Reposted from the C-6 thread
A lot of great points have been raised in this thread, from a lot of established points of view. None of us are wrong... but then, none of us are completely right (myself included)
Quoting Widow:
Quote:
Again, I agree that pilot error is often the last link in the chain of events leading to an accident. Perhaps the pilot isn't experienced, or educated enough to make the right decision
Pilot error is not the last link in the chain of events, as much as it is the investigators first cop out. Somewhere down the line every accident comes down to a flaw in the Safety Management System.
For example...
The following is a ficticious scenario - Prop spun off the engine resulting in a forced approach over rocky terrain killing all on board -
Some might feel its sufficient to say the cause of the accident was the fact that the prop separated from the aircraft, forcing the pilot to make a decision to land without power.
why...
Investigation of the crank showed broken prop bolts at 4 locations
Conclusion is therefor that the prop seperated due to sheared prop bolts
why...
Tests of the remaining 'bolt' segments show rotational stress at the point of fracture indicating they may have been over-tightened
Conclusion therefore is that the prop separated from the aircraft because the prop bolts sheared off, because they had been overtightened
why...
Reveiwing the maintenance logs, the AMO was contacted and further investigation ensued. Speaking with the AME logged as having worked on the aircraft, investigators found the actual torque wrench used. Upon testing, investigators find the wrench is calibrated 50lb lighter than it should be.
Conclusion therefore is that the prop separated from the aircraft because the prop bolts sheared off, because they had been overtightened because the torque wrench used was calibrated 50lb lower than true
why...
Investigating the AMO's SMS, Investigators find record of several reported instances of faulty or inadequate equipment; but no indication of equipment repair, training, maintenance or replacement.
Conclusion therefore is that the prop separated from the aircraft because the prop bolts sheared off, because they had been overtightened because the torque wrench used was calibrated 50lb lower than true, because the company had an inadequate management system in place to replace, maintain or inspect equipment.
Now this was a ficticious scenario, however... I don't beleive in Pilot Error, nor do I beleive in 'Human Error' as its called in other industries.
- uneducated pilot decisions = SMS has failed to provide proper orientation/education
- unforseen circumstances = SMS has failed to encompass all available situations
- pilot 'Bad Attitude' = SMS has failed to provide disciplinary guidelines
- Faulty Equipment/Facilities = SMS has failed to put proper inspection system in place to identify needs.
- and so on.....
The key word is system... Safety Management System is just that, and no matter what type of situation... 9 times out of 10... no... 99 times out of 100, it's the system that has failed!
I am an occupational Health and Safety Coordinator with 15 years experience in the patch... drilling rigs which started out as one of the most dangerous places to work, and which, through use of SMS's have now grown into one of the safest. (AB WCB Statistics 2005)
The SMS systems presented by TC are terrific... some may find this odd.. but using parts of their system, I am likely the only airshow performer in NA with a safety manual. In presenting us with the system however... TC needs to focus training on their own personnel to allow for uniformity and understanding the requirements placed on Employers as well as employees as they relate to SMS's, The Aviation OH&S regs, and The Canada Labor Code.
We need the same informed answer from the first TC phone... as the next.
