Sources:
School of Public and Environmental Affairs, Indiana University, MT, USA
Clinton V. Oster Jr.
Mason School of Business, College of William and Mary, Williamsburg, VA, USA
John S. Strong
School of Public and Environmental Affairs, Indiana University, 1315 E. Tenth St., Bloomington, IN, USA
C. Kurt Zorn
A LEGAL APPROACH
Classify each aviation
accident according to a SINGLE CAUSE after you having dissected the event chain
of failures.
There have been
decades of the misused term, LOSS OF CONTROL (in flight), to describe many written
real causes of aviation accidents in the Final Investigation Report, since such
term it overcharges the Pilot's onus and, legally prejudices the flight deck
crew.
It's because
categorizing every accident into a SINGLE CAUSE (the first event of the chain)
is now an absolute requirement (Judicially). The investigators have
responsibility to find 'what was the "atomic particle" of influencing
the LOSS OF CONTROL, not only writing a generalized "accusation"
without determining the first cause in the events chain, which it promoted to
end up in the accident.
Widespread "prosecution" of pilots is illegal as using the term LOSS OF CONTROL without the determination of the first event that started the events chain for resulting the LOSS OF CONTROL. Those investigated aviation accident concluded as LOSS OF CONTROL they could have occurred for another main cause, such as maintenance failure, engineering design, mechanical failure, or a running software routine error.
If the Final Aviation
Accident Investigation Report does NOT specify the first event that caused the
result, the Report must NOT synthetize the cause as LOSS OF CONTROL.
“Protected
Disclosure”
Protected Disclosure means any good faith communication that
discloses
• suspected
improper governmental activity (IGA), or
• any
significant threat to public/employee health or safety
PORTUGUÊS
"Divulgação Protegida"
Divulgação Protegida significa qualquer
comunicação de boa-fé
que revela
• atividade suspeita imprópria do governo (IGA),
ou
• qualquer ameaça significativa à saúde ou segurança pública/funcionário
Purpose of the Written Report
• To evidence a
timely and impartial institutional response
• To accurately
document the investigation conducted
• To provide
decision-maker with facts needed to decide the matter
• To ensure a
successful investigation
• To best defend
the investigation
The TOP-SET
headings:
T ime, Sequence and History
O rganisation / Control / Responsibility
P eople and their involvement
S imilar events
E nvironment and its effects
T echnology, equipment & processes
Loss of lives it
isn’t to be summarized on a mere wide-ranging technical aviation term, like
LOSS OF CONTROL. That’s vague statement.
Even vague
suggestion of Criminal Conduct may be defamatory Per Se.
Vagueness refers to a lack of clarity in meaning. For example, “Go
down the road a ways and then turn right” is vague because “a ways” does not
precisely explain how far one should go down the road.
Ambiguity is when there is more than one clear meaning, and it
is difficult to choose which meaning was intended. For example, “Paul went to
the bank” is ambiguous because bank could mean a river bank or a financial
institution. “He was cut” could mean he was cut from the team or he was cut by
a sharp object.
Another example:
“The stool is in the garden” is ambiguous because stool could mean poop or
chair.
A "acusação" generalizada aos pilotos é
ilegal. O acidente poderia ter ocorrido por outra causa, como falha de
manutenção, projeto de engenharia, falha mecânica e, erro de execução de rotina
de software.
Houve décadas do termo mal utilizado, PERDA DO CONTROLE
EM VOO, para descrever muitas causas reais escritas de acidentes aéreos no
Relatório de Investigação Final, uma vez que tal termo sobrecarrega o ônus do
Piloto e, legalmente, prejudica os membros da tripulação. É porque categorizar cada acidente em uma
ÚNICA CAUSA (o primeiro evento) é agora um requisito absoluto.
QUESTIONS ON REPORT TO BE ASWERED
- Who was
involved in the accident?
- What actually
happened?
- When it
happened?
- Where it
happened? And
- Why did the
first failure event take place?
When planes
crash, we want to know what happened. The good news is that there’s technology
available today that it would give us the answers. The bad news is that the
Federal Aviation Administration (FAA) has not
mandated that aircraft operators install it [the tech], citing privacy,
security, cost, and other concerns.
Commercial airliners
are required to have only flight data recorders and cockpit voice recorders,
commonly called “black boxes”, but the
NTSB has long called for cockpit image recorders, as well. Such video would
have been extremely helpful in determining flight crew actions in recent
crashes in Texas, Indonesia, and Ethiopia.
Part 121 regulations or under Part 135 regulations.
Airline
passenger service in aircraft with more than 30 seats has always been provided
under Part 121 regulations. Traditionally, scheduled commuter service with aircraft
with fewer than 30 seats and on-demand air taxi service has been provided under
Part 135 regulations.
The goal of the analysis
Not all
accidents are investigated by organizations with the resources or technical
expertise of the National Transportation Safety Board in the United States, the
Air Accidents Investigations Branch in the United Kingdom, the Bureau of
Enquiry and Analysis for Civil Aviation Safety in France.
For example, an
engine failure during takeoff where the crew fails to take the needed actions
to land the plane safely with the result of an accident.
If more
information is available for accidents in some sectors of aviation than others
or in some countries than others, then there may be a tendency to find more errors
in accidents where more information is available which could result in giving
those accidents more weight in aggregate statistics.
The analysis of
the example above should consider both the
engine failure and the improper crew
response as causes.
Approach to
classify each accident according to a SINGLE
CAUSE
An advantage of
this simplification is that it is possible to compare a much broader range of
accidents.
There are two
basic approaches to assigning a cause or causes to an accident.
FIRST - Why did
the engine fail?
SINGLE: Engine
failure would be identified as the cause of the accident.
The absence of
the factor that initiated the chain of events resulting in an accident, the
accident could have been avoided.
SECOND - Why
didn't the crew respond properly?
SINGLE: The
cause of the factor that initiated the sequence of events that culminated in
the accident.
I've called it
"the atomic particle of influencing crew error".
That is an
“unforced” pilot error rather than a failure to respond properly to an
emergency.
One approach
would be to assign the cause that was the last point at which the accident
could be prevented. Pilot error would be indicated as the cause of the accident
provided in the example above.
An example of
the approach of assigning multiple causes to an accident is the Human Factors
Analysis and Classification System (HFACS) developed originally for the
Department of Defense and more recently applied to civilian aviation accidents
(Shappell & Wiegmann, 2000).
HFACS has focused on aircrew behavior but
could also be applied to human factors in maintenance, air traffic management,
cabin crew, and ground crew.
In a
re-examination of the link between an airline’s
profitability and its safety record, Madsen (2011, p. 3) suggests that the
“strikingly inconsistent results” in the existing empirical literature are due
to an inflection point in the relationship between profitability and safety. His analysis “demonstrates that safety
fluctuates with profitability relative to aspirations, such that accidents and
incidents are most likely to be experienced by organizations performing near
their profitability targets” (Madsen, 2011, p. 23).
If an airline is
slightly below its profitability target,
it has an incentive to increase its risk
of accidents by spending less on safety. Or, if it is slightly above its target, a reduction in spending on safety can
have a significant effect on its ability to remain above the profitability
target. Conversely, when an airline is substantially above or below its
profitability target, the incentive to reduce spending on safety is
considerably less.
Investigating the link between maintenance and
aviation safety
Marais and
Robichaud (2012) look at the effect that maintenance has on aviation passenger
risk. They found a small but significant impact of improper or inadequate
maintenance on accident risk.
The effect that
aging aircraft may have on accidents and overall safety levels
In an
investigation of the effect the adoption of strict product liability standards
has had on the general aviation industry, it was found that liability insurance
costs for new planes increased significantly (Nelson & Drews, 2008).
The concept of
latent and active failure and considers four levels of failure:
1) unsafe acts
2) preconditions
for unsafe acts
3) unsafe
supervision
4)
organizational influences
Individual error
categories within each causal category (Wiegmann et al., 2005)
In one study of
human error in commercial aviation accidents, the results were reported
aggregated into 18 causal categories (Shappell et al., 2004). Not all accidents were included in the analysis,
only those where there was some error by the aircrew. The results were reported
as the number of accidents in the data set that were associated with one or
more of the error categories that make up each causal category.
Part 135 air
carriers operate smaller aircraft in both scheduled (often referred to as
commuter) and nonscheduled (often referred to as on-demand) service typically
into and out of smaller airports than those served by Part 121 air carriers.
Within the Part
135 industry, the distribution of accident causes for scheduled and nonscheduled
services are very similar, so they are not presented. However, the
distributions of causes for Part 135 accidents in Alaska services are
noticeably different than for service outside of Alaska.
For Part 135
service in Alaska, pilot error is even more prominent, accounting for 83
percent of both accidents and fatalities. The reasons for these differences are
also not understood.
The Swiss cheese theory
The “ Swiss
cheese effect ,” also known as the “cumulative act effect,” comes from the work
of James Reason, a British psychologist who analyzed systemic failure in terms of four levels of human error:
1. Unsafe
supervision
2. Preconditions
for unsafe acts
3. The unsafe
acts themselves
4. Organizational
influences.
The Swiss cheese model of accident causation
The Swiss cheese
model of accident causation illustrates that, although many layers of defense
lie between hazards and accidents, there are flaws in each layer that, if
aligned, can allow the accident to occur.
The Swiss cheese model of safety
The theory is that
the multiple layers of cheese represent a process safety system. If several
slices of cheese are stacked on top of each other, the hypothesis is that the
holes would not align, which would shield the beam of light, preventing a
hazard from passing through the layers (and resulting in catastrophe).
Human error theory
With human error
theory, a violation occurs when an individual
deliberately and knowingly chooses not to follow a guideline or rule. These
latter types of error are cognitive failures and are either due to actions not
going as planned (slips/lapses) or plans being inadequate to achieve the
objective (mistakes).
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