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Tag: blame
Aircraft Do Not Crash of Themselves.
“Aircraft do not crash of themselves.” Tough love? Too harsh? Nevil Shute did include designers and managers in his paradigm of human error. Quote from Slide Rule: The Autobiography of an Engineer, 1954.
This Hits Close
A new episode of the National Geographic Air Crash Investigation TV show, titled Killer Attitude is hard for me to watch. It describes the crash of a perfectly good Northwest Airlink Jetstream 31 from MSP to Hibbing, MN, on 1 December 1993. I was flying out of MSP that night, same airplane type, same airline. I knew the captain, Marvin. I remember …
Why Would a Ship Sail into a Hurricane?
This time last year the American ship SS El Faro went down in a hurricane with the loss of all thirty-three crew (Wikipedia page). It seems impossible ‘in this day and age’ that such a thing could happen. It wasn’t a mechanical issue, or a rogue crew, or pirates, or a freak storm. The Washington Post reported one of the …
Death Before Embarrassment
One of the best books written by a test pilot/astronaut is Carrying the Fire: An Astronaut’s Journeys by Mike Collins. He was a USAF test pilot, spacewalked on Gemini 10 and went to the Moon on the historic Apollo 11 mission. Here he talks about an interesting airmanship trap — Death by Embarrassment: It’s hard to admit a slip or …
It’s No Accident — It’s a Crash
Interesting article yesterday in the New York Times, titled ‘It’s no accident: Advocates want to speak of car ‘crashes’ instead’. It’s about safety advocates changing language use from a car accident to a car crash. The AP recently revised their style guide. Dr Rosekind of the US National Highway Traffic Safety Administration is on board, saying, “When you use the …
Airmanship at a Distance
This is a sad story. But important to think about. For we are all our brother’s keeper. The news headline this weekend was ‘Flight school sued over death of student‘. Fox5 reported: A 21-year-old’s dream of becoming a pilot was cut short when during flight school his plane came crashing down, killing him, according to a lawsuit filed Friday in …
Procedural Drift and the Sandbar
On 3 January 2015, the large ship MV Hoegh Osaka left the British port of Southhampton. An hour later she made a turn to port, then began listing markedly to one side. Soon enough the rudder and propellor were out the water. In flying terms, ‘departure from controlled float’ we could say. Fifteen minutes after the turn she was grounded on the …
How the Swiss Air Force Learns
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. …
We Will Not Accept Any Kind of Lapses
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 …