I have been thinking for a long time and have wondered, who is ultimately responsible for the dismal safety record of 2018? The regulator, manufacturer or the operator?
Are we in a state of denial? That is a psychological aspect of human being but when we have advanced processes like the safety management system mandated by the ICAO Annex-19, there is no option but to comply.
If we carry out a simple root cause analysis using the 5 times why, we come to the following conclusion.
1st, Why did the accident happen?…..Pilot could not control the aircraft
2nd, Why could the pilot not control?…The pilot was not trained for it or could not comprehend the situation
3rd, Why was the pilot not trained or comprehend?…The system was too complicated or pilot could not recall
4th, Whay wans’t the pilot trained adequately or recall…….The pilot passed all the trainings and checks with the reqired standards
5th, The root cause is the subjectivity in evaluating training of pilots and trainers.
Dreyfus defined the levels of skill development.
|Rigid adherence to taught rules or plans|
|Little situational perception|
|No discretionary judgment|
|Level 2||Advanced Beginner|
|Guidelines for action based on attributes or aspects|
|Situational perception still limited|
|All attributes and aspects are treated separately and given equal importance|
|Coping with crowdedness|
|Now sees actions at least partially in terms of longer-term goals|
|Conscious, deliberate planning|
|Standardized and routinized procedures|
|See situations holistically rather than in terms of aspects|
|See what is most important in situation|
|Perceives deviations from the normal pattern|
|Decision making less labored|
|Uses maxims for guidance, whose meaning varies according to the situation|
|No longer relies on rules, guidelines or maxims|
|Intuitive grasp of situations based on deep tacit understanding|
|Analytical approaches used only in novel situation or when problems occur|
|Vision of what is possible|
If all pilots and trainers are proficient/competent/experts as per the definitions above, then why do they fail?
The manufacturer produces and gives information to the operator, the operator trains and complies with the regulators standards. At every stage there is a slip in quality which is suffering due to subjectivity in the system.
The first gate to prevent errors is selection and training of pilots and trainers. I am not saying the we have recruited people with wrong skill sets but the fact that the deficiencies in the training process escape through this gate. The primary reason being subjectivity in the training assessment and evaluations.
The Air Canada incident at San Francisco where the A320 almost landed on top of 4 aircrafts on the taxiway is a glaring example of poor training standards leading to a near disaster. The co-pilot had failed twice in his attempt to upgrade as a commander. The reasons being poor crew resource management and situational awareness. When qualifying back after his failure, he was judged as above average in the areas in which he had failed. His poor performance in supporting the captain at San Francisco was a contributory cause of the incident.
There is a need to slow down and spend time, money and effort in training of pilots and trainers. The foundation of training needs to be strengthened. The commercial world will keep producing an engineering control for every error that a pilot makes but that is not reaching a solution. We need to get back to the basics and nurture Higher Order Thinking Skills. This inculcates deeper understanding of the subject so that even if there is a change in the environment factors or design deficiency. the pilot is able to comprehend the situation and fly the aircraft to safey.