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The Colgan Air disaster was a milestone in aviation safety
- delinka 8y agoBased entirely on the headline: doesn’t every crash prevent most future crashes that would have had the same cause?
- XMPPwocky 8y agoThe article opens by explaining that the cause of this crash wasn't ever determined- rather, it's the changes in safety regulations that resulted.
- elliekelly 8y agoThis reminds me of the book "Black Box Thinking" that basically says it's more important to learn from mistakes so we don't repeat them than to assign blame. The commercial aviation industry does this better than any other industry, even medicine.
- tialaramex 8y agoYes. Blame is poisonous. Humans hate blame, they'll deflect blame onto the innocent, they'll lie and cheat, to avoid blame. The correct focus is prevention of future harm. Not "who is a bad person?" but "what will we do differently next time to avoid this outcome?". In that frame suddenly the driver stops saying they weren't too drunk to drive and says next time they'll take a cab. The policeman stops saying the suspect "wasn't complying" and agrees that they need training on how to de-escalate situations. Medicine does have tools for this, the M&M conference (medics discussing why somebody died or had a bad outcome and how to do better next time) is under-used. Humans are fallible, blaming a specific human makes us feel better but does not prevent the same thing happening again.
- spockz 8y agoI’m completely with you on this and have been implementing this in practice. Sometimes, however, I still meet resistance. Do you have any source/literature that underpins this method?
- elliekelly 8y ago... Black Box Thinking, by Matthew Syed.
- FabHK 8y agoA nice book explaining some techniques used in aviation and how to transfer them eg to medicine is Atul Gawande's The Checklist Manifesto.
- slededit 8y agoBlame isn't the only problem. Humans also hate change. Eliminating blame reduces the resistance to implementing better policies but does not completely resolve it.
- jonas21 8y agoAviation accident investigations always assign blame when it can be determined. In this particular case [1]: > The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions. [1] https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1001.pdf https://www.ntsb.gov/investigations/AccidentReports/Reports/...
- elliekelly 8y agoThe primary purpose of the NTSB is to prevent future accidents. Any "blame" they assign is in furtherance of that purpose, not punishment. So critical is this to the NTSB's mission that any conclusion the agency draws as to the cause of an accident cannot be submitted as evidence of civil liability[1] in court and every NTSB report includes a footnote to that effect. You'll find it on page 4 of the document you've linked. [1] The report would be hearsay in a criminal case and admissible only if the government demonstrates an exception to the rule against hearsay evidence.
- FabHK 8y agoWoah, slow there. The NTSB tries to determine "Probably cause". That's a far cry from assigning blame. In particular, on every NTSB report there's a big box specifically saying (my emphasis): > The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. Furthermore, to "ensure that Safety Board investigations focus only on improving transportation safety, the Board's analysis of factual information and its determination of probable cause cannot be entered as evidence in a court of law."
- jaredwiener 8y agofrom the article: "By any measure, the safety record since the crash is unprecedented. Out of more than 90 million flight departures on U.S. airlines carrying billions of passengers since then, there has been just the single death: A woman died on April 17 on a Southwest Airlines Co. flight near Philadelphia when an engine failed, sending debris into a window next to where she was sitting."
- mikeash 8y agoOnly if they’re actually investigated and the lessons learned are translated into real changes. Fortunately, commercial aviation is really good about that.
- mannykannot 8y agoIn this case, however, the problems were already recognized. What this crash did was to provide the impetus to stop arguing and finally do something effective about them. In "Fate is the Hunter", Gann lamented that the airlines had to be forced by regulation to adopt as straightforward a safety measure as the rotating beacon (flashing red light), a change that pilots of the day had to lobby for.
- AceyMan 8y agoEarnest Gann's Fate is the Hunter is a must-read for aviation buffs which flies under the radar in discussions on the great books on flying. I worked in the business and I'd never heard of it until a hardware engineer (with WDC) told me I had to read it. He was right. It's a nail-biting, seat-of-the-pants diary of the author's career during the early days of commercial aviation. So good. Highly Recommended. (me: aircraft dispatcher in my previous life)
- misiti3780 8y agoYep, I always loved this line from Antifragile: > “But recall that this chapter is about layering, units, hierarchies, fractal structure, and the difference between the interest of a unit and those of its subunits. So it is often the mistakes of others that benefit the rest of us—and, sadly, not them. We saw that stressors are information, in the right context. For the antifragile, harm from errors should be less than the benefits. We are talking about some, not all, errors, of course; those that do not destroy a system help prevent larger calamities. The engineer and historian of engineering Henry Petroski presents a very elegant point. Had the Titanic not had that famous accident, as fatal as it was, we would have kept building larger and larger ocean liners and the next disaster would have been even more tragic. So the people who perished were sacrificed for the greater good; they unarguably saved more lives than were lost. The story of the Titanic illustrates the difference between gains for the system and harm to some of its individual parts. The same can be said of the debacle of Fukushima: one can safely say that it made us aware of the problem with nuclear reactors (and small probabilities) and prevented larger catastrophes. (Note that the errors of naive stress testing and reliance on risk models were quite obvious at the time; as with the economic crisis, nobody wanted to listen.)”
- CamperBob2 8y agoThe engineer and historian of engineering Henry Petroski presents a very elegant point. Had the Titanic not had that famous accident, as fatal as it was, we would have kept building larger and larger ocean liners and the next disaster would have been even more tragic. So the people who perished were sacrificed for the greater good; they unarguably saved more lives than were lost. The story of the Titanic illustrates the difference between gains for the system and harm to some of its individual parts. The same can be said of the debacle of Fukushima: one can safely say that it made us aware of the problem with nuclear reactors (and small probabilities) and prevented larger catastrophes. Another interesting argument along the same lines is that if we hadn't bombed Hiroshima and Nagasaki, there would have been no reason for Truman to stop MacArthur from using bombs a hundred times worse in the Korean conflict. It's a sobering thought regardless of one's opinion on the atomic bombings in Japan. The lesson was going to be learned one way or the other, and arguably humanity got off easy.
- zzless 8y agoLike our chief pilot used to say: "All regulations are written by dead people".
- gingerbread-man 8y agoThe most significant regulatory change following the Colgan crash was the added requirement that all airline (Part 21) first officers possess an Airline Transport Pilot (ATP) certificate prior to hiring. Previously, only captains (as pilots-in-command) were required to hold that certificate, which requires a minimum 1500 hours of flight experience. [1] In practical terms, this wasn't a big change (insurance underwriters already required it), but 1500 hours is a significant hurdle at at time when the US is facing a shortage of pilots. [1] https://www.flyingmag.com/news/faa-finalizes-atp-rule-first-officers https://www.flyingmag.com/news/faa-finalizes-atp-rule-first-...
- sokoloff 8y agoIt's not required prior to hiring; it's prior to flying your first revenue flight. The distinction is somewhat important as it's not as easy to get an ATP (any more) with the introduction of the ATP-CTP requirement. Though I have no need for an ATP, I considered getting one under the old (quite easy) rules.
- bronco21016 8y agoIt was most definitely a huge change in practical terms. When regional airlines began their boom cycles they frequently lowered their minimum requirements to essentially only requiring a brand new commercial pilot certificate. In theory that could be as low as 275 hours or so. I know many people were hired in the 300-500 hour range. Raising the bar to 1,500 hours drastically changed the hiring landscape and coupled with mass retirements due to the age 65 rule (retirement is required at age 65 for 121 airline pilots), the airlines have had to improve working conditions to continue attracting qualified candidates. All you have to do is follow the money. The regional airline association of America lobbies extensively for lowering the bar again to save regional airlines money.
- danaliv 8y agoOne of the biggest changes that came out of the Colgan crash is the so-called "1500 hour rule." Before Colgan, only the captain needed to have an airline transport pilot (ATP) certificate, the highest level of pilot certification. First officers (copilots) could fly with a commercial pilot certificate, a lower grade of license. Now, both pilots are required to hold ATP certificates. ATP applicants need to have 1500 hours of flight experience—hence "1500 hour rule"—though there are exceptions if you've attended specific approved aeronautical schools or have military experience. Commercial applicants need only 250 hours. (Here too there are exceptions for certain training programs.) The standards on the flight tests are tighter for ATPs and the written exams are worlds apart. As an instructor I can tell you the difference between a 250-hour pilot and a 1500-hour pilot can be enormous. Not always—some pilots have 1500 hours, and others have the same hour, 1500 times in a row—but there can be a huge difference. This rule has been controversial though, not least of all because both pilots in the Colgan crash already had more than 1500 hours. And the FAA made so many changes after Colgan that it's been hard to tell which of those changes actually made the difference, and which, if any, were simply no-ops. Critics of the rule have especially focused on how many flight tests the Colgan captain failed, and how the response by the pilots to an aerodynamic stall was completely backwards. Aerodynamic stalls are something you learn in your first ten hours of training as a private pilot and drill constantly throughout your career, so to get that wrong at the air carrier level speaks to an incredible failure in training and evaluation.
- dpflan 8y ago"Not always—some pilots have 1500 hours, and others have the same hour, 1500 times in a row—but there can be a huge difference." This is an excellent statement emphasizing the importance of concepts like deliberate practice and a varied curriculum/experiences. I think this idea applies to all learning.
- danaliv 8y agoAlso the importance of regular evaluation. You can develop a lot of bad habits in 1500 hours.
- peterwwillis 8y agoCompare this to cars. Every year in the US there are about 6 million car crashes, 3 million injured people, and about 33,000 dead people (so, imagine a city like Dover, Delaware being wiped off the face of the earth every year). The most typical causes are alcohol, speeding, and reckless driving. In addition, seat belts cut the risk of death by 45%. So, if we wanted to keep people safe the way we do for airlines, we would just attack these four problems. There are many solutions, but the simplest ones would involve 1) a mandatory breathalyzer, 2) speed limiters, 3) sensors that shut down the car when reckless driving is detected, and 4) shutting down the car if seatbelts are not used. These all exist today, and would save tens of thousands of lives a year, and prevent millions of casualties, lawsuits, traffic jams, etc. Why don't we do these things? My theory is the illusion of safety. In a car, you're wrapped inside 2 tons of steel and plastic, and you feel safe. Even if you know other people are dying inside, you feel like it won't happen to you. So we don't worry, so we don't care about changing things to save lives, because it'd be an inconvenience. But in an airplane, you're not in control; some pilot is. And you're hurtling along at at 500 miles per hour, 40,000 feet above the sky. That's scary. We better make sure those planes are safe.
- hiimnate 8y agoI think another aspect of it is the auto industry's reluctance to admit that cars are dangerous. Before seatbelts were introduced, manufacturers didn't want to include any overt safety systems, because they introduced the idea that we needed protection from the cars. There were no dangerous cars, just bad drivers. There's a great 99% invisible episode about it: https://99percentinvisible.org/episode/nut-behind-wheel/ https://99percentinvisible.org/episode/nut-behind-wheel/
- adamson 8y agoInterestingly enough, as you'll learn in that episode, the push for automobile safety was inspired by innovations in airplane safety!
- stefs 8y ago> There were no dangerous cars, just bad drivers. i remember reading about airplane accidents almost always being labeled as "human error", as it's cheaper to replace pilots than it's to replace whole airplanes.
- misiti3780 8y agoI flew into buffalo that night about an hour before the crash. I remember thinking when we were landing that these conditions were some of the worst, and I fly a lot into Buffalo.
- huangc10 8y agoMy brother is a commercial airline pilot who flies world wide and pilot fatigue is real and very common. Airlines have been making bank for the last few years and all they need to do to prevent pilot fatigue is reduce hours for pilots and increase the number of pilots/flight, especially for international flights. These simple measures (albeit costly), will overall help reduce commercial flight fatalities across the globe.
- dopamean 8y agoMy father was an airline pilot for years (American, US Airways, and then Etihad) flying domestically and then internationally. I'd guess that if the airlines wanted to reduce pilot hours the pilot unions would have a lot to say about that.
- SmellyGeekBoy 8y agoAre they paid by the hour? I'd assume that pilots would earn an annual salary.
- huangc10 8y agoMost pilots do earn an annual salary. I'm not sure what the previous comment meant. Pilots simply have to work minimum number of hours per month, but the issue is that most pilots are now working up to the maximum number of hours therefore there are actually pilot union striking because of overwork!
- cm2187 8y agoI wish one could write the same title about software...
- ChuckMcM 8y agoThis is an excellent example of how regulation should work as opposed to how it works in regulatory capture situations. In a prisoners dilemma like set up, if any airline unilaterally changed their rules for pilots and crews, they would "lose out" when they didn't have crews to fly, while other airlines would "win more" by overworking their flight crews. The only "win" was for all airlines to not implement these changes. But when the changes were forced on everyone, it removed the advantage of not following the guidelines (well it added a criminal or civil prosecution risk) and so all airlines have at least minimally rested crews. That message seems to get lost sometimes.
- smacktoward 8y agoI would say this is an excellent example of how regulation shouldn't work. Even before the Colgan Air crash, it was widely understood that regional airlines' overworking and undertraining of their pilots was risky. But the regulators either weren't able to do anything about it in the face of industry opposition, or didn't care enough to do so. It took a plane actually crashing, 50 people dying and Congress, which was lobbied hard by the families of the victims, passing new legislation ordering them to do something about the problem to get them to take action. It's great that we have regulations protecting passengers from these problems now. But it would have been much better if it hadn't taken the deaths of those 50 people to create an environment where it was possible for such regulations to be enacted. Good regulators protect people before there's blood on the floor, not after.
- dopamean 8y agoThough I do agree with the a lot of what you're saying it does seems like what you are suggesting is that had the regulations worked "as they should" then we could have always prevented accidents like this. I'm not sure that's realistic.
- hire_charts 8y agoIf the regulations had been enacted before the incident, how would anyone know whether or not they even worked?
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- edoo 8y agoOn youtube now you can find flight simulator reenactments of most every crash and air incident. They are quite fascinating and much much better than TV style dramatizations. Here is this incident: https://www.youtube.com/watch?v=LzY-hzxlqig https://www.youtube.com/watch?v=LzY-hzxlqig
- cf498 8y agoThe air traffic control recordings alone are really great. When the guy stole a plane from Seattle airport to take it for a joyride, i got stuck and clicked myself through what felt like half the ATC recordings on youtube. Can only recommend it, the level of international communication is rather astonishing. https://www.youtube.com/channel/UCuedf_fJVrOppky5gl3U6QQ https://www.youtube.com/channel/UCuedf_fJVrOppky5gl3U6QQ
- austincheney 8y agoHow catastrophic must a software disaster be to receive the benefits of such safety regulation?
- bdamm 8y agoThere are software glitches responsible for the deaths of on the order of 100 people, which has resulted in industry-localized development and deployment standards. When we see tragedies where 1000 people die because of a software glitch, or more likely, a systems or security failure, then I think we'll see legislators start coming for the software industry in general. There are already critical systems development and systems requirements; likely legislators will expand and formalize those kinds of programs. All we need to do is have a public tragedy that can be pinned on "software".
- Simulacra 8y agoI think something we haven’t learned from the Colgan disaster is how regional airlines are configuring these smaller jet and turboprop planes to fit more passengers, in ways they were not designed. That is leading the way towards profit over safety.
- nkanetka 8y agoMeanwhile in Canada regulations are still appalling and some of the worst in the world: https://www.cbc.ca/news/politics/garneau-pilot-safety-airline-regulations-1.4942385 https://www.cbc.ca/news/politics/garneau-pilot-safety-airlin...
- bernardom 8y agoThis is real engineering. And this is what I'm most excited about with autonomous cars- black boxes allow the NTSB to get involved and work accidents out of the process.