The unvarnished truth about all airline accidents

The following statements apply to all accidents involving all airlines flying all types of aircraft, whether people in them were hurt or not:

1. If the accident involves a big Western-built jet airliner with lots of people on it, it will either be an Airbus or a Boeing, because they are the only Western aircraft manufacturers left on the planet that make big jet aeroplanes.

2. Accidents do not happen because the aeroplane is an Airbus or a Boeing (or an Embraer or a Tupolev), they happen because of a combination of circumstances that often involves natural phenomena like bad weather or darkness (or both), sometimes involves a technical problem, and almost always involves human mistakes or frailties (plural).

3. The humans who made the mistakes will either have made errors of commission or omission (or both), and the errors can become contributory factors or directly causal – usually the former. The list of people (not exhaustive) who might have made a contributory mistake includes:  aircraft and aero-engine manufacturers: airframe, engine and avionics maintenance engineers; airline operations personnel; airport handling agents; cargo or baggage  managers; air traffic controllers; or pilots.

4. The part played by the corporate or departmental managers whose employees made the front-line errors or omissions might prove to be critical in an accident if the mistakes were the result of inadequate employee selection, training, supervision, or management communication (two-way).

5. Pilots are ”the system’s goalkeepers”. Their main job may be to aviate, navigate and communicate, but they also have to deal with the results of any failure at any point in the organisation upstream of them (see item 3). If the system bangs enough fast balls at them, they will eventually let a goal through, and the media will call it pilot error.

6. Prof James Reason (who invented the “Swiss cheese” model of organisational safety management) was right. Humans will inevitably make some mistakes, so to imagine you can prevent them completely is delusional. The optimum answer is to build a system that is error-tolerant, with multiple layers of defences that will identify and correct a mistake before it combines with other circumstances to become dangerous. That applies to both companies and to aircraft design. Pilots are the last line of defence against errors in either.

7. It is not at all rare for the cause of an airline accident to remain a mystery for a long time, especially if human factors are involved, which they usually are.

8. Accident investigators tend to establish lots of individual facts very quickly because it is easy to see what the result was, but the cause is usually not evident.

9. The flight data recorder and cockpit voice recorder (“black boxes”) are both very important to gaining a full understanding of precisely what happened and why it did. But if most of the wreckage, including critical parts like the flight deck, the engines and the control surfaces, is recovered, a great deal can be deduced without them.

 

 

4 Responses to The unvarnished truth about all airline accidents

  1. Breaking Wind 2 July, 2009 at 2:47 am #

    How about an 11th? If you cannot figure out what happened in an accident, go and look at data from other incidents. And the data will set you free…trick is to know where to look….

  2. Fweezabird 3 July, 2009 at 5:08 pm #

    Never mind an eleventh factor – how about a sixth factor?

  3. David Learmount 3 July, 2009 at 5:27 pm #

    Thanks Fweeza.

    I’ve made myself a little less of a hostage to fate, editing and other people’s good ideas by taking out the “ten commandments” connotation. The list is no longer decimal.

    If anybody comes up with additional valid generalisations about the nature of airline accidents and accident investigations I promise to add to the numbers without prejudice to how many items we end up with.

  4. Beck Nader 7 July, 2009 at 3:26 pm #

    Airbus launches initiative to reinforce flight data recovery capability.

    I think this should be an industry initiative and not only from Airbus. I think the regulator authorities should participate and help. At lest the automatic information that could enhance the understanding of the reason for an accident should be attempted (by this initiative) to be transmitted automatically.

    Safety must come first and although the the Western built types involved in accidents are subject to stringent regulations and norms, we all have learned that predictive models can some times fail and unpredicted conditions might have an important role in an accident.