Flawless operation or a Mishap Free Operation: What Should You aim for?

It has been said, “You seem to be convinced that a flawed world can be actually made flawless.” My response is this. Human error is part of our nature. However we can make our own flight operations mishap free by remembering Miller’s Rule for Safety Management: ALL SAFETY IS LOCAL. Any one safety manager cannotContinue reading “Flawless operation or a Mishap Free Operation: What Should You aim for?”

Just Culture: 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.Continue reading “Just Culture: Why is Jailing Pilots a surprise?”

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.Continue reading “Flawed Investigations?”

Flaw Free or Mishap Free Operations?

We can forecast by learning from the mishaps of other organizations. We learn by observing the mistakes that are made. That being said, I would add that we actually have a more superior ability to observe these mistakes as they are made on the line and before they contribute to a mishap. Did you knowContinue reading “Flaw Free or Mishap Free Operations?”

How the NTSB, FAA and BEA Add to the Aviation Disaster Tragedy

Safety Mishap Investigations are intended to prevent the same mishap from ever happening again, from ever reoccurring. But what often really does go on during the investigations conducted by NTSB, FAA, BEA, ATSB and other national boards around the world? Here is my opinion, here is a look into what often goes on in theContinue reading “How the NTSB, FAA and BEA Add to the Aviation Disaster Tragedy”

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 sumsContinue reading “AF447 Investigation Fails to Deter Future Mishaps”

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 ofContinue reading “AF 447: Proof of Incomplete, Possibly Incorrect Investigation?”

AF447 again and again?

AF447 will undoubtedly reoccur again and again because the aircraft mishap investigation board failed to discover the cause of the mishap and instead blamed the mishap on the crew. Not only is this an inaccurate and unsubstantiated conclusion, it is also a conclusion that is misinformative. No airline reading this report will be able toContinue reading “AF447 again and again?”

Is Your Safety Investigation Local?

The information gathered from a local investigation to determine ‘what went wrong and how do we prevent it from recurring’ needs to be local. There is a tendency to defer investigations to higher authority, most likely because the local safety managers just do not have the equipment to analyze the DFDR and other technical records.Continue reading “Is Your Safety Investigation Local?”

Go Arounds, Missed Approaches and variations?

I would like to suggest that each reader spend a few minutes thinking about how many different procedures that their airline or aviation organization has for conducting a missed approach and/or a go around. Your first reaction might be “Just one.” But take another minute and consider the variations. Each aircraft type has a slightlyContinue reading “Go Arounds, Missed Approaches and variations?”