Replying to LO24713 --
I would like AM de Lange to tell us some more about his reaction to the
ALPA letter about the South African air crash..
I ask because we are doing/have done projects with international airlines
and aviation regulatory authorities around issues to do with safety using
an organisational learning frame. The question of access to CVR tapes
following accidents is a defining issue in thinking about learning and
reflection as preventative processes.
Here in New Zealand there is currently a similar issue (although less
politically charged). A domestic flight suffered a CFIT accident
(controlled flight into terrain). Some passengers died, but the flight
crew survived. Subsequently the police seized the CVR tapes and the pilot
has been charged with manslaughter. The trial opens soon.
The issues about this, and the South African, story, are:
(1) If use of CVR tapes to ascertain flight crew culpability is permitted
(that is, as part of a blaming exercise), what impact does this have on
the use of the same tapes as data in a double loop learning exercise to
derive learnings (that is, as an accountability device)?
(2) If we make use of advanced technologies for monitoring individual
performance in aviation safety what counterbalancing processes can we use
to ensure that latent, systemic and organisational causal factors are
considered with equal rigour.
To declare my own hand - in my view the evidence is clear. The more that
aviation (or medical) misadventure investigations focus on the individual
and blaming, the more safety promoting information will be concealed, and
the more accidents there will be.
Phillip Capper
Wellington
New Zealand
[Host's Note: And... What can we draw from this for organizations and team
other that airline flight crews? In the US, the NASA Safety Reporting
System is a feedback of incident data to support learning. ..Rick]
--"Phillip Capper" <phillip.capper@webresearch.co.nz>
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