Posts by user "PEI_3721" [Posts: 6 Total up-votes: 19 Page: 1 of 1]¶

Could "an element of judgment or choice" be applied to those who approved the procedure ?
or
Those who hold responsibility for safety management, where 'the' element of judgment or choice differed from industry standards or recommendation.

Those fiddling with decent angle, flight path clearance, routing, etc are only considering the symptoms of this accident; not the illness which created the situation, and which could generate other, similar situations not effected by minor interventions.

Beware of fixing the last accident, whereas the underlying issues remain, festering until the next opportunity.

# 1194 Caley,
"… and yet that is precisely how ICAO stipulates that accident investigation should work. The consequent focus on such things as ‘proximate cause’ and the inherent unwillingness to deal with underlying aetiology work against holistic approaches and generate exactly the outcomes you warn against. "

In part yes, I agree.
However, as you might know, ICAO does not 'stipulate', it provides recommendations and standards of practice (SARPS), e.g. Annex 13, on which nations can base their investigation and reporting.
As such it is the interpretation of by individual nations and their investigators which direct investigation, findings, and recommendations.

Some nations interpret SARPS better than others.

There is an interesting example (amongst many others) of wider investigation and reporting in the Fukushima accident report: Pprune Safety Forum Fukushima Nuclear Accident Investigation

Reforming the regulators
The Commission has concluded that the safety … cannot be assured unless the regulators go through an essential transformation process. The entire organization needs to be transformed, not as a formality but in a substantial way. … regulators need to shed the insular attitude of ignoring international safety standards and transform themselves into a globally trusted entity .

P.S. Re the investigation above, also noting 'Cosmetic Solutions'; if the findings from this DCA investigation warrant it, would the NTSB conclude 'This was a manmade accident, made in the USA'
.ii

WMF # 1207,
"… don't think there's anything to be gained from going down the ICAO route. The NTSB has it's own charter and that's what dictates what happens in the USA."

If so then the NTSB (FAA, USA) attitude raises safety concerns.

From systems theory, all systems (i.e. aviation) will change with time, tending towards greater disorder (increasing entropy), often referred to as complexity.
To date, the industry has managed this change and simultaneously improved the level of safety, and with economic benefit.
A contribution to this is the use of world standards (ICAO, UN charter) enabling, aiding, inter-country operations, and refection on one's own, home standards and assumptions

Independent, fixed attitudes may encounter more safety issues as the overall system changes.
Safety minds, thinking, has to change just to keep up with the changes in aviation - what has been done safely before may not apply today or in the future.

WMF,
… well having searched the usual places and the NTSB, you will have to help with directions and text for reference.

There is a NTSB Charter for data, but nothing which explains the link between ICAO and the USA, and thence to the NTSB and investigation, or the required statement of any USA deviation from the ICAO guidance (Annex 13).
Notwithstanding https://www.ntsb.gov/about/organizat...office_as.aspx
" fulfill U.S. obligations under International Civil Aviation Organization agreements"
"to examine specific aviation safety problems from a broader perspective. "

But back to the thread. Are there any reasons why NTSB might not comment on the wider organisational aspects as indicated in the discussion. Also noting that the NTSB have no powers of enforcement, relying on the FAA; thus if the FAA process were to be identified as deficient, who mandates change.
,,

The legal approaches are like sweeping up after the 'Lord Mayors Show' (a parade with horses).

The core issue remains that of air safety;

An independent US view focussed on safety:- "The night everything at DCA finally went wrong"

https://theaircurrent.com/aviation-s...pecial-report/

Lessons that aviation can learn now, without waiting for a trial or raking though the embers of investigation.

Note the heat map of reported incidents - the data existed, but not acted on.

"\x85 only one pilot out of four interviewed by the NTSB had an accurate and complete understanding of the structure of the D.C. helicopter routes \x97 an individual who happened to have seven years of prior experience as a military pilot in the area. Two pilots had no awareness that published routes for helicopters even existed." And other telling quotes.

Knowledge, information sharing, published approach charts, normalisation of deviance (Dekker); a systemic accident (Reason).
'Safety' is easy with hindsight, but there are many people who's job is to have foresight - to review and act on reports, at least ask 'what if', to think about, and seek an understanding of every day work (Hollnagel).