Airline Pilot Forums

Airline Pilot Forums was designed to be a community where working airline pilots can share ideas and information about the aviation field. In the forum you will find information about major and regional airline carriers, career training, interview and job seeker help, finance, and living the airline pilot lifestyle.




View Full Version : Just Culture Accident Model


ptarmigan
10-08-2017, 11:40 AM
This paper proposes that the concepts developed for Just Culture may provide an avenue to broaden the scope of accident investigation and move away from the “blame” outcome of most reports through the use of a simple Just Culture algorithm to mitigate cognitive bias on the part of the investigator. Absent a formal strategy, cognitive bias has a high probability of occurring, and becoming integrated into the investigators subconscious during the early stages of an accident investigation. Just Culture is becoming widely accepted, and as such the transition to integrating an investigative model utilizing the concept should be easier to implement and may encounter less political push back than some of the more complex approaches proposed in recent years, yet still provide a robust path to causality and human factors aspects that is more comprehensive than that offered through the traditional models that are still in use by most organizations.
https://airlinesafety.blog/2017/10/07/just-culture-accident-model/


UAL T38 Phlyer
10-08-2017, 12:19 PM
It already exists at many airlines, by different names: FSAP, ASAP, or NASA's ASRS.

ptarmigan
10-08-2017, 12:30 PM
It already exists at many airlines, by different names: FSAP, ASAP, or NASA's ASRS.

I am well familiar with those, in fact, helped write a manual for ASAP. I think you're missing the topic of this article. None of those things do what this proposes.


rickair7777
10-08-2017, 03:41 PM
ASAP is more of a forcing function which simulates just culture where none exists, ie square peg in round hole.

FAA's new compliance philosophy is more along the lines of just culture.

ptarmigan
10-08-2017, 04:20 PM
ASAP is more of a forcing function which simulates just culture where none exists, ie square peg in round hole.

FAA's new compliance philosophy is more along the lines of just culture.

Agreed. The concept of this paper came after witnessing early bias in a number of investigations I was party to. Overcoming it becomes really difficult if not caught early so I wanted to develop a "back pocket" method that could be easy to apply to help offset that.

cardiomd
10-12-2017, 06:54 PM
ASAP is more of a forcing function which simulates just culture where none exists, ie square peg in round hole.

FAA's new compliance philosophy is more along the lines of just culture.

Exactly. I'd not discount ASAP which helped pave the way.

The 'paper' was 16 pages of nothing new, but I guess the good people at FIT need to present stuff, but I don't think we need another buzzword. Compliance Philosophy is a very good thing and may very well save lives.

That being said, I find a lot of people use "compliance philosophy" to think that there is complete impunity or blamelessness. Sorry, you still can suck as an aviator, even if the system sets you up to fail (e.g. AF447). The paper's use of US1016 or DAL191 are very good examples of good pilots doing what they thought was right with the info they had and are nice case studies.

Thanks for posting.

rickair7777
10-12-2017, 08:55 PM
Oh I'm not knocking ASAP, I'm a satisfied customer. Just saying it's not the same as just culture, or safety culture.

ptarmigan
10-13-2017, 12:48 PM
Exactly. I'd not discount ASAP which helped pave the way.

The 'paper' was 16 pages of nothing new, but I guess the good people at FIT need to present stuff, but I don't think we need another buzzword. Compliance Philosophy is a very good thing and may very well save lives.

That being said, I find a lot of people use "compliance philosophy" to think that there is complete impunity or blamelessness. Sorry, you still can suck as an aviator, even if the system sets you up to fail (e.g. AF447). The paper's use of US1016 or DAL191 are very good examples of good pilots doing what they thought was right with the info they had and are nice case studies.

Thanks for posting.

I am sorry you think that the AF447 pilots just "suck", as when you dig deeper you'll find the same sort of gaps in knowledge got them as happened with the DL191 and US1016 crews. Exactly the same, actually. And that is the problem.

As for the paper, it is not about Just Culture per se, but a specific issue that needs to be addressed during the field phase of an accident investigation.

Adlerdriver
10-14-2017, 06:21 PM
I am sorry you think that the AF447 pilots just "suck", as when you dig deeper you'll find the same sort of gaps in knowledge got them as happened with the DL191 and US1016 crews. Exactly the same, actually. And that is the problem.
What “knowledge gap” is associated with a fully qualified A-330 pilot somehow deciding that a continuous full aft stick input was appropriate? Isn’t that more indicative of an individual deficiency rather than some systemic issue? How many of us here have ever encountered a situation flying a modern transport category aircraft in which they made a full deflection nose up pitch input and held it?

Beyond the mishandling of the aircraft, another major factor in this accident was the FBW flight control and ergonomic setup of the Airbus family of aircraft. Could anyone really see this happening in any aircraft with a yoke in front of both pilots being held full aft for almost the entire duration?


This seems like a very specific problem that you want to make into a general one.

ShyGuy
10-14-2017, 08:35 PM
What “knowledge gap” is associated with a fully qualified A-330 pilot somehow deciding that a continuous full aft stick input was appropriate? Isn’t that more indicative of an individual deficiency rather than some systemic issue? How many of us here have ever encountered a situation flying a modern transport category aircraft in which they made a full deflection nose up pitch input and held it?

Beyond the mishandling of the aircraft, another major factor in this accident was the FBW flight control and ergonomic setup of the Airbus family of aircraft. Could anyone really see this happening in any aircraft with a yoke in front of both pilots being held full aft for almost the entire duration?


This seems like a very specific problem that you want to make into a general one.

Don't start. He's got a book to sell :D


But on a serious note, to answer your question yes it happened on a Boeing 757. BirgenAir Flight 301. It took off with the CA pitot only blocked by a mud dauber (wasp) insect colony/eggs. The standby and FO airspeeds were accurate the entire time. Despite the mis-match airspeeds at 80 knots, the CA continued. Once airborne, the CA side airspeed goes up like an altimeter and got a high speed warning and rudder ratio. Once the nose pitched up high enough the stick shaker and low speed cues came. CA was super senior, FO was super junior and so was the SO/relief FO. The two only made minor suggestions to the CA about the problem and what to do (serious CRM issues). Both FOs seemed to know what was wrong but didn't intervene. Again, only the CA side airspeed was faulty. Standby and FO airspeed were both accurate the entire time. Long story short, the CA pulled back the yoke, got the stick shaker, continued pulling, and no one reduced the AOA. One engine failed in the high AOA situation, the other one still at full power, and it went into a spin. No one lived, worst death toll of a 757 crash ever. 189 fatalities.

So it has happened on a Boeing. The yoke feedback is useless if the FO doesn't feel empowered to takeover and actually do something about it....

Adlerdriver
10-15-2017, 10:37 AM
But on a serious note, to answer your question yes it happened on a Boeing 757. Hardly the same thing. One, I seriously doubt the captain pitched the aircraft in the attempt to control his erroneous airspeed using full aft stick and held it. Two, since both crew members were able to see his yoke, they were fully aware of what he was doing with it (regardless of whether they agreed with the inputs or felt like they could say anything). Three, I wasn't suggesting that a pitot-static malfunction has never lead to an aircraft loss.

My point was simply that the other crew members on AF447 had no idea that Bonin was holding full aft stick. That would not be possible or at least extremely unlikely on another aircraft type.

ShyGuy
10-15-2017, 07:39 PM
Hardly the same thing. One, I seriously doubt the captain pitched the aircraft in the attempt to control his erroneous airspeed using full aft stick and held it. Two, since both crew members were able to see his yoke, they were fully aware of what he was doing with it (regardless of whether they agreed with the inputs or felt like they could say anything). Three, I wasn't suggesting that a pitot-static malfunction has never lead to an aircraft loss.

My point was simply that the other crew members on AF447 had no idea that Bonin was holding full aft stick. That would not be possible or at least extremely unlikely on another aircraft type.

Perhaps :)

As for a pitot-static accident, there was a Northwest Orient 727 out of New York that was empty except the crew and the pitots were blocked (due to ice IIRC) and all 3 airspeeds acted as altimeters and read high values. The crew commented this must be because they were so light. They continued pulling back, stalled, they were above 10k feet but couldn't recover and ended up crashing.

You are correct that the Airbus design did help to mask what Bonin was doing. I'm just not convinced the outcome would be different for *sure* , given Boeing crews that have crashed due to either 1 or all 3 pitots blocked (BirgenAir and Northwest Orient crews, respectively).

Adlerdriver
10-16-2017, 12:34 PM
Shy,
It really doesn't seem like we're on the same page. I understand that there have been pitot-static failures resulting in hull losses. Yes, Boeing crews can (and have) put their aircraft out of control (why not thrown in Aeroperu 603 for good measure). However, I think the rather benign flight path and nature of the flight control inputs required to lose control of the AF447 aircraft from cruise altitude are considerably different from any of the accidents you mentioned.

I have to strongly disagree with your opinion that this specific accident could have happened in a non-Airbus aircraft. Let's just say Boeing for the sake of the discussion, especially since I've only flown Boeing and Airbus. The main thing I think you're not considering is the nature of the stall warning system on a Boeing.

The AF447 crew exceed the flight envelope in less than one minute from the initial auto-pilot disconnect. This was achieved via persistent full aft stick input by the PF in spite of multiple audible voice stall warnings. These stall warnings eventually stopped due to system logic. Consider the ease as which an Airbus pilot can bring the pitch control input to full aft. A simply tilt of the wrist aft with a relatively short travel to the aft stop, barely perceptible to his crew member in the darkened cockpit.

In order for a Boeing pilot to do the same thing, the PF would have to apply considerable back pressure, bringing the yoke in close proximity to his abdomen as well as the PNF's for more than a minute. Impossible to ignore, IMO. Additionally, once the stall warning activated, the presence of the stick-shaker would be continuous. Also practically impossible to ignore, unlike a voice warning that can be tuned out as events increase the saturation level of the crew.

In my opinion, it took some extreme and persistent misapplication of the flight controls to place that A330 outside it's flight envelope in a deep stall. I just don't see that being possible in most aircraft equipped with a conventional flight control configuration and stall warning system.

ptarmigan
10-19-2017, 05:18 PM
The aircraft stalled prior to full aft stick. You are also ignoring the flight control logic which would apply full aft elevator regardless of stick position once it starts to lose altitude (absent pushing forward which would require knowing you were stalled). Depending on the failure mode (look up integrated modular avionics) you could get the same in the Boeing, and in both cases it can result in full nose up trim for the horizontal stabilizer with no pilot input.

METO Guido
10-20-2017, 06:39 AM
Problem is, airplanes just don't understand Just Culture. Pitch angles above 15 degrees can't be sustained at FL350.

ptarmigan
10-21-2017, 06:18 AM
Problem is, airplanes just don't understand Just Culture. Pitch angles above 15 degrees can't be sustained at FL350.

"In social psychology, the fundamental attribution error (FAE), also known as the correspondence bias or attribution effect, is the claim that in contrast to interpretations of their own behavior, people place undue emphasis on internal characteristics of the agent (character or intention), rather than external factors, in explaining other people's behavior. The effect has been described as "the tendency to believe that what people do reflects who they are".[1] " (https://en.wikipedia.org/wiki/Fundamental_attribution_error)

Adlerdriver
10-21-2017, 09:17 AM
The aircraft stalled prior to full aft stick.. Would it have stayed stalled if he let go? From what I read, the deep stall developed as a direct result of his post-stall continuous aft stick input (commanding the elevator to trim full nose up). Correct?

You are also ignoring the flight control logic which would apply full aft elevator regardless of stick position once it starts to lose altitude (absent pushing forward which would require knowing you were stalled). Must be some strange Euro-logic. Without a target altitude to maintain and the auto-pilot off, why would flight control logic command full aft elevator in response to altitude loss? If a crew clicked off the A/P at cruise and began to descend, is that going to trigger full aft elevator?

METO Guido
10-21-2017, 10:31 AM
"In social psychology, the fundamental attribution error (FAE), also known as the correspondence bias or attribution effect, is the claim that in contrast to interpretations of their own behavior, people place undue emphasis on internal characteristics of the agent (character or intention), rather than external factors, in explaining other people's behavior. The effect has been described as "the tendency to believe that what people do reflects who they are".[1] " (https://en.wikipedia.org/wiki/Fundamental_attribution_error)
I'm a golfer, believe me, I know. Had my head up the caboose once or twice in the airplane too. Okay, maybe more than twice. Which is why we rely on the other guys/gals to set us straight. Sometimes..pitch, bank, yaw and power; that's all you get.

https://s1.postimg.org/2tpfnx42pr/The_Duke.jpg (https://postimages.org/)

ptarmigan
10-22-2017, 02:14 AM
It is a function of C* law. Both Airbus and Boeing it is g-dot command at higher speeds/altitudes, vs theta-dot (pitch rate) when slower/lower. Hence neutral stick is attempting to hold 1-g flight.

One of my concerns is that we don’t teach this stuff so pilots really do not have an understanding to the point they can anticipate what the automated systems will do.

ptarmigan
10-22-2017, 03:10 AM
Would it have stayed stalled if he let go? From what I read, the deep stall developed as a direct result of his post-stall continuous aft stick input (commanding the elevator to trim full nose up). Correct?

Must be some strange Euro-logic. Without a target altitude to maintain and the auto-pilot off, why would flight control logic command full aft elevator in response to altitude loss? If a crew clicked off the A/P at cruise and began to descend, is that going to trigger full aft elevator?

Prior to stall entry the correct answer would be “it depends”. Early on, probably not, as it got closer, likely yes.

On the second question, on a constant rate descent you’re at 1-g so that is fine, it is responding to the change, g-dot, not steady state case.

ptarmigan
10-22-2017, 06:07 AM
Prior to stall entry the correct answer would be “it depends”. Early on, probably not, as it got closer, likely yes.

On the second question, on a constant rate descent you’re at 1-g so that is fine, it is responding to the change, g-dot, not steady state case.

More directly, once the initial correction to the indicated altitude error was made it would have taken direct input to prevent it.

METO Guido
10-23-2017, 06:32 AM
More directly, once the initial correction to the indicated altitude error was made it would have taken direct input to prevent it.
Yeah well, hard lessons, this line of work has them in spades. Don't really know where Just Culture begins and ends. But there are some things I know a pair of wings won't do for you. Sustaining lift at that deck angle, weight and altitude being one of them. Pure conjecture on my part, this is a pilot and crew that refused to accept they had to come down, no longer within the boundaries of controlled flight. The aforementioned complications of restricted manual flying and only then, exclusively through augmented joy stick pointers coupled to thrust levers that don't move, probably didn't help.

Ever observe guys using procedures trainers or FTD's that aren't intended for maneuvers yet they persist & somehow manage do a pretty fair job of flying the thing? Pilots don't fly like FMS algorithms, they use control authority as presented or remaining available and put the airplane where it must be given present circumstances. In other words, get it right, whatever it takes.

Ernie Gann and the Duke. Never thought I'd see the day their influence departed Just Culture.

ptarmigan
10-23-2017, 07:44 AM
The use of Just Culture as proposed is just a tool to try to dig deeper than "they screwed up" at the early stages of a major investigation.

The problem with the AF447 scenario (which got conflated into this thread) is that it is a lot harder to understand what is happening when you're in the situation than it is when you are reading about the event timeline while knowing the outcome.

METO Guido
10-23-2017, 08:59 AM
The problem with the AF447 scenario (which got conflated into this thread) is that it is a lot harder to understand what is happening when you're in the situation than it is when you are reading about the event timeline while knowing the outcome.


I believe that for sure. So how's what occurred important to me? Know your target pitch & power settings verbatim. IVSI pegged down, altimeter winding down, buried in a warning avalanche, "WHO HAS CONTROL?"

Very much appreciate the valuable time given explaining the framework of opinions shared. I read posts to learn, pushing into the corners sometimes to find out if there's more. Happy landings, gentlemen.

ptarmigan
10-23-2017, 11:40 AM
I believe that for sure. So how's what occurred important to me? Know your target pitch & power settings verbatim. IVSI pegged down, altimeter winding down, buried in a warning avalanche, "WHO HAS CONTROL?"

Very much appreciate the valuable time given explaining the framework of opinions shared. I read posts to learn, pushing into the corners sometimes to find out if there's more. Happy landings, gentlemen.

Yes, but add learn what stalls really look like, learn aerodynamics, understand intimately your airplanes systems, including the Flight control system and control algorithms, learn meteorology and how to get the most out of the Weather avoidance equipment installed in your airplane.

Yes, your company SHOULD be training all of this. Don’t hold your breath, you may actually die waiting!



Search Engine Optimization by vBSEO 3.6.1