Where Birds Don't Fly

When the airplane crashed the probable cause was determined to be flight crew’s preoccupation with matters unrelated to cockpit duties. About sixty years later the probable cause in an airplane crash was the pilot’s failure to maintain airspeed and correct pitch attitude. Over a period of 60 year the probable cause was turned upside down, or 180 degrees and had gone from tasks performed to tasks that was not performed. In the 50’s they got the correct probable cause, while today the cause is assigned to an event that didn’t take place. The difference is that it is impossible to fail to comply with a task since one task or another is always performed. In addition, it becomes impossible to develop corrective action plans to a task that did not occur.  Airplane crashes happens because of human behavior and not because of human error, or failure to comply with an arbitrary defined task. There is a reason for the Safety Management System to consider human factors, organizational factors, su

Hazard identification is the foundation of a healthy Safety Management System. Events and occurrences are the consequences of hazards and a simple task to identify. In the old days of aviation safety incident and accidents were defined as pilot error. Without any further analysis, pilot error became the standard solution to past occurrences. After a major occurrences new regulation were implemented, technical standards were changed, and new equipment were installed. Still, after decades with new and improved changes, accidents still happened. As an attempt to overshadow the inherent hazards of flying accidents were defined as meaningless and safety defined as common sense. Hazards were trivialized and flying was promoted as the safest mode of transportation. After thousand of hours of accident investigations hazards were brushed aside as an insignificant element of safety since safety was common sense and accidents meaningless.  It’s not always the change, but the process change itself

When the CAP is too complex for the regulator to understand they will dump it, reject it and without any attempt to analyze it, trash it. A complex CAP is nothing more than a reflection of publicly available guidance material issued by the regulator. This guidance material comes in the form of an Advisory Circular (AC).  Guidance material is communication. The purpose of guidance material is to communicate the regulator’s expectation to the aviation industry.  An AC for a root cause method is a document which explains the root cause analysis and corrective action process to address internal audit findings or oversight inspection findings of non-compliance. A root cause AC incorporates ideas from experts in the field of causal analysis. Each ICAO State may have different objectives, but their common goal is to ensure a level of safety in aviation that the flying public will accept. One goal a regulator publishes is to provide a safe and secure transportation system moves people and good