To paraphrase Goethe, we learn from history that we do not learn from history. Since learning from the future is not an option, recognising and making better use of lessons from the past may be the only answer to many of the most persistent generic problems in flight safety management.
That is exactly what the European Joint Aviation Authority's Future Aviation Safety Team (FAST) has been set up to do.
A continual criticism of aviation safety management is that it is reactive - nothing significant gets done until people are hurt. So an attempt to be imaginatively proactive is welcome, and that is the new path FAST is now attempting to chart. It is true that trying to predict and avoid future potential mistakes is not a new idea; it is what the manufacturers and regulators have always tried to do during the certification process. The difference now is that FAST is taking account of a factor which has not been tackled before in its own right: change itself.
Real change has always caused at least a momentary dip in industry safety performance.
Change comes in the form of technology advances, but it also arrives more predictably and inevitably as a result of industry growth, producing effects like increased traffic congestion which the industry has to prepare for - often by using yet more technology.
Radical technological advances which have provided examples of what change can do include the introduction of the jet engine, and of the highly automated "glass cockpit". Early accident rates for the de Havilland Comet and Boeing 707 belied the massive increases in safety and reliability that they would herald in the long run. And since the highly automated cockpit arrived in the early 1980s, it has not only been a major factor in a few accidents, but 20 years later it can still be argued it has not improved safety beyond that achieved by "classic" fleets in the hands of mature airlines today.
One of the things that cockpit automation was supposed to do, by taking on a number of tasks that the crew used to perform, was to reduce the number of errors the crew can make. But it is an undisputed fact that human and crew error remains a primary factor in just as high a percentage of serious accidents as it ever was, and that the automation itself introduced new forms of error - like flight management system mode confusion. The accident rate certainly continues to reduce, but almost entirely because aircraft and their systems are becoming more reliable.
Another example of change itself as a factor in an accident is the 1988 Air France Airbus A320 crash at Habsheim airfield, in south-eastern France, an event that the world witnessed on television. This much-heralded new aircraft type was carrying out a very low, very slow pass over the aerodrome for an air show, but then it disappeared into trees at the far side. Nothing was found to have gone wrong with the aircraft or its new fly-by-wire control system - indeed the system prevented the aircraft from stalling before it hit the ground, enabling almost all those on board to survive the accident.
But there is a strong case for saying that the concept of total flight envelope protection was so new that the pilots had not yet "got their heads around" either the idea or the equipment's limitations, and that they had conducted the flight in a way that they never would have done in, say, a Boeing 737, believing that the new aircraft could save them from virtually anything. Whenever radically new equipment is introduced, pilots have to cope not only with what it can do, but how it does it and what it cannot do.
Human beings have to get used to ideas which are truly original before they can really understand them. That is a fundamental truth which has been ignored in the past, and FAST has been created to try to predict how humans will react to the new equipment and challenges of the future.
When Goethe said that the human race does not learn from history he was talking about the behaviour of individual human beings and of society as a whole. Where we have come from is the only clue to where we are going, but a more precise study of how we behave when confronted with the demands of change is welcome.
Source: Flight International
