The Essence of Safety

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The Essence of Safety

The Essence of Safety

@EssenceOfSafety

The Essence of Safety podcast goes beyond root cause analysis and Swiss cheese slices, combining safety science with practical expertise.

Katılım Ekim 2021
158 Takip Edilen317 Takipçiler
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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
Recently, the topic of pilot error / human error / human factor has come up a lot again, and I thought it might be useful to start a 🧵 summarizing how modern safety science views the human role in safety-critical systems – and particularly in accidents.
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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
There's no button for the crew to push to preserve cockpit voice recordings. Rather, the CVR has to be disabled by pulling a circuit breaker. This also legally grounds the aircraft and means that the return flight won't happen. At the same time, there is no certainty that the
Avgeek Jan@Avgeek_Jan

🔴 A TAP Air Portugal pilot ignored four separate warnings before nearly crashing his Airbus A320neo into the hills near Prague Airport, this past January. Two warnings came from his co-pilot, two more from air traffic control. None of them made him pull up. Investigators believe he fell into a state of "tunnel vision" and misread the navigation map, thinking he was already 13 km closer to Prague than he actually was. He began descending as if on final approach to the airport, while still flying over forested terrain west of the city. The emergency pull-up only started at 295 meters above the ground. The plane climbed to 1,784 meters, with passengers experiencing 2G forces in the cabin during the sharp ascent. The crew then made a hard left turn to loop back and try the approach again, which investigators say further confirms the pilot believed he was already near the airport. To make things worse, the cockpit voice recorder captured none of the crew's communication during the critical moments. The pilots never pressed the required button after the incident, so the recording was overwritten. Investigators also noted that the crew arrived late at the cockpit before departure and skipped the mandatory pre-landing briefing. The final investigation report is expected later in 2026. #Aviation #TapAir

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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
@OnDisasters Apparently there was a news article in the Czech media, referencing statements by an investigator. It is unclear to me if an interim report has been published.
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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
@Subflyer Even 25 hours won't be sufficient, even if the crew had filed a report right away. In my experience it takes a few days for the boards to determine whether they wish to investigate these events (obviously it also depends on how dramatic the event was).
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Sven-Hajo Sieber
Sven-Hajo Sieber@Subflyer·
@EssenceOfSafety Quite honestly, after an incident like that i would expect the FO to call the duty pilot to make sure all procedures are followed, same as filing his own ASR before any return flight can take place. But, this is exactly the reason why EASA demands 25h recording time now.
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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
@OnDisasters Which runway was the AI even trying to land on? And during a go-around, you might want to retract the spoilers.
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Francisco Cunha
Francisco Cunha@OnDisasters·
And on today´s feature of AI Slop... a lightning strike 🤡🤡🤡 "Electric Blue Mega Jet Surrounded as Lightning Explodes Across the Runway — Cinematic Scenario Visualization. How dramatic does this electrical storm feel as the runway lights up around the aircraft? Share your thoughts in the comments".
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Francisco Cunha
Francisco Cunha@OnDisasters·
Scott Snook – a military and sociologist – penned “Friendly Fire: The Accidental Shootdown of U.S. Black Hawks over Northern Iraq” a book with an in-depth analysis of the case, recommend by aviation safety expert @EssenceOfSafety amazon.com/Friendly-Fire-…
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Sven-Hajo Sieber
Sven-Hajo Sieber@Subflyer·
@choffstein True. But I wouldn’t know what to do with a check once i find it. Haven‘t seen or used one in 40 years or so. I live in developed countries after all.
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Corey Hoffstein 🏴‍☠️
Week 1: Don't move. You are given distance D1. Week 2: Go 100 miles north. You are given a new distance, D3. Week 3: Go 100 miles east. You are given a new distance, D3. Draw three circles on your map based on your three starting points and their radiuses D1, D2, and D3. Where those three circles intersect is where the box is. You have 49 more weeks to hone in exactly. Good luck.
Hazel Appleyard@HazelAppleyard

Absolutely not????

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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
@OnDisasters @em1kk @visegrad24 Both the first investigation led by MAK (in which the Polish investigators assisted) and the second Polish investigation actually raised many interesting organisational factors.
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Visegrád 24
Visegrád 24@visegrad24·
🇵🇱 16 years since the Smolensk Air Disaster On April 10th, 2010, the Polish presidential plane crashed near Smolensk North Airport, killing all 96 people on board. Among them was the President of Poland, Lech Kaczyński, along with his wife, the Chief of the General Staff, along with the heads of all branches of the Polish Armed Forces, senior government officials, members of parliament, and key figures of Poland’s political and intellectual elite. They were on their way to commemorate the victims of the 1940 Katyn massacre in which 22 000 Polish officers were murdered by Soviet secret police. The shock reshaped Polish politics for years. It deepened internal divisions, fueled distrust toward Russia, and became a defining trauma in modern Polish history. The official investigation concluded the crash was caused by pilot error and poor weather conditions. But the story didn’t end there. Alternative investigations, backed by parts of the Polish political establishment, argued that the crash may not have been accidental, pointing to possible involvement of Russian special services. What further fueled suspicion is that several individuals connected to the investigation or re-investigation later died under unclear or controversial circumstances. For example: - Remigiusz Muś — a technician who was among the first witnesses to events at Smolensk, was found dead in 2012 in what was officially ruled a suicide. - Sławomir Petelicki — the first commander of the famous Polish special forces unit GROM, who had criticized aspects of the investigation, died in 2012 from a self-inflicted gunshot. Until this day, the Russian authorities haven't returned the wreckage despite Polish demands.
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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
@em1kk @OnDisasters @visegrad24 Maybe because they have more to gain from the division that the conspiracy theory creates? Remember that both the first and the second investigation both found that it was a CFIT, albeit identifying different contributing factors.
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Jennifer Homendy
Jennifer Homendy@JenniferHomendy·
Happy 59th birthday to @NTSB! Thank you to all NTSBers - past and present - for your support of our critical #safety mission!
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Michael Gerald Gibbs🏳️‍🌈🍁 🇺🇦 (He/Him)
The more we learn the more it is clear that the Air Traffic Controller was doing his best. His compulsion to take all the blame and responsibility is deeply honourable. He did so acutely aware the world would hear his words. As such he deserves the forgiveness, respect and compassion of all Canadians. His life will be very difficult going forward. I hope he gets all the support he needs. #AirCanada
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Dcms1000
Dcms1000@dcms1000·
Never forgotten
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Francisco Cunha
Francisco Cunha@OnDisasters·
Everyone, keep it cool regarding the CRJ-900 Air Canada crash. Accident was like 4 hours ago but you will find a lot of speculation. Just because a post has 1.1 million views doesn´t mean it's quality content; some is literally a lie, taken from another liar. Others just like to steal each other content without credit and reach 1.5 million views in hours. There are choices Here´s an example of how to report (facts only and not cropping the TV news crop) ⬇️
R A W S A L E R T S@rawsalerts

🚨#BREAKING: Officials have just announced that both the pilot and co-pilot have tragically been confirmed dead following the plane collision with a fire truck at LaGuardia Airport in New York.

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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
While everyone rushes to be as fast and as loud as possible with blame and speculation, here are a few calm and thoughtful comments on the Jazz/Air Canada accident today.
Aakash Gupta@aakashgupta

The air traffic controller cleared the fire truck onto the runway. Seconds later, the same controller screamed “stop, stop, stop.” The plane was doing 93 to 105 mph. Both pilots are dead. Everyone will frame this as controller error. One controller was simultaneously managing a United flight that aborted takeoff after an anti-ice warning, dispatching a fire truck across an active runway, and sequencing an inbound Air Canada landing at highway speed. At 11:40 PM. On a mandatory overtime shift at a facility that has been understaffed for years. A system that assigns one person that workload will produce exactly this outcome. The only variable is when. The FAA is short approximately 3,000 controllers. The headcount dropped 13% from 2010 to 2024 while flight volume rose 10%. Over 40% of the FAA’s 290 terminal facilities are understaffed. The New York TRACON, which manages the most congested airspace in America across LaGuardia, JFK, and Newark, has been chronically below target. Newark was operating at 59% of its staffing goal. LaGuardia handles 900 flights a day. The hiring pipeline is broken at every stage. Only 2% of applicants complete the full process. Training takes up to 6 years. The FAA Academy in Oklahoma City is a bottleneck, with roughly 35% of trainees washing out. Congress blocked legislation to build a second academy. In one recent hiring cycle, the FAA brought on 1,512 candidates and lost 1,300 in the same window. Net gain: around 160 controllers for an entire country. Three things need to happen and everyone who can make them happen has known for years. Congress needs to fund and authorize a second FAA training academy. One facility in Oklahoma City cannot produce enough controllers for 900 million annual passengers. Members of Congress from Oklahoma have actively blocked this. That needs to end yesterday. The FAA needs to cut certification time. Six years from application to fully certified controller is absurd. The agency’s own data shows tower simulators reduce certification time by 27%. They’ve installed them at 95 facilities. That should be every facility, and the simulated hours should count toward more of the certification requirement. The FAA needs to stop plugging staffing gaps with mandatory overtime. Controllers at understaffed facilities are working six-day weeks rotating between morning, mid, and night shifts. The NTSB has flagged fatigue repeatedly. The controller last night was managing overlapping emergencies during a nighttime operation. Overtime is not a staffing plan. It’s a countdown to the next runway collision. The controller said “I messed up” to a Frontier pilot who watched the whole thing. The pilot responded “No man, you did the best you could.” One of them is right. The answer determines whether this happens again.

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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
OTD in 2018, Elaine Herzberg became the first person killed in a self-driving car collision. The investigation revealed familiar patterns: Reliance on automation, human factors, unforeseen scenarios, and organisational pressures. Listen: A Meditation on Automation
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The Essence of Safety
The Essence of Safety@EssenceOfSafety·
OTD in 2017, Rescue 116, a SAR helicopter on a support mission, crashed into Blackrock, an island on Ireland's west coast. All four crew members on board, Captain Dara Fitzpatrick, Chief Pilot Mark Duffy, winch operator Paul Ormsby, and winch man Ciarán Smith were killed.
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Francisco Cunha
Francisco Cunha@OnDisasters·
Sent by a reader as "707 navigator". Anyone can confirm if it's the case? Reverse search didn´t yeld much results
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