My summer reading list included books on aviation history (yes, I am an airplane junkie). But it’s not possible to read North Star over My Shoulder, Bob Buck’s personal memoir, or A Few Great Captains, DeWitt Copp’s account of military aviation’s beginnings, without appreciating how far we have come in terms of standards, training, certification, and continued operational safety for airmen and aircraft. Modern aviators owe much to those pioneers whose efforts-and, all too often, whose mistakes-led to improvements.
It Could Have Been Me. We can still learn from mistakes. Given the harsh penalties that aviation errors can impose, however, most would agree that it’s infinitely preferable to profit from other pilots’ pratfalls. To paraphrase my college French professor, whose brutal grading practices provided a powerful incentive for grammatical perfection, why repeat a mistake when there are still so many to be made for the first time?
Fortunately, the FAA has a great resource to help us learn from the faux pas of fellow flyers. Specifically, the FAA Web site now has an online Lessons Learned from Aviation Accidents library that presents some of aviation’s major accidents and the lessons we can take from them. The library uses three different “perspectives” to organize the accidents and illustrate the complex interrelationship of causes. Each accident contains at least one high-level lesson related to a threat element, and at least one lesson related to a theme element.
Airplane Life Cycle. The first perspective offers accident summaries organized relative to the life-cycle element most prevalent in each accident. These elements include:
Threat Categories. The second perspective in the library presents the selected hazards in terms of threat categories. These include bird hazards, cabin safety/hazardous cargo, flight-deck layout/avionics confusion, crew-resource management, fuel exhaustion, fuel-tank ignition, inclement weather/icing, incorrect piloting technique, in-flight upsets, lack of system isolation/segregation (e.g., where a malfunction or failure affects more than one system or cascades a failure into subsequent failures), among others. While not every category applies to general aviation operations, most are relevant to aviators at any level of experience and equipment.
Common Themes. The third perspective organizes accident summaries according to a set of common themes. These include flawed assumptions, human error, organizational lapses, pre-existing failures (e.g., a problem that can cause an accident when combined with other malfunctions), and unintended effects. Similar to the cliché about unintended consequences, the latter theme addresses those situations where an initiative, change, new process, or other activity intended to improve something actually produces, not only the improvement, but also an undesirable outcome. This theme in particular underscores the complex interdependence of human beings, machines, systems, and environments.
To Visit the Library. The Lessons Learned From Aviation Accidents library can be found at http://accidents-ll.faa.gov/index.cfm. Who knows what you could learn from another’s mistake? (FAA Aviation News SepOct 2009)