ptarmigan

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/2017/10/0...ccident-model/

UAL T38 Phlyer

It already exists at many airlines, by different names: FSAP, ASAP, or NASA's ASRS.

ptarmigan

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

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

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

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

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

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

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

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


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....