The Anatomy of an Accident
Certain industries make it a practice to painstakingly dissect accidents and incidents to determine their causes. They know it will not bring the dead back to life, but they hope that by doing so, something that will protect the living may be learnt. One such industry is Aviation, and many pilots and passengers owe their lives to lessons learnt at the expense of others misfortune, through the systematic reporting of accident investigations in publications affectionately known as “Crash Comics”.The majority of aircraft accidents arise from pilot error, and not from structural failures of airframes or aircraft systems. This is partly due to built in redundancy in aircraft systems, where key instruments are duplicated to provide backup in the event of one failing, and because airframes are built to withstand substantially more stress than that expected from normal operation of the aircraft. It is also partly due to the variability of human capacities over time, and the tendency for complacency to gradually erode trained response to critical events. This is why the performance of airline pilots is constantly reviewed through inservice training and testing, often involving simulators.
A key finding from aircraft accident analysis is that accidents seldom arise from a single cause. They usually require the failure of multiple systems before an accident occurs. The reports often show for example that clear warning signs were ignored by either engineers or flight crew in certain critical decisions, then perhaps compounded by an environmental factor, while the pilot was distracted by a systems failure. No single element would have given rise to an accident, but because all three contributing factors arose in conjunction, an accident became inevitable. This implies that any risk assessment must take into consideration not simply the risk posed by a factor in isolation, but also its potential to contribute with other factors within the same environmental context to produce a compounded hazard.
This practice of review and publication within the aircraft industry not only creates a culture of learning and adaptation, but it also allows hazardous practices and dangerous equipment to be identified and corrected by other operators in the same industry, or within the same organization, before an accident occurs. Much of this activity is precautionary, and is probability based, rather than evidence based. This is partly because airframe faults can be difficult to detect without partial disassembly, or specialist testing, with x-ray equipment for example. Operator errors might be dealt with by changes to methods of pilot training, or if necessary, the redesign of cockpit ergonomics.
The important feature of this culture is that it actively seeks to learn from experience, even if that experience is adverse and painful. It does not seek to protect the public reputation of the industry by hiding the causes of accidents, although there have been incidents where individual corporations have falsified records in the attempt to hide company errors or omissions from investigators. The result of this willingness to acknowledge and learn from past mistakes is an industry with an excellent safety record, and one which generally enjoys the trust of the public.
This contrasts sharply with the safety practices at our school, where it appears the reputation of the School and the Department of Education and Training takes priority over potential improvements in safety that might be gained from the objective analysis of accidents and incidents, and the development of a transparent culture, willing to learn from adverse experience. Instead we appear to have a culture of denial, selective reporting, and misreporting of incidents and accidents which allows breaches of contract by service providers to go unreported, misconduct by staff to go unchallenged and corrected, substantial damages to arise, while potential causes of catastrophic outcomes remain intact and undisturbed.
posted by kwoll @ 8:39 PM
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