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> It's unbelievable This applies to most catastrophic failures, not just in aviation but in any other place that puts reasonable effort into preventing them. U

> It's unbelievable This applies to most catastrophic failures, not just in aviation but in any other place that puts reasonable effort into preventing them. Usually there are plenty of safeguards, which means that most of the times, when something goes wrong, one of the safeguards prevents a catastrophic outcome and you don't hear about it. But when you do hear about it (due to the catastrophic outcome or a very near miss), it'll usually be a tale of many mistakes, very egregious misbehavior, multiple failures etc. - because it generally has to be to cause a bad outcome or even get close to it. Keep in mind that despite this, nothing seriously bad actually happened here. It was a near miss that needs to be addressed, of course, but nobody died, there likely was no serious equipment damage, etc. Ultimately, the system worked.

captainredbeard 5y ago
> nothing seriously bad actually happened here Incorrect! They exposed their pax to unnecessary risk. You do not think like an aviator.
- bumby 5y ago
  I think the OP was focusing on the consequence, not the probability. Since risk is often defined as consequence x probability, I think you are both talking about distinct but related things
  - captainredbeard 5y ago
    Negligence, even if it does not directly cause a negative outcome, is still a mistake and a consequence of bad aeronautical decision making.
    - bumby 5y ago
      I agree, that's covered by the probability part of the risk equation. Even if you got lucky and nothing bad happened, the negligence still increased the risk by increasing the probability that something may have happened.
toss1 5y ago
>>Keep in mind that despite this, nothing seriously bad actually happened here. This is the exact wrong way to think about it. With substantial experience with managing risk, the most important thing I know is that you MUST UNDERSTAND the difference between managing risk with knowledge, technology, planning, and skill, vs rolling the dice and getting away with it. With risk management by knowledge, technology, planning, and skill, you can make an ordinary practice of very risky activities very safely. But when you are rolling the dice and getting away with it, you may get away with it for a long time, long enough to think you are safe, but it WILL bite you, and hard. "Near misses" are very clear indications that your risk management has a failure mode you didn't account for - and you are now in the zone of rolling the dice. If you do not attend to that, you are about to get bitten. So, just because no one was hurt or died — this time — does NOT mean you can be relieved.
- PicassoCTs 5y ago
  Crew Resource Management should have kicked in and the Pilot Monitoring should have taken over on rotating the moment the Pilot flying did not steer after V1. That this did not happen, and nobody actually concentrated on flying the plane, while the other party went through the corresponding checklists and diagnosis - thats cultural rot and a major issue.
  - toss1 5y ago
    Yup, and that cultural rot is also a key failure to manage risk. Just because you are [using knowledge, technology, skill, & planning] to manage risk once does NOT mean that the job is done. It needs to be constantly maintained. If it is not constantly maintained, you are slipping back into the zone of [rolling the dice and getting away with it]. It will bite you. What comes to mind is the last video from the very experienced skydiver which was normal until chute-opening-time, then got very chaotic and ended - he'd become so comfortable/complacent that he didn't do his checklist, jumped with only a knapsack instead of his chute. I'm sure he started out checking everything well. But getting casual and complacent killed him.
- tgsovlerkhgsel 5y ago
hluska 5y ago
Flying was one of my most irrational fears until Westjet introduced me to a pilot. He went into a truly massive amount of detail on their systems (both manual and automated) that prevent things like this. I’m not a pilot (I’m still very scared) and it’s been a long time so forgive me if my language isn’t correct. However, my understanding from that conversation is that this sort of thing is a system failure. Nobody got hurt and there may have been no damage, but they would consider this an overall system failure. Several people made mistakes here. There was the pilot who made the near fatal entry. And many pilots failed to spot the error. They didn’t perform their pre-flight properly and would have had to forget a checklist. They apparently didn’t even figure it out when the runway lights changed to signify “you done fucked up.” (Can a pilot weigh in?? Is that an aviation term?) :) This system failed. It’s pure luck that everyone survived.
- tgsovlerkhgsel 5y ago
  It definitely was a failure in the sense of "we need to do failure analysis and make sure we don't get this close again", but it also was a success in the sense of "ultimately, something prevented a catastrophic outcome" (and studying that, and potentially trying to replicate those positive aspects at other airports, is also something that should to happen).
  - silexia 5y ago
    The real problem here is that many overseas governments and airlines don't hire pilots based on competence, but on their coziness with the ruling class. Events like this are not Boeing's fault and will continue until foreign airlines can get rid of corruption.

captainredbeard 5y ago

> nothing seriously bad actually happened here Incorrect! They exposed their pax to unnecessary risk. You do not think like an aviator.

bumby 5y ago
I think the OP was focusing on the consequence, not the probability. Since risk is often defined as consequence x probability, I think you are both talking about distinct but related things
- captainredbeard 5y ago
  Negligence, even if it does not directly cause a negative outcome, is still a mistake and a consequence of bad aeronautical decision making.
  - bumby 5y ago
    I agree, that's covered by the probability part of the risk equation. Even if you got lucky and nothing bad happened, the negligence still increased the risk by increasing the probability that something may have happened.

toss1 5y ago

>>Keep in mind that despite this, nothing seriously bad actually happened here. This is the exact wrong way to think about it. With substantial experience with managing risk, the most important thing I know is that you MUST UNDERSTAND the difference between managing risk with knowledge, technology, planning, and skill, vs rolling the dice and getting away with it. With risk management by knowledge, technology, planning, and skill, you can make an ordinary practice of very risky activities very safely. But when you are rolling the dice and getting away with it, you may get away with it for a long time, long enough to think you are safe, but it WILL bite you, and hard. "Near misses" are very clear indications that your risk management has a failure mode you didn't account for - and you are now in the zone of rolling the dice. If you do not attend to that, you are about to get bitten. So, just because no one was hurt or died — this time — does NOT mean you can be relieved.

PicassoCTs 5y ago
Crew Resource Management should have kicked in and the Pilot Monitoring should have taken over on rotating the moment the Pilot flying did not steer after V1. That this did not happen, and nobody actually concentrated on flying the plane, while the other party went through the corresponding checklists and diagnosis - thats cultural rot and a major issue.
- toss1 5y ago
  Yup, and that cultural rot is also a key failure to manage risk. Just because you are [using knowledge, technology, skill, & planning] to manage risk once does NOT mean that the job is done. It needs to be constantly maintained. If it is not constantly maintained, you are slipping back into the zone of [rolling the dice and getting away with it]. It will bite you. What comes to mind is the last video from the very experienced skydiver which was normal until chute-opening-time, then got very chaotic and ended - he'd become so comfortable/complacent that he didn't do his checklist, jumped with only a knapsack instead of his chute. I'm sure he started out checking everything well. But getting casual and complacent killed him.
tgsovlerkhgsel 5y ago

hluska 5y ago

Flying was one of my most irrational fears until Westjet introduced me to a pilot. He went into a truly massive amount of detail on their systems (both manual and automated) that prevent things like this. I’m not a pilot (I’m still very scared) and it’s been a long time so forgive me if my language isn’t correct. However, my understanding from that conversation is that this sort of thing is a system failure. Nobody got hurt and there may have been no damage, but they would consider this an overall system failure. Several people made mistakes here. There was the pilot who made the near fatal entry. And many pilots failed to spot the error. They didn’t perform their pre-flight properly and would have had to forget a checklist. They apparently didn’t even figure it out when the runway lights changed to signify “you done fucked up.” (Can a pilot weigh in?? Is that an aviation term?) :) This system failed. It’s pure luck that everyone survived.

tgsovlerkhgsel 5y ago
It definitely was a failure in the sense of "we need to do failure analysis and make sure we don't get this close again", but it also was a success in the sense of "ultimately, something prevented a catastrophic outcome" (and studying that, and potentially trying to replicate those positive aspects at other airports, is also something that should to happen).
- silexia 5y ago
  The real problem here is that many overseas governments and airlines don't hire pilots based on competence, but on their coziness with the ruling class. Events like this are not Boeing's fault and will continue until foreign airlines can get rid of corruption.