the better accident reports represent an upward view.
We cannot sit back and expect that management will make us safe (you were not saying that), but often this is a view held in industry and thus the grass roots do not engage with safety, they do not contribute. Apply this view to you police analogy; yes we can do something, perhaps not much, but we should at least engaged with the problem; if we don’t then the potential for complacency, indiscipline, and lowering standards in aviation could be mapped to an analogy of a changing UK society, PC, and failing law and order; and how is that accident going to be investigated.
Thus it is an appropriate reminder for everyone to remember that they are accountable for safety before the incident/accident.
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Airline flying is stunningly safe and despite the growing impact of third world operators and low cost airlines (and third world low cost operators) it seems to be getting even safer. Perhaps one reason is the fact that crash investigations are so public and that so many people take an interest in the details, amateurish or not .
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Originally Posted by twistedenginestarter
Airline flying is stunningly safe and ...... it seems to be getting even safer. Perhaps one reason is the fact that crash investigations are so public and that so many people take an interest in the details, amateurish or not
There is another factor. ICAO signatories are obliged to investigate (some) accidents and report on them according to a standard format. And most nations are ICAO signatories. I think minimal international standards play a role, even if they are minimal.
I took a couple weeks off to rethink my participation in PPRuNe, and was gratified to find this thread, which it seems I partially started. It also seems from moderator's comments as if the thread has been extensively pruned of immoderate comments. Let me say that there are professional safety people contributing to this thread and what is left after moderation represents a series of worthwhile comments.
Let me also state my interests. We (I and my coworkers) investigate inter alia aircraft accidents. Two of the recent accidents we have been asked to investigate have been of extensive interest to PPRuNers. The third one is a microlight aircraft accident. Interestingly enough, I believe the microlight accident contains the most significant lessons to be learnt about criminalisation of accidents. Those PPRuNers who are not aware of this trend are in my opinion well advised to inform themselves. I hope to be able to write about it, once official proceedings are concluded.
I welcome the interventions from PJ2 and alf5071h on "safety culture". I myself am not so particularly concerned with this aspect of safety, but I recognise its value, as do all safety professionals with whom I regularly correspond. In the microlight accident to which I referred, the lesson about developing a functioning safety culture is perhaps the most important lesson to be learnt. The big question is how to implement one.
And (of course) I would like to restate my original point that attempts from creative people to answer questions are helpful, no matter what the background of those creative people. Much of the Turkish MD-83 thread centered on where the impact point actually was. I suspect that those who found this discussion pointless (including, it seems, some moderators) have never been involved in the investigation of an actual accident. Stuff that should be banal is sometimes unusually hard to figure out. That is the way of the world.I suspect it will remain so.
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PBL:
I believe I've read some of your work, and found it quite insightful. I personally believe that the process of investigation is made more meaningful by varied, conflicting and sometimes combative discussion. Any contribution which is based on provable fact and logic should be admissible, regardless of the source.
This is a good point which should be remembered. The answers are not always so easy as reading out the data from an FDR and shouting "Aha!". I have been through an experience where the various parties involved could not even agree on what happened, much less why, and as far as I know still haven't. It was quite frustrating, needless to say.
I believe I've read some of your work, and found it quite insightful. I personally believe that the process of investigation is made more meaningful by varied, conflicting and sometimes combative discussion. Any contribution which is based on provable fact and logic should be admissible, regardless of the source.
Much of the Turkish MD-83 thread centered on where the impact point actually was. I suspect that those who found this discussion pointless (including, it seems, some moderators) have never been involved in the investigation of an actual accident. Stuff that should be banal is sometimes unusually hard to figure out. That is the way of the world.I suspect it will remain so.
I personally believe that the process of investigation is made more meaningful by varied, conflicting and sometimes combative discussion
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... but we manage to keep some of the more outlandish folk in line .. at least some of the time ..... fortunately Tech Log discussions generally tend to be goal oriented most of the time ...