5 ms·

The FAA, NTSB, and airlines have made air travel incredibly safe over the years by operating the way you described.

CaptSpify 9y ago
I am by no means an expert on this subject so correct me if I'm wrong but.... The exception that I've noticed from the airline-industry, is that they actually want to solve problems systemically and don't care who has to take the blame. For something to go wrong, multiple failures have to happen, and there's not a lot of blame put on individuals, as much as "the process". In most other organizations, IME, fixing "the process" is expensive. It takes time, and effort, and it's quicker and easier to blame "those idiots in IT/accounting/HR/etc". Most of those types of organizations don't actually want to solve problems, they just want the problem to go away. So they end up choosing the easier option, rather than dealing with the problem systematically. /bitter rant
- jfoutz 9y ago
  NTSB, i think, no one takes the blame. For example, if the error is something like "Mechanic didn't tighten bolt to appropriate torque." So, what's wrong? maybe they forgot and need a checklist item? Maybe the reading on the wrench should be recorded in the log? should there be a second person that verifies? They know they ask a lot of people, and it has to be right, every time. People get sick, tired, distracted, whatever. we're people. People are the least reliable part of the system. I think blame only falls to a person when they've lied. Falsified a log, claimed to do something they didn't etc.
  - pbecotte 9y ago
    That's the thing. In the Air Force (at least)- there is no thought of cost/benefit analysis. A single machine fails once because a bolt wasn't torqued and causes $5000 of damage ... So they add the checklist item, and the second person, and an extra training item, and a log record that has to be maintained. The list of special rules and required documentation only ever gets longer. Eventually, you spend all your time on the checklists and maintaining the documentation, and none on actually doing whatever procedure you were originally messing with that bolt for.
    - stinkytaco 9y ago
      As someone who was a mechanic in the Army, I feel that checklists more often helped then harmed. Many mechanical problems we saw in the shop were easily attributable to an operator skipping a step on their PMCS. Doing something relatively dangerous or confusing could be error prone, especially for people who haven't done it much, and a checklist can help ensure the safety of everyone in the shop. A good example is running an engine indoors. Before you did it, there were a serious of steps you had to walk through before you turned it on, that reduced people getting sick from carbon monoxide quite a bit.
      - zimpenfish 9y ago
        "The Checklist Manifesto" is an -excellent- read on the helpfulness of checklists in preventing problems and mistakes (primarily from a surgeon and medical viewpoint but he covers airlines as well.) http://atulgawande.com/book/the-checklist-manifesto/ http://atulgawande.com/book/the-checklist-manifesto/
    - zentiggr 9y ago
      As a submarine fire control tech, I always thought it was cumbersome to have three full size binders open in my lap during weapon firing drills, casualty drills, everything except calm open water transit. But flipping those pages and grease pencilling things even while in the hot of prepping weapons to leave the tube avoided a LOT of "hurry up and whoops!" mistakes. Sometimes crufty stuff needs a review and rewrite but, n the whole, I'd rather know what happen wrong the previous times and avoid it myself.
- KGIII 9y ago
  I am not an expert but I know many pilots, watch only documentaries, read research papers almost exclusively, and have stayed in a Best Western. NTSB is, as far as I understand, actually very careful about not blaming anyone. They look for causes and solutions, not blame. They, as far as I know, pride themselves on this. They try, again inasmuch as I know, to not blame a person - but to blame a process. This is not a distinction without difference. It fosters an attitude of cooperation and openness. Again, I'm not an expert but I know a bunch of pilots and listen when they speak. If the NTSB blamed people, I suspect they'd have a lesser willingness to speak positively about NTSB. Edit: Someone beat me to it. I will leave this as I think it offers a bit more of a comprehensive view.
  - hueving 9y ago
    >They look for causes and solutions, not blame. They, as far as I know, pride themselves on this. If the cause is a person's behavior, that is the same thing as blame. Look at the report of the Pinnacle 3701. Probable causes from [1]: 1. the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship; 2. the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; 3. the pilots' improper management of the double engine failure checklist It's hard to look at that and say that the pilots weren't being blamed. 1. https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701 https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701
    - KGIII 9y ago
      It does happen, but is the exception. Look at the aftermath section. You can also look at the aftermath sections of other flights. Sometimes, a human is to blame and there's no getting around that. This doesn't change their goal.
    - ahhhhhhhhhh 9y ago
      The difference is the approach — they look for the cause and sometimes the cause is the blame. When you only look for the blame, you tend to be satisfied once you reach that goal and might ignore the cause.
- nradov 9y ago
  But unlike the NTSB, the military still routinely blames "pilot error" to cover up problems with terrible aircraft designs. http://www.military.com/daily-news/2016/01/29/billows-of-dust-a-sudden-pop-and-an-osprey-falls-from-the-sky.html http://www.military.com/daily-news/2016/01/29/billows-of-dus...
- matt4077 9y ago
  This kinda contradicts the idea further up that too much attention is paid to process, at the detriment of, for lack of a better term, "skill" (or "personal responsibility") I think the focus on process can be terribly annoying, because it's so much easier to say "Bob fell asleep at the machine" than diving into all the events that led up to Bob falling asleep. Note that both can be true or, more accurately, the process problems actually need the statement "bob fell asleep" to be true to make sense. The idea to prioritise processes is that it's repeatable. Individual behaviour isn't within your control, except for the processes that hired somebody, educated them, defined their tasks, and created the environment in which they perform these tasks. In a small team, or family, or group of friends, it's perfectly fine to dock Bob's allowance for falling asleep. And the instinct to exact revenge, or punish people is strong, because those instincts are the result of evolution and norms of society, both of which until recently only knew small groups where everyone knew everybody. That's why it takes a lot of discipline to act against these instincts, and obviously, as you said, because focussing on the process may also uncover others who failed, and it is more tedious. People get frustrated with bureaucracy. Sometimes they're obviously right. But the idea that all bureaucracy is wasteful, or (equally common) that governments have any particular talent for wasteful bureaucracy is somewhat misguided. Because there aren't many examples for organising teams of sometimes hundreds of thousands of people to work on shared goals without a wasteful bureaucracy, and governments and the private sector tend not to differ that much. I've seen one interesting example of a different structure for organising a large number of people: capitalism. It arguably works, being excellent at delegating authority to exactly the right person for any possible decision. But I believe even that example isn't convincing, if you start considering all the "waste" that capitalism hides in plain sight: advertisement, competing efforts doubling work, the complete financial sector, non-monetary losses due to financial hardship, the losses from unemployment being essentially wasted potential etc.
  - deleted 9y ago
    [deleted]
ashark 9y ago
I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp.
- AnthonyMouse 9y ago
  > I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp. The problem being that the ass-covering is a predictable response to known stimuli. What do you propose to do to get them to stop doing that?
raverbashing 9y ago
Not accepting "shit happens" makes sense in aviation, and you're right about that But taking out decision control and relying on automation has had its problems.

I am by no means an expert on this subject so correct me if I'm wrong but.... The exception that I've noticed from the airline-industry, is that they actually want to solve problems systemically and don't care who has to take the blame. For something to go wrong, multiple failures have to happen, and there's not a lot of blame put on individuals, as much as "the process". In most other organizations, IME, fixing "the process" is expensive. It takes time, and effort, and it's quicker and easier to blame "those idiots in IT/accounting/HR/etc". Most of those types of organizations don't actually want to solve problems, they just want the problem to go away. So they end up choosing the easier option, rather than dealing with the problem systematically. /bitter rant

jfoutz 9y ago
NTSB, i think, no one takes the blame. For example, if the error is something like "Mechanic didn't tighten bolt to appropriate torque." So, what's wrong? maybe they forgot and need a checklist item? Maybe the reading on the wrench should be recorded in the log? should there be a second person that verifies? They know they ask a lot of people, and it has to be right, every time. People get sick, tired, distracted, whatever. we're people. People are the least reliable part of the system. I think blame only falls to a person when they've lied. Falsified a log, claimed to do something they didn't etc.
- pbecotte 9y ago
  That's the thing. In the Air Force (at least)- there is no thought of cost/benefit analysis. A single machine fails once because a bolt wasn't torqued and causes $5000 of damage ... So they add the checklist item, and the second person, and an extra training item, and a log record that has to be maintained. The list of special rules and required documentation only ever gets longer. Eventually, you spend all your time on the checklists and maintaining the documentation, and none on actually doing whatever procedure you were originally messing with that bolt for.
  - stinkytaco 9y ago
    As someone who was a mechanic in the Army, I feel that checklists more often helped then harmed. Many mechanical problems we saw in the shop were easily attributable to an operator skipping a step on their PMCS. Doing something relatively dangerous or confusing could be error prone, especially for people who haven't done it much, and a checklist can help ensure the safety of everyone in the shop. A good example is running an engine indoors. Before you did it, there were a serious of steps you had to walk through before you turned it on, that reduced people getting sick from carbon monoxide quite a bit.
    - zimpenfish 9y ago
      "The Checklist Manifesto" is an -excellent- read on the helpfulness of checklists in preventing problems and mistakes (primarily from a surgeon and medical viewpoint but he covers airlines as well.) http://atulgawande.com/book/the-checklist-manifesto/ http://atulgawande.com/book/the-checklist-manifesto/
  - zentiggr 9y ago
    As a submarine fire control tech, I always thought it was cumbersome to have three full size binders open in my lap during weapon firing drills, casualty drills, everything except calm open water transit. But flipping those pages and grease pencilling things even while in the hot of prepping weapons to leave the tube avoided a LOT of "hurry up and whoops!" mistakes. Sometimes crufty stuff needs a review and rewrite but, n the whole, I'd rather know what happen wrong the previous times and avoid it myself.
KGIII 9y ago
I am not an expert but I know many pilots, watch only documentaries, read research papers almost exclusively, and have stayed in a Best Western. NTSB is, as far as I understand, actually very careful about not blaming anyone. They look for causes and solutions, not blame. They, as far as I know, pride themselves on this. They try, again inasmuch as I know, to not blame a person - but to blame a process. This is not a distinction without difference. It fosters an attitude of cooperation and openness. Again, I'm not an expert but I know a bunch of pilots and listen when they speak. If the NTSB blamed people, I suspect they'd have a lesser willingness to speak positively about NTSB. Edit: Someone beat me to it. I will leave this as I think it offers a bit more of a comprehensive view.
- hueving 9y ago
  >They look for causes and solutions, not blame. They, as far as I know, pride themselves on this. If the cause is a person's behavior, that is the same thing as blame. Look at the report of the Pinnacle 3701. Probable causes from [1]: 1. the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship; 2. the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites; 3. the pilots' improper management of the double engine failure checklist It's hard to look at that and say that the pilots weren't being blamed. 1. https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701 https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701
  - KGIII 9y ago
    It does happen, but is the exception. Look at the aftermath section. You can also look at the aftermath sections of other flights. Sometimes, a human is to blame and there's no getting around that. This doesn't change their goal.
  - ahhhhhhhhhh 9y ago
    The difference is the approach — they look for the cause and sometimes the cause is the blame. When you only look for the blame, you tend to be satisfied once you reach that goal and might ignore the cause.
nradov 9y ago
But unlike the NTSB, the military still routinely blames "pilot error" to cover up problems with terrible aircraft designs. http://www.military.com/daily-news/2016/01/29/billows-of-dust-a-sudden-pop-and-an-osprey-falls-from-the-sky.html http://www.military.com/daily-news/2016/01/29/billows-of-dus...
matt4077 9y ago
This kinda contradicts the idea further up that too much attention is paid to process, at the detriment of, for lack of a better term, "skill" (or "personal responsibility") I think the focus on process can be terribly annoying, because it's so much easier to say "Bob fell asleep at the machine" than diving into all the events that led up to Bob falling asleep. Note that both can be true or, more accurately, the process problems actually need the statement "bob fell asleep" to be true to make sense. The idea to prioritise processes is that it's repeatable. Individual behaviour isn't within your control, except for the processes that hired somebody, educated them, defined their tasks, and created the environment in which they perform these tasks. In a small team, or family, or group of friends, it's perfectly fine to dock Bob's allowance for falling asleep. And the instinct to exact revenge, or punish people is strong, because those instincts are the result of evolution and norms of society, both of which until recently only knew small groups where everyone knew everybody. That's why it takes a lot of discipline to act against these instincts, and obviously, as you said, because focussing on the process may also uncover others who failed, and it is more tedious. People get frustrated with bureaucracy. Sometimes they're obviously right. But the idea that all bureaucracy is wasteful, or (equally common) that governments have any particular talent for wasteful bureaucracy is somewhat misguided. Because there aren't many examples for organising teams of sometimes hundreds of thousands of people to work on shared goals without a wasteful bureaucracy, and governments and the private sector tend not to differ that much. I've seen one interesting example of a different structure for organising a large number of people: capitalism. It arguably works, being excellent at delegating authority to exactly the right person for any possible decision. But I believe even that example isn't convincing, if you start considering all the "waste" that capitalism hides in plain sight: advertisement, competing efforts doubling work, the complete financial sector, non-monetary losses due to financial hardship, the losses from unemployment being essentially wasted potential etc.
- deleted 9y ago
  [deleted]

ashark 9y ago

I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp.

AnthonyMouse 9y ago
> I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp. The problem being that the ass-covering is a predictable response to known stimuli. What do you propose to do to get them to stop doing that?

raverbashing 9y ago

Not accepting "shit happens" makes sense in aviation, and you're right about that But taking out decision control and relying on automation has had its problems.