Flawed Investigations?

I cite a flawed investigation as the cause for re-occurrence because in aviation you have one chance to get it right.  You must gather the right facts, gather the right testimony, analyze the data, reach the correct conclusions and create recommendations for corrective actions. In the process you will find human error or human factors. This is where the mishap occurred. It was not the thunderstorm that caused the weather, it was the failure of the humans to avoid the thunderstorm that caused the mishaps, for example.

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 to inform us on how to react to inflight encounters with microbursts.


Published by Capt. Paul Miller

Aviation safety expert with 43 years in the sky

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