View Single Post
Old 09-10-2017, 05:17 PM
  #65  
ptarmigan
Gets Weekends Off
 
ptarmigan's Avatar
 
Joined APC: Aug 2006
Position: B777 Captain
Posts: 562
Default

Originally Posted by METO Guido View Post
Close to the same page here, I think? The crew in question more than proficient to standard, professionally expert even on approach to stall recovery, maneuver validation, textbook aerodynamic theory. They clearly knew enough about loss of lift due to relative wind/airfoil separation. What specific, panic classification blocked all three from working it out, given the time available, we can only guess at.

All I suggested was, a root cause of an accident may prove uncomplicated, examined in isolation. Drafting/approving a comprehensive fix that fits all sizes is, more often than not, complex as chit. Symposiums, sunshine meetings and white papers can serve a worthy function. As well a time and place for procedural revision based on clinical, human behavior discovery. Standardizing how we perceive, problem solve, advocate and correct for error, critical to all aspects of best practice operation. ASAP, SMS pillars, IOSA, all for it. But who better than you, line flight officers, to best determine if any of it really drives safety forward, out there day & night, slipping the surly bonds?
I would say that that the concept of "root cause" is entirely a human construct. Accidents these days are a complex interaction of many components that are not possible to separate out. They are also not linear event sequences (the idea that it is layers of cheese as Jim Reason once used, but even he disavowed later) is really just a domino model. With complex and highly coupled systems we see interactions that are very difficult to anticipate using conventional methods. This was actually the topic of a talk I co-presented at the ISASI annual seminar a few weeks ago. The conference paper is available on the ISASI website, here http://isasi.org/Documents/library/t...20Systems.docx
ptarmigan is offline