Dangerous accidents lie in the system, not in the components. (Perrow, 1984)
Learning from experience is a critical element in system safety. In this blog post, I will revisit the impact of safety culture on what response can be expected from an organisation when a major accident happens. More specifically, I will explain the main reasons why a pathological organisation is not supportive of public inquiry and, as a result, unable to learn from a tragic safety loss. Read more…
In aviation circles, the Grumman F-11 Tiger is known as a capable carrier-based fighter aircraft, the second operational jet in US Navy service that could fly faster than the speed of sound. In popular culture, it is better known as one of the first types flown by the Blue Angels and, most regrettably, it can also claim the title as the first fighter jet that managed to shoot itself down.
The accident occurred on this day, 68 years ago. Thomas W. Attridge, Jr, a young Grumman test pilot, was flying his second sortie of the day. He was tasked to take off from Grumman's airbase on Long Island, proceed to the designated firing range over the Atlantic Ocean, and clear a test point on the performance flight envelope by strafing the water in two short bursts. Attridge was an experienced naval aviator who flew combat missions during WW2. The planned test sortie would have been a low risk operation for him. Except that it was not. Read more…
Last week, I was confronted (yet again) by the common misconception that workplace safety and system safety have the same objectives and, as such, a "real" safety expert should wear both hats at the same time. In short, wrong. With few exceptions, mixing up workplace and system safety management is not only counterproductive, it can also lead to serious consequences.
In the past (think a 100 years ago), there was a large overlap between "industrial" and "product" safety efforts, but that was before we introduced complex systems into our everyday environment. Read more…
I have just returned from a visit to the Georgia Tech campus in Atlanta, GA. I was fortunate enough to have been invited by distinguished faculty of the Daniel Guggenheim School of Aerospace Engineering (AE School) to hold some introductory lectures.
My topic of choice for the guest seminar was (naturally) system safety-related: I explained the potential risk involved in making flawed design assumptions when developing safety-critical systems. Similar to previous lectures, I used some cautionary tales from accident investigation reports as a guideline. You may wish to refer the links page for more details. Read more…
My recent trip to the States and back involved connections in Auckland (NZ) and Houston (TX).
Over the years, I have been a passenger/crew member on more commercial models that you can poke a finger at, but never on a MAX. And I have to admit, as a former B737 chief engineer, I was a bit uneasy about the prospect. Read more…