accident

How the Swiss Air Force learns

By Dave English

A great Swiss Air Force video shows us all how an enlightened high risk organization should use mistakes to get better, by moving away from a blame game and towards a learning culture. If people get blamed for their mistakes, the only thing one achieves is that people will keep their knowledge about mistakes, safety gaps or dangerous situations for themselves. Ask “why?” like a mantra to get deeper and deeper to the cause, to put yourself into the actor’s shoes and to understand, why the event had been happen. Mistakes or incidents can be seen as free lessons. If we … Continue reading How the Swiss Air Force learns

We will not accept any kind of lapses

By Dave English

It became public this month that Qatar Airways has fired all four pilots in the cockpit when their Boeing 777 tail broke a set of runway lights during takeoff from Miami International last September. They mistakenly left from an intersection thousands of feet short of the planned full runway length. It was a serious accident, no doubt. There was a visible tear to the aircraft’s skin, the pressure vessel was damaged, and MIA airport needed some new approach lights. The crew continued with the overwater thirteen plus hour flight uneventfully, apparently unaware of their close brush with disaster. But damage of … Continue reading We will not accept any kind of lapses

Airport worker killed in “freak accident”

By Dave English

The Daily Express newspaper reports today that an airport worker was killed in a “freak accident.” He was sucked into a jet engine. Or as human factors professionals calls it, a “normal accident”. An Air India official told The Hindustan Times: At the moment, we are absolutely clueless on how this person was near the aircraft. Only an inquiry can establish whose negligence it was and whether the engine should have been switched on at that time.   Comforting to know the negligence witch-hunt has started. Someone must be at fault. Wonder if any management or regulatory people will get blamed for … Continue reading Airport worker killed in “freak accident”

“We’ll get that straight when we get airborne”

By Dave English

It’s better to look a little stupid now, than a lot stupid later. The US NTSB has released full investigative notes on last year’s crash of US Airways flight 1702, an A320 taking off from Philadelphia International airport. We can learn a lot from this crash of a fully airworthy Airbus. It actually got into the air, and then the captain decided to force it back onto the runway. There was substantial damage. It departed the runway. I’m glad all 149 passengers and 5 crew exited the aircraft via emergency exits with no serious injuries. But the jet didn’t look good: Airline … Continue reading “We’ll get that straight when we get airborne”

Blame the pilots?

By Dave English

Air Force Times article from two days ago sums up the results of a six-week investigation of the October 3rd bombing of a Doctors Without Borders hospital in Afghanistan that killed 30 people – Crew Blamed. However the news story also notes deeper systematic issues, a culture that places pilots into impossible situations. But you can’t discipline a procedure or a rule or a culture. And no general is going to fall on his sword when there are crew that can be blamed for their ‘human error’.  “The direct result of human error, compounded by systems and procedural failures.” Army … Continue reading Blame the pilots?