Posts by user "safetypee" [Posts: 7 Total up-votes: 19 Page: 1 of 1]¶

A poor system will ultimately defeat even the best humans.
Eighty-five percent of the reasons for failure are deficiencies in the systems and process rather than the employee.
The role of management is to change the process rather than badgering individuals to do better.
W. Edwards Deming

makobob … " we need to hire pilots and air-traffic controllers based on merit and experience "

' Even the best pilots can make the worst mistakes ' James Reason
The point is that accidents involve many converging, often unforeseen factors in situations not envisaged by risk assessment.

From NTSB interim report on DCA aircraft / helicopter collision.

"Near Midair Collision Events at DCA
Review of information gathered from voluntary safety reporting programs along with FAA data regarding encounters between helicopters and commercial aircraft near DCA from 2011 through 2024 indicated that a vast majority of the reported events occurred on approach to landing. Initial analysis found that at least one TCAS resolution advisory (RA) was triggered per month due to proximity to a helicopter. In over half of these instances, the helicopter may have been above the route altitude restriction. Two-thirds of the events occurred at night.

A review of commercial operations (instrument flight rules departures or arrivals) at DCA between October 2021 and December 2024 indicated a total of 944,179 operations. During that time, there were 15,214 occurrences between commercial airplanes and helicopters in which there was a lateral separation distance of less than 1 nm and vertical separation of less than 400 ft. There were 85 recorded events that involved a lateral separation less than 1,500 ft and vertical separation less than 200 ft."



What is seen - reported; and what is dismissed … diminishes the value of reporting.
A system broken: a broken safety management system at the national level.

Prescriptive safety; do as I say not as I do.

Safety via regulation, an illusion of control.

Dr David Woods PhD

"\x85 to everyone in safety: look at the DCA midair collision given info in urgent action letter from NTSB. Widespread systems issues, total breakdown of proactive safety; repeats history from Herald of Free Enterprise to Challenger, Columbia etc. see my chapters on (Columbia testimony to Congress, RE book 2006 & 2005 Organization at the Limit book). Highlights real issues of multiple sometimes conflicting goals over multiple jurisdictions/perspectives, signals discounted in the face of ongoing production pressures, etc. Also note the reactions to failure. All well understood in 3 books capturing the new look work of the 80's -- 1990 (Reason) / 1994 (Woods etal) /1997 (Reason)."
Yet here we are all over again. All over again.

https://www.linkedin.com/posts/davidwoods3_to-everyone-in-safety-look-at-the-dca-midair-activity-7307401640821563392-I5Ez/?utm_source=share&utm_medium=member_ios&rcm=ACoAAAizWBQBjDn2 SfSP5os0fcB7hU2U_S8Iv3k

..

As James Reason explained such issues; "the difference between swatting mosquitoes and draining the swamp."

"\x85 leaders across all sectors - government, business, education - must model critical thinking in their decision-making. By demonstrating a commitment to reason, evidence, and open mindedness, they can inspire others to do the same. \x85 Imagine a society where people listen to understand rather than to respond, where debates lead to solutions rather than stalemates, and where progress is driven by thoughtful analysis rather than knee-jerk reactions."

The Decline of Critical Thinking in the West

https://medium.com/@steveinadelaide/...t-7fc2d297a666

While many views grovel in the dross of detail and avoidance of litigation, the systemic weaknesses remain 'hidden'.

" The reliance on supra-normal vigilance to compensate for an unsafe system is not a practical solution, it\x92s a surrender. It\x92s inaction, squatting where action should be. If all you have is \x91be careful\x92, you are out of ideas."

"Mandating one half of a barrier function is akin to fixing half the holes in your boat: it achieves nothing."

https://journals.sagepub.com/doi/pdf...?download=true

The document is a medical view, but then the FAA and others appear to require medication.

" A revolution in attitude is long overdue ."