Landing Incident @ SFO

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Boris Badenov said:
OK, let's do a thought experiment, JC. That's reasonably non-confrontational, isn't it?

So. There's no longer such a thing as a "screw up". Or if there is, then certainly, those who have been victimized by the System and have commited these "screw ups" aren't worthy of being sent to hit the bricks and peddle their wares elsewhere. No! They've been failed by The System! There are no losers, just winners-in-waiting! There are only actions that are taken by people who are insufficiently trained. Which, presumably, can be corrected by right-thinking new-age "non-judgmental" training programs. Oh, you forgot where the airspeed indicator was? Gosh, guess we failed you again! Here you go, we'll put neon in the instrument. Bad pilot, BAD! Don't do it again! Here, have a chewtoy. GOOD pilot.

Forget about the people who die in agony in the back (they're just pax, after all...numbers! This is a numbers game!), let's talk about pilots. If nothing is your fault, then nothing is your responsability either. You're just another redundant component which might malfunction from time to time (hey, everyone does!). I think it's high time that we recognize that we have all the free will, anima, and legitimacy of a broken sprocket. It's the new reality, and we'd best consign ourselves to it. Who's really flying this airplane? Uhm, not sure. The Safety Department? Dunno, NOT ME, anyway! I'm just here for the view and the free peanuts.
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You have consistently failed to accept what PhilosopherPilot has said about a just safety culture and are going off assumptions.
 
TFaudree_ERAU said:
Is there not a sense of fear within the training department that if they cut someone due to repeated poor performance, there will be a firestorm of legal implications?
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Not at all. Pilots at Colgan were let go after we unionized due to their lack of proficiency.
 
Derg said:
We went from a phase of "heads down in the books and the FMS/let the automation do the work" where the accountants got ahold of the training program (bad), then FOQA data showed a marked spike in certain situations, now we've swung to the "hands on throttle and stick"/FD's off occasionally/know how to hamfist your way through a visual approach.
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Your Central Air Safety Chairman, who was my boss when I was an intern at 'north' a while back, does an awesome presentation on the theme of automation addiction. Last safety council in the winter it was a half hour talk of the evolution of sort of what you just mentioned, and even further back well before the merge and into the early 90s. Very well done speech and lots of real specific examples, ranging from MD-88 to 747-400.

Looking forward to hearing the perfected version put on for the public next week in DC.
 
Seggy said:
You have consistently failed to accept what PhilosopherPilot has said about a just safety culture and are going off assumptions.
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I'm not sure what "going off" means, but I suppose that you're right that I've "failed to accept" SOME (some of it seemed pretty reasonable, but let's set that aside) of what Socrates has posted. Congratulations, you've correctly characterized some of my sentiments. Would you like to go for Double Jeopardy and comment on them?
 
Boris Badenov said:
OK, let's do a thought experiment, JC. That's reasonably non-confrontational, isn't it?

So. There's no longer such a thing as a "screw up". Or if there is, then certainly, those who have been victimized by the System and have commited these "screw ups" aren't worthy of being sent to hit the bricks and peddle their wares elsewhere. No! They've been failed by The System! There are no losers, just winners-in-waiting! There are only actions that are taken by people who are insufficiently trained. Which, presumably, can be corrected by right-thinking new-age "non-judgmental" training programs. Oh, you forgot where the airspeed indicator was? Gosh, guess we failed you again! Here you go, we'll put neon in the instrument. Bad pilot, BAD! Don't do it again! Here, have a chewtoy. GOOD pilot.

Forget about the people who die in agony in the back (they're just pax, after all...numbers! This is a numbers game!), let's talk about pilots. If nothing is your fault, then nothing is your responsability either. You're just another redundant component which might malfunction from time to time (hey, everyone does!). I think it's high time that we recognize that we have all the free will, anima, and legitimacy of a broken sprocket. It's the new reality, and we'd best consign ourselves to it. Who's really flying this airplane? Uhm, not sure. The Safety Department? Dunno, NOT ME, anyway! I'm just here for the view and the free peanuts.
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First off, this thread reminds me of http://xkcd.com/386/.

OK, now back to your "thought experiment". The problem is that you have so focused in on your position, that you are excluding what is actually being said here (confirmation bias and some of this https://medium.com/editors-picks/adfa0d026a7e).

The problem here is that you are actually missing the point here. Let me put this in a different context, and there are two separate items here to consider:

1. Is our justice system working? Do higher punishments actually deter crime? (if you do not know the answer to these, I suggest search scholar.google.com);

2. Do higher punishments make a professional (pilots, doctors, mechanics, etc.) to be more careful?;

Now, let me clarify what we mean by "just culture". There are three levels. Do not read into these, they are very simple:

• Human error – an inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.

• At-risk behavior – a behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.

• Reckless behavior – a behavioral choice to consciously disregard a substantial and unjustifiable risk.

Now, let's look again at our two questions. In the first case, I think we would agree that most "crimes" would fall into the reckless category. The individual gets hammered in that case, but there are times when we are doing that but probably shouldn't. In most countries, a pilot that crashes an airplane is subject to CRIMINAL penalties. Do you think they should? What about doctors?

Let's start with errors. An error is something that we know, through studies of human performance (that came about very recently, and were not available to law makers who wrote the foundation of Western law several hundred years ago) that humans are going to miss things in certain situations. We also know that human memory is a LOT worse than we ever thought it was (the entire legal use of witnesses is deeply flawed as a consequence).

So, let's use the witness issue. As we now can PROVE that a person will literally "create" a "memory" to fill in gaps and match their expectations, let's say a witness says something that is later provably false on a witness stand. Was that an intentional error or the product of human fallibility? If it was the former, then there are legal repercussions, but if the latter, there is a different outcome and it should be considered an "error", as we should (and we REALLY should) know that humans are really poor at this sort of cognitive task.

How about we set up a scenario where a flight crew is REQUIRED to use a certain amount of automation, and they get so caught up programming it that they lose SA and crash their airplane? Should we not know in advance that we are creating a situation where someone is going to be subject to attentional narrowing?

At-Risk:

Suppose there is a brand new medical device that a doctor just got into her office. She has not been trained on it, but understands essentially how it works. A patient shows up who has the medical problem the new device was designed to help. If nothing is done, the patient will die. Now, there are several possible outcomes:

1. The doctor could use the device:
Possible outcome A: Patient is saved
Possible outcome B: Patient dies, possibly because doctor was not yet trained or possibly could not be saved.


2. The doctor does not use the device:
Possible outcome: Patient dies.
Possible outcome: Patient lives as a result of a miracle, but this is VERY low probability.

Ok, so the doctor has a choice. If she chooses not to use the device, the patient dies. Would she be legally liable for choosing not to use a device she has not been trained on at all? I think the answer is obvious that it would be a strong affirmative defense in a court of law.

If the doctor chooses to use a device she was not trained for, she is now violating a procedure knowingly, even though it is the only possible way for the patient to live in this scenario. If the patient lives, she is a hero! If the patient dies, do you think she would be legally liable? You can be pretty sure that the patient's estate would sue and win in this scenario, as she was clearly negligent trying to use a device that she was not trained on.

Take another example You are driving on the highway. Posted speed limit is 45, but the road is clear and open and there are no other hazards of any sort present. All the traffic is driving 65. Do you drive 45, with cars slamming on their brakes when they see you, then passing you, or is it less risk to keep with the flow of traffic? If you choose the latter, that is "at-risk", as you are doing the wrong thing, technically, but you are trying to do it for the right reason (keep things safer).

Finally, let's look at "reckless". Now, let's take the same traffic situation but this time there are workers present, all the other cars are driving at 45 and the road is icy. You choose to drive 65, holding your beer and saying "watch this". That is reckless, and you deserve to be hammered.

Just culture does not excuse bad behavior at all. On the contrary. However, it also creates a framework for really looking at the situation and looking deeper to see if there was extenuating circumstances.

Perhaps one other way to look at it: If we take away someones food supply, are they still a criminal if they try to steal food for their dying child, or is that justifiable? What if the person who has plenty of food steals the food from a person trying to feed their child? Is that different? If you think that the former was justifiable while the latter is not, then you should agree with the "Just Culture".
 
OK, maybe I can help the dialogue here, first.

My personal belief, which I foist upon no one else, is that when I sign the paperwork to fly an aircraft, I am responsible for every conceivable circumstance that might befall the people inside it. Obviously, I'm going to take the cowardly duck for strokes and terrorist actions. Outside of that? Me. I'm where the buck stops. If someone has that heart attack and there's supposed to be a defibrillator but it's not properly charged? Me. I wear the brown helmet. Someone forgot to charge the oxygen and we've got some kid that's dying back there? Me. Wing falls off? Until they go through the logbooks, that's me, too. It's not always fair, but it's always clear. The dumbass who signs the book that says the airplane can go fly is the dumbass who wears the brown helmet when stuff goes wrong. I'm not at all sure where we lost this, well, what I THOUGHT was a fairly fundamental idea. Certainly, if the damned thing crashes, pending evidence of an act of God, I expect to be blamed. I'd be pissed if I weren't.
 
Boris Badenov said:
Certainly, if the damned thing crashes, pending evidence of an act of God, I expect to be blamed. I'd be pissed if I weren't.
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Right. We know that. Unfortunately, that is the attitude that the airline industry and hopefully the aviation industry as a whole is trying to reverse. (ASAP, FOQA, voluntary reporting, etc. are all a result of just culture.) Even the military is adopting the just culture model, though admittedly that's an uphill battle.

You can be responsible, yet not blameworthy. If you make an error, you made the mistake, and you are responsible for your actions. But you are NOT blameworthy because error is inevitable. It's the human condition.
 
seagull said:
Just culture does not excuse bad behavior at all. On the contrary. However, it also creates a framework for really looking at the situation and looking deeper to see if there was extenuating circumstances.
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I'm honestly baffled by the wall of text in response to what I thought was a fairly succinct and delineated explication of my (what I conceive to be) fairly simple set of ideas as to what the PIC's responsability is/isn't. One thing I'm sure of, though, is that the Safety Gestapo are inveterate Enemies of Grammar. "...was extenuating circumstances"?

I am genuinely trying to engage, but 95% of what you posted seemed to me to have nothing to do with the conversation that I thought that I was a part of...help me find common ground.
 
Boris Badenov said:
I'm honestly baffled by the wall of text in response to what I thought was a fairly succinct and delineated explication of my (what I conceive to be) fairly simple set of ideas as to what the PIC's responsability is/isn't. One thing I'm sure of, though, is that the Safety Gestapo are inveterate Enemies of Grammar. "...was extenuating circumstances"?

I am genuinely trying to engage, but 95% of what you posted seemed to me to have nothing to do with the conversation that I thought that I was a part of...help me find common ground.
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From the peanut gallery, I think there's a lot of good experience an analytical thought from some others and perhaps the answer just wasn't as "simple" as we think it should have been.

I guess, I don't know or care but there you have it! :)
 
PhilosopherPilot said:
You can be responsible, yet not blameworthy. If you make an error, you made the mistake, and you are responsible for your actions. But you are NOT blameworthy because error is inevitable. It's the human condition.
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I make all kinds of errors, naturally. As you point out, that's Human. I don't try to wriggle out from under them or blame the ILS that isn't in any way required or even to be expected. I conceive that I labor under this old fashioned idea that I am, in fact, blameworthy, because I'm the PIC. That's part of what it means. It's not just getting first call on the crew meal or the most bling on your sweat-stained uniform. 1912 = go down with the ship. 2013 = White Star Lines failed to properly train me to avoid the icebergs and I mean really who wouldn't have punched a child in the face to get on that liferaft!?
 
Boris Badenov said:
I make all kinds of errors, naturally. As you point out, that's Human. I don't try to wriggle out from under them or blame the ILS that isn't in any way required or even to be expected. I conceive that I labor under this old fashioned idea that I am, in fact, blameworthy, because I'm the PIC. That's part of what it means. It's not just getting first call on the crew meal or the most bling on your sweat-stained uniform. 1912 = go down with the ship. 2013 = White Star Lines failed to properly train me to avoid the icebergs and I mean really who wouldn't have punched a child in the face to get on that liferaft!?
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That's a straw man argument, my friend.
 
Boris Badenov said:
OK, maybe I can help the dialogue here, first.

My personal belief, which I foist upon no one else, is that when I sign the paperwork to fly an aircraft, I am responsible for every conceivable circumstance that might befall the people inside it. Obviously, I'm going to take the cowardly duck for strokes and terrorist actions. Outside of that? Me. I'm where the buck stops. If someone has that heart attack and there's supposed to be a defibrillator but it's not properly charged? Me. I wear the brown helmet. Someone forgot to charge the oxygen and we've got some kid that's dying back there? Me. Wing falls off? Until they go through the logbooks, that's me, too. It's not always fair, but it's always clear. The dumbass who signs the book that says the airplane can go fly is the dumbass who wears the brown helmet when stuff goes wrong. I'm not at all sure where we lost this, well, what I THOUGHT was a fairly fundamental idea. Certainly, if the damned thing crashes, pending evidence of an act of God, I expect to be blamed. I'd be pissed if I weren't.
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That is fine, but there is NO WAY you can check everything on the aircraft, regardless of whether you are "legally responsible", so the problem with your view is that it does NOTHING to prevent a future accident or event. NOTHING.
 
Let me ask a question here that may help clarify my own understanding, and by proxy, that of others:

Is the following statement accurate?

A Just Safety Culture does not excuse or absolve error - accountability exists. However, whatever errors were made should be examined from top-to-bottom - including training factors - to ensure that said error conditions do not repeat, or that conditions for said errors are at least most reasonably mitigated.

Thank you, in advance. This is all new stuff to me.
 
Boris Badenov said:
I'm honestly baffled by the wall of text in response to what I thought was a fairly succinct and delineated explication of my (what I conceive to be) fairly simple set of ideas as to what the PIC's responsability is/isn't. One thing I'm sure of, though, is that the Safety Gestapo are inveterate Enemies of Grammar. "...was extenuating circumstances"?

I am genuinely trying to engage, but 95% of what you posted seemed to me to have nothing to do with the conversation that I thought that I was a part of...help me find common ground.
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I think the problem is that I am looking to prevent future accidents/events, rather than worry so much about who goes to jail for the previous ones. If putting people in jail does NOTHING to stop a future accident and actually creates an environment where those that were in control of the policies that set up an environment making that error more likely, get off with NO penalties, then why would you do it?

Remember that old "definition of insanity", trying to do the same thing over and over and expecting different results?
 
Haven't crashed yet. But, ok. Let's say that my time is coming. Any minute now I'm going to accept an unairworthy craft to go fly. Who's to blame? More to the point, who would you prefer to be to blame? If I've said it once, I've said it a million times (ok, maybe just 10,000 or so); if you abdicate responsability, you also abdicate authority. You can't have it both ways. We can't keep bitching and moaning about how underpaid and put-upon we all are if every time something goes wrong we blame anything that looks easy and can't outrun us. "We" are slitting the wrists of our own careers with this culture of "not my fault". Plane crashes? My fault, until proven otherwise. I accept that, as did generations of aviators before me. Why is this suddenly declasse? Because I assure you, we're not helping ourselves by pointing in every imaginable direction when bad things happen. Quite the opposite.
 
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