Sunday, November 20th, 2016
One area where progress constantly is being made is in the investigation of aircraft accidents. Given the number of people whose lives are at risk, the aviation industry understandably stands out in terms of embracing levels of safety above all others.
Every aircraft accident is investigated (sometimes involving years of work) in order to identify the root cause(s), whether it be the result of pilot error, mechanical failure, weather, sabotage or other human errors. These can result from a myriad of sources, including equipment design flaws, ineffective training, maintenance or operating procedures or even things such as wake turbulence caused by another aircraft.
After an exhaustive investigation of each incident is complete, a final report is written and corrective recommendations made. Changes are then put into place worldwide to prevent recurrences.
Pilot error tops the list of the five most commonly identified causes of aircraft accidents. Pilots are human. They make mistakes, as do all humans, which can account for the inordinately high percentage of the root causes of accidents.
All of the information on the subject of accident investigation warns against defaulting to operator error as the easiest conclusion. Failure to conduct a comprehensive fact-finding investigation of an accident, incident or near-miss may settle on the cause of the event to operator error, the real root cause will not be identified, and similar accidents continue to happen. This is not so with aircraft investigations.
The incredible strides in aviation safety are the result of systematic, by-the-book accident investigations and implementation of effective remedial action. The most important takeaway from accident investigations is to learn from each event. Other industries need to take notice.
Summing-up: Accident causes are not root causes. Root causes are the reasons that lead up to the causes. If the reasons are not addressed and acted upon, we have little hope of reducing the number of needless accidents. The airline industry is a model for what can be done to reduce accidents. Why not learn from the best?