Human Error and Training

I certainly can see why airlines with good safety records have vigorous training programs, and in many if not in most cases of mishaps, if not in all cases, human error should be found as the cause of the mishap. Let's examine the AF Toronto mishap. Human Error: crew continued approach and landing during adverse wind field encounter. Crew did not brief a runway that had failed to have been grooved by the national airport authority contractor, presuming dry runway - like stopping performance.
I would bet dollars to donuts that the Toronto AF flight crew training program DID NOT include a segment of approach briefing covering whether or not the runway was grooved, porous friction coated or not grooved. [by the way this information is on the 10-9A page]. And yet wet runway stopping and control performance degradation is a commonly known hazard. Yet look at the investigation and you will see virtually all the blame heaped upon the flight crew, with little or no mention of this severe training deficiency. Also if the crew was trained and certified upon dispatch by AF and French CAA, why did they continue their approach to land into an adverse wind field generated by convective weather occurring in the approach corridor? Were they acting in accordance to the procedures for which they had been trained and qualified? Yet no where in the investigation do you see any questions raised about AF convective weather avoidance procedure training and why is that?

For a safety investigation to have any merit, it must identify what went wrong and what steps can be taken that will prevent the mishap from recurring. Why do so many airlines have their pilots "practice to proficiency" the windshear go around procedure, auto and manual?
Why do so many airlines require their flight crew, by procedure to brief whether or not the landing runway is grooved or not? How could any airline operating be oblivious to the notes on 10-9A about grooving? How could any airline not make this information an element of the approach runway briefing?

How could the Canadian national airport authority contractor make a decision to not groove their main instrument runway in their biggest city, or any runway in the country for that matter, and ICAO and not one other global safety authority object? How is it that ATSB could complete their investigation and not cover these subject areas? Is it possible that the humans on the ATSB made an error? Of what use is their report? What steps did they recommend to prevent the re-occurrence of this same mishap?

Is it possible, just possible, that what the ATSB really did was conduct a legal and administrative investigation where they found fault and laid blame for the damage and injury, but never really found the cause and recommended the actions to prevent a re-occurrence?

Lastly, the purpose of training is to put a crew together, working as a team, using standard operating procedures, designed to give crew members a pretty comprehensive set of well practiced actions to deal with whatever is expected to be encountered. The argument that no one can not make no mistakes is irrelevant. When you look at any and all of the major airline mishaps, the crew made massive errors, the crew did not trap the error and correct each other (two heads are better than one theory of CRM.)

I am not arguing the academic argument of purity from error. Rather I am arguing the very practical argument that a crew well trained in well written procedures will be able to handle just about anything that it encounters.

In the mishap reports that I have read, not only did one crew member make an error, but moreover other crew members did little or nothing to trap and correct the procedures in use. Take the Amsterdam B737-800 mishap where the crew allowed the aircraft to stop in the air and fall out of the sky. What kind of procedures were those? Where was the training to proficiency program for that airline?

Flawed Investigations?

I cite a flawed investigation as the cause for re-occurrence because in aviation you have one chance to get it right. If you connect coincidental events together but then label them as "causation" you will fool all the people some of the time. An example is placing pilot error as the cause, when in reality when the pilot reported for work, was assigned the flight and climbed into the seat, he/she was "fully qualified" according to the FAA, the company and any other regulator. If that pilot made a pilot error as gross as stalling the aircraft on final and not recovering, the pilot, a product of the company and FAA training and qualification program to me, appears to be untrained and unqualified in this area. Since most would consider this area of flight procedures to be a skill critical to safe flight it would appear to me that the training and qualification program was deficient. Failing to correct the training and qualification program in my mind would be an example of a flawed investigation, wherein I would expect a same or similar mishap to occur at some time in the future at that airline, or to similarly trained and qualified airmen.

If you miss this opportunity to get the investigation right, then you can pretty much expect that the next pilot, similarly trained and qualified, facing similar circumstances to make the same mistakes. The purpose of the investigation is to find these flaws and recommend training to overcome this skill deficiency.
Look at how we all do windshear recovery training to proficiency now. Too bad the pilots at Kenner, Kennedy, DFW, Charlotte and other places did not have that training. We are lucky that we had Dr. Fujita and the training that resulted from his models and those of NCAR in the 1980's.

Why is Jailing Pilots a surprise?

Does not the person in charge of any vessel or organization bear some legal responsibility? If so, why would anyone be surprised to see a pilot jailed following an accident? Are we really just seeing the terribly weak legal profession just beginning to realize how much work has gone undone in the past 70 years?

If in an accident, lives are lost and property is destroyed, why wouldn't victims, survivors and claimants seek some form of compensation?

Is it really the accident investigation profession which has been dropping the ball all these years? Has ICAO really taken all the action that it could to actually promote safety and promote learning from investigations?
Or has the case really been made year after year that it is the pilots who made the errors and that is all the blame that we need to know about?

So finally everyone is reading these atrociously poorly prepared and written accident reports and noting what was written so often.

For years airlines, the FAA and NTSB has been laying all blame on pilots, often those deceased in the mishap, and directing attention away from ATC, manufacturers, the weather guessers, airport operators, and everyone else. So here we are in 2011, surprised and complaining.

And yet even as we write this blog, the BEA has issued a scathing reproach of the AF447 pilots who could not decipher the cryptic puzzle presented before them, struggled to save their own lives for several minutes before perishing. No where in the report is any mention made of the responsibility of the dispatch office to advise of foul weather, of the manufacturer to sell good equipment, of the airline to verify that the equipment works, of ICAO and other agencies to keep updating all technology for the benefit of the flight crew. A passenger sitting in row 24 on that airbus could have accessed the internet and obtained the most up to the minute satellite pix, but the flight crew had on board pix probably over 4 hours old.
How fantastically ridiculously inaccurate weather data process could anyone ever invent? Make a copy of the last sat shot an hour before brief time, have it ready for the crew who show up an hour and a half before take off and give them one hour old data. By the time they take the runway, the data is 2 1/2 hours old. At three hours into the flight the data is 5 1/2 old.
But wait, isn't the entire life cycle of convective weather defined as a matter of minutes, may be an hour tops? Doesn't convective weather around the tropics often build at 4000 to 6000 feet per minute?
So how could 4-5 hour old weather ever be considered accurate or useful data for safety purposes? Wouldn't the airline and their dispatch office know this? Why would the official weather guessers not offer more accurate weather data, some form or method of updating that sat pix in flight to the flight crew????????????

Oh yes the passenger in 24E has the latest sat shot on his PC.

So I can easily see why ICAO and BEA and everyone else are so determined to blame the pilots and not give a seconds care about what might happen to passengers tomorrow who might be in similar jeopardy.

Do you not think that the same mishap cannot happen tomorrow, think harder. It can and it will.

AF447 Investigation Fails to Deter Future Mishaps

It is with great sadness that I note the issuance of BEA's recommendation for new data streaming requirements for all pax acft.
In other words, BEA is saying, "To help us reduce our costs in locating the next accident site, we would like all of you to stream your DFDR."

Well, that pretty much sums up what BEA expects- many more mishaps. This is a terribly failed approach to a Safety Investigation of such a serious nature.

Rather, BEA should be devoting themselves to ensuring that this mishap never happens again. Plain and simple.

AF 447: Proof of Incomplete, Possibly Incorrect Investigation?

What is the purpose of a Safety Investigation of an aviation disaster?

The answer is simple and singular: the purpose of a Safety Investigation is to determine what happened and what actions can be taken to ensure that the event does not reoccur?
This is the simple and singular purpose of a Safety Investigation of an aviation disaster.

Pilot associations and other line pilot advocates world wide have been asking the question, "Has the BEA's investigation of the AF 447 aviation disaster met the purpose of a Safety Investigation?"

Has the BEA's investigation asked and answered the question, "What happened and what actions can be taken to ensure that the event does not reoccur?"

It is the opinion of pilot associations and line pilot advocates that the BEA's investigation is incomplete in this regard and possibly incorrect as a result.

It appears that the question that BEA was asking and answering was, "Who was at fault and who is responsible for damages?"

Why is that important? Are the two statements of inquiry really just the different versions of the same question?

Well, actually no, not at all.

The question of "Who was at fault and who pays for the damages?" is not a safety question at all. Rather this is legal question. It addresses English Common Law negligence and compensation. The investigation does not seek to prevent further occurrences of the same event. Rather, it seeks damages for negligence.

Meanwhile the safety question, "How did this happen and what actions can be taken to ensure that the event does not reoccur?" actually does not appear to be addressed completely by BEA.

Why is this statement important? The answer is simple. Every other airline flying an aircraft manufactured by this manufacturer has been reading the BEA report over and over again. But have they found anything in the report that they can take action on to prevent this event from occurring to their operation?

If the answer is not totally and completely yes, then the investigation is incomplete and possibly incorrect.

Prevention by Investigation vs AF 447 Blame Game

If prevention of a mishap similar to the one being investigated is not the purpose of the safety mishap or incident investigation, then what is the purpose of the investigation?
If the purpose is to level blame, for one party to escape blame, to shift blame to someone else, to share blame with other parties, well then that investigation is a lawyers investigation, a damages investigation, an insurance investigation- but it is not a safety investigation. Remember that a safety investigation is purposefully tasked with determining the cause so that a prevention process can be developed to keep the event from reoccurring.
Where has the AF 447 investigation taken us in terms of prevention?
Is the investigation really living up to its purpose?