Heavy reading

[Kip Powick]

This link will take you a brief summary of the Space Shuttle Columbia re-entry catastrophe. On the LH side you will see 4 reports with their separate links.

Extremely interesting reading but very lengthy. Report Number 4 was very enlightening and very detailed.......especially if you are not familiar with all the gear and equipment in the shuttle.

Remember the everglades incident decades ago. ???...it, in its own way, comes back... a bit of a precursor, just before the disaster.

Columbia Disaster

[Don Hudson]

Kip;

Thank you for the link to this important report. The NASA site has a number of links as well, to the CAIB (Columbia Accident Investigation Board) Report and is, in my view, important reading for all aviation managers and not just those interested in "what happened". There were serious organizational issues which were not addressed and fixed after the Challenger accident. The "normalization of deviance" process now well-understood through the work of Diane Vaughan, ("The Challenger Launch Decision") that apply to all aviation enterprises and not just high-risk space-flight work. The book by William Starbuck and Moshe Farjoun entitled, "Organization at the Limit" discusses these aspects and again is well worth reading for aviation/airline managers.

The accident rate, which has been falling, initially dramatically after 1960 as technological solutions to causes of accidents such as collision with terrain, mid-air collision, loss of control, poor weather were implemented leaving "Human Factors" as the primary cause of accidents.

"SMS" has been touted as a response to this primary cause but has not been implemented widely, fully, or long enough to judge it's effects. There are also indications that the active role of the regulator, while changing, does remain. Responses such as "A Just Culture", and "GAIN", (Global Aviation Information Network), are heading in the right direction but will not survive or flourish in an organization where the CEO him/herself does not take an active, championing, unequivocal role such that the message from the top is unmistakable.

Safety feedback programs are mandated under SMS but little definition and metrics are provided by those implementing SMS so a "box-tick" mentality is fostered within an SMS airline management community which is struggling with costs and an extremely difficult economy.

In today's business model the notion of "profit centers" figures strongly. Such notions have even been applied to Flight Safety Departments. Flight safety departments and programs are seen as "expensive" because they produce "nothing", and therefore do not "show a profit". As such, flight safety departments, if they exist at all, does not traditionally receive either the attention or the support of an executive which must concern themselves with daily numbers and a difficult operating environment. This may degrade to the point where airlines under pressure to perform and cut costs have all but stopped examining the data being collected and which may lie dormant,... until an accident.

In today's increasingly litigious environment the official response to an accident is likely to be criminal as opposed to an intelligent and ethical use of the safety tools available to prevent the first accident. Such a response may place the organization itself at risk, for, as the old saying goes, "If you think safety is expensive, try an accident". A ten-billion dollar bill is not out of the question when all is said and done and all factors are accounted for. The Challenger and Columbia accidents have much to say to airline managements which talk a good shop but don't necessarily walk the talk.

Today that is a greater challenge than ever and the initial indications are that the industry may be "satisficed" with the accident rate, dramatically low as it is, and may have already "normalized the deviance". The slight increase in fatal accidents, (though not fatalities) may or may not be a trend. From "Flightglobal", this month:

Global airline accidents snapshot for 2008 to 23 December

By David Leamount

An assessment of global airline crashes for 2008 at 23 December shows a considerable rise in the number of fatal accidents, but a fall in the number of resulting deaths.

This squares with the International Air Transport Association's snapshot of the year to 1 December, in which it revealed that airline safety has stopped improving, although IATA's figures are based on jet hull-loss accidents, and not all of these involve fatalities.

Flightglobal's safety snapshot for the year to 23 December shows 33 fatal airline accidents, whereas the whole of 2007 produced only 25, which was an all time low.

But this year to 23 December has seen only 589 fatalities worldwide compared with the 744 recorded by the end of 2007.

The rest of the story may be found at Flightglobal's site.