Safe Speed Forums

While working late this week I switched to Radio 4 by way of a change and there was a programme about a pilot that lost his wife after a routine hostipal operation. He wanted to find out what went wrong and what could be learnt. His thinking was that in aviation there is an investigation after every minor and major incident, with the objective being stopping it happening again and not prosecution. While investigating his wifes death, he found a blame culture in hospitals that was hampering patient safety and being counter productive. A doctor, nurse or whoever would make a mistake, but because making a mistake = fines/prosecutions/bad press the mistake maker keeps quiet until they get found out, instead of nipping it in the bud and stopping it happening again. Which made me think of roads.

Aviation safety speaks for itself, so what could be learnt from it to make the roads safer? Prosecuting people less and engauging with them more would surely be more productive wouldn't it?

[

I thought vehicle accident investigations were not to see what happened in order to try and stop it happening again, but were to work out who is to blame for what (and therefore who owes the police/government what amount of money)?

There's one of the problems with the current system.

_________________
Andrew.

_________________
The Rules for ALL ROAD USERS:
1) No one gets hurt
2) Nothing gets hit, except to protect others; see Rule#1
3) The Laws of Physics are invincible and immutable - so-called 'laws' of men are not
4) You are always immediately and ultimately responsible for your safety first, then proximately responsible for everyone's
Do not let other road users' mistakes become yours, nor yours become others
5) The rest, including laws of the land, is thoughtful observation, prescience, etiquette, decorum, and cooperation

As I've said in previous posts, the disparity of road 'safety' and other branches of safety is glaring yet often overlooked - aviation accident investigation uses a form of root cause analysis to work out the cause and also how to prevent.

With road 'safety' there is little how did this happen and how do we prevent. JJ Leeming made note of it in his book.

We are missing many tricks much to the detrement of improvements in safety.

_________________
Gordon Brown saying I got the country into it's current economic mess so I'll get us out of it is the same as Bomber Harris nipping over to Dresden and offering to repair a few windows.

Chaos, panic and disorder - my work here is done.

http://www.wildcrafts.co.uk

Herbie, if so much is being learnt about the causes of road accidents, then why is this information not being promulgated? In aviation safety, I receive a flight safety circular weekly, with details of incidents and their causes, along with monthly publications from all three services and two civilian organisations, and every major aircraft incident, >cat4 I believe, has its own dedicated report, detailing the chain of events that led up to the incident and highlighting all causal and contributory factors. This is facilitated by the lack of a blame culture, despite what you may think, as people are more than willing to speak out about their own experiences, scares and near-misses to help their colleagues become safer, secure in the knowledge that they will receive no censure for doing so.

Incidentally, "pilot/driver error" is pretty much never the cause of an accident, it is a symptom of the underlying cause. In aviation the days of chalking everything up to "pilot error" are long, long gone. With a greater understanding than ever before of human factors and similar issues, it is almost always the case that the cause can be traced back to something like fatigue, disorientation, lack of experience/training etc.

The "driving community" could learn a lot from these practices.

_________________
Regulation without education merely creates more criminals.

Herbie, you're coming across as rather condescending for someone who is illustrating that you don't really know what you're talking about.

I am not in the "aviation industry", I am a military pilot, and my aircraft does nothing for me that I do not require of it. There is always something to do other than "just die". If you had bothered to familiarise yourself with Reason's Swiss Cheese model, then you would understand that the removal of any causal factor, however insignificant, is enough to break the accident chain.

I say that pilot error is pretty much never the cause of an accident to try and avoid the kind of semantic insignificances you seem keen on highlighting. It is never the cause. Pilots may make mistakes, but that is a symptom of shortcomings elsewhere, often in experience/decision making, sometimes in training, and sometimes in other human factors. Nobody sane intentionally puts themselves into a crash, and if they did it would not be pilot error, because they would have achieved exactly what they set out to! If they are not sane then we have supervisory failings, as they should not be at the controls.

The publications I am privvy to are not merely a catalogue of every incident, they are used to highlight trends that can affect flight safety, and as such could definitely be carried over to motoring. The vast majority of articles involve no serious incident at all (those tend to get their own accident report) but are of the ILAFFT variety ( I Learnt About Flying From That). Due to the lack of a blame culture, people are at ease reporting circumstances where they have felt that flight-safety was preventably below the optimum, such that others can learn from them. They're not willy-nilly publications of every little thing, and are edited to ensure they are relevant.

As an example, there was a spate of incidents involving oil-filler caps being left untightened on helicopters, with varying severity of results. Road-safety dogma would suggest that we put it down to "engineer error", and slap the engineers with sanctions for every offence. Fortunately we're a little bit more enlightened than that, and it was discovered that, as part of the maintenance routine, they were easy to overlook. Routines and equipment were altered, and it happens much less frequently now.

You're getting really hung up on the blame aspect, and seem to be completely missing the point that learning from the causes, rather than pointing the finger, can help to reduce or eliminate occurrences of similar incidents.

_________________
Regulation without education merely creates more criminals.

Quote Origin

Wiki Link

The phrase 'Pilot Error' used to mean a we don't know what happened so we will blame the pilot as he can't answer back,

It slowly changed to we know the mechanics worked so it must be the pilot

It's now more a case of the pilot was in error but these factors were present for that error to occur, factors such as those that Robin mentioned (i.e. organisational factors amongst others) can allow otherwise mitigatable errors to reach an unwanted conclusion.

I would dearly love to see a road incident investigation that uses TOPSET methodology or similar, they do not and I suspect it is unlikely it ever will, Why? because it also looks at organisational / policy / procedural factors that in turn will mean that HMG / local government and its arms will have to look at itself, whilst this may be very cost intensive to carry out on every incident, it should at least be conducted on major incidents.

Of the incident reports I've seen in my career most of the road incidents I've seen focus on what has happened, with a view to ascertaining guilt for prosecution rather than what happened and then taking the extra leap of WHY did it happen.

Of the incidents at work I've seen many organisations do not go into organisational factors because it opens up shortfalls within the organisation, that it does not want to explore.

Aviation, petrochem, explosives and other high risk industries learnt (often in through painful experience) that selective investigation, blame searching and failing to address organisational factors fails to deliver the potential improvements in safety that a thorough investigation brings.


TOPSET Description

_________________
Gordon Brown saying I got the country into it's current economic mess so I'll get us out of it is the same as Bomber Harris nipping over to Dresden and offering to repair a few windows.

Chaos, panic and disorder - my work here is done.

http://www.wildcrafts.co.uk

One would hope it'd be easy to enlighten you, because you are clearly talking about something completely different to the rest of us.

Yes, it is human instinct to want to wreak vengeance upon those who we feel have wronged us. Yes perhaps society demands that some shortcomings are attributed in punitive measure to an individual. No, this never, ever, ever prevents accidents of a similar ilk caused by other people. Are we on the same page?

Blame and prevention come from two very different schools of thought. You will never stop someone making a genuine mistake merely because they are afraid of the sanctions that mistake will bring. Believe me, I have been through flying training, and I know that this is one of the worst kind of pressures you can bring to bear on someone. Unless it is an integrity issue, inexorably linked to safety (I'm thinking of the example of reporting an overtorque, for those "in the know") it can't possibly bring positive results. Even in that example, my experience bears out the idea that it is an obligation to your fellow aviator that garners the response, not the threat of punishment. This is the attitude we need to foster amongst road users.

If you are not familiar with Reason's Swiss Cheese model, then I suggest you look a couple of posts above, to the one quoted by The Rush. If all else fails, Google is your friend. If you find it condescending that I accuse you of having no clue what you are talking about, then I suggest you furnish us with your credentials for professing to have a comprehensive understanding of aviation safety reporting.

Commercial aircraft will not gaily carry their pilots to their doom, and to suggest so is to do a disservice to the highly talented designers that have incorporated pilot aids that will not interfere with the emergency handling of the aircraft.

Your 'last comment for now' misses the point by a country mile. Any apportioning of 'blame' needs to be to the root cause, often systemic, rather that resting with the first individual it falls upon. This 'blame' also needs to be of a nature that influences change that will prevent further accidents, rather than just punitive measures to sate vengeance. Your drunk driver is a perfect example; society's opinion of drink driving has changed, rightly or wrongly, from wishing the police would leave people alone when they just enjoy the night and drive home, to demonising those who attempt to take to the wheel whilst impaired to a dangerous degree. The problem is, taking away one drink driver's licence does not stop another one ploughing into a taxi rank full of people the following night! An increase in the threat of sanctions hasn't alleviated the problem either. Blame clearly isn't working, how would you suggest we tackle the problem now?

Regulation without education merely creates more criminals. Write that down.

I've just spent the night flying round the country with glowing green bog-rolls strapped to my face. I'm off to bed.

_________________
Regulation without education merely creates more criminals.

.

Sorry Herbie, the only person I can see throwing insults is you. Since you clearly have an adverse reaction to being shown to be wrong by strangers on the internet, I would suggest that you go and talk to some of those current serving military pilots you know, and get the same story from them, perhaps then you'll start to listen.

_________________
Regulation without education merely creates more criminals.

Providence, attempting to intervene?

Ouch, they were not the most comfortable of things at the best of times !!

_________________
Gordon Brown saying I got the country into it's current economic mess so I'll get us out of it is the same as Bomber Harris nipping over to Dresden and offering to repair a few windows.

Chaos, panic and disorder - my work here is done.

http://www.wildcrafts.co.uk

Blaming someone, whether it was their fault or not, does not stop the accident from having happened. It doesn't stop it from happening again.

_________________
Andrew.

To this, I will so stipulate.
We are all for more training (don't forget better training, testing, etc).
Though it may be hard to find out who these people are, and by what standard to find them wanting, removing the worst 10% of drivers from the road would very effectively communicate that the bar has been raised for everyone - provided they were given an opportunity to meet or exceed the new, higher levels of qualification.

While the reengineering of roads and road furniture can surely improve safety for all road users, that would most likely only occur in a culture willing to address and attempt to alter ALL the known causes of system failures / crashes, including the culture itself.

_________________
The Rules for ALL ROAD USERS:
1) No one gets hurt
2) Nothing gets hit, except to protect others; see Rule#1
3) The Laws of Physics are invincible and immutable - so-called 'laws' of men are not
4) You are always immediately and ultimately responsible for your safety first, then proximately responsible for everyone's
Do not let other road users' mistakes become yours, nor yours become others
5) The rest, including laws of the land, is thoughtful observation, prescience, etiquette, decorum, and cooperation

I have decided to withdraw from this site as there are in my opinion too many people who feel enlightened when they are not, arrogance, dismissive ignorance and abuse are far from the bed fellows of enlightenment.I may be a reactionary but not an instigator.There is also far more self importance than the will to read, understand, comprehend even the english language and its true meaning which leads to little positive input.There are far too many educated but blinkered people here promoting nothing more than look at me look at me Im right(when often they are wrong), with the enevitable attempts at ridicule when they have clearly mis-read and mis-understood something thereby failing to see it as their error and mistake.'Enlightened' as one person claimed to be is no more enlghtening to me simply because it was expected. It is amazing how little a accidental or deliberate comment or gramatical error can make some so self important and ignorant at the same time. Its equally sigificant how easily many of you can immediately drift away from the subject matter and start forming the playground alliances and present yourselves in no better way than kids going naa naa na na naaa! and you have the cheek to attempt ridicule of me.Some of you are collectively a fine example of the real problems the whole world faces and one of the reasons little gets done. People are the worlds problem not its savior, people who take a formal education then focus on one profession may be good at what they do but it is no certificate of excelence in everything else, but unfortunately too many think it is. Ive read enough posts by many of the so called enlightened and educated but no logical or sensible answers. Also the ammount of conflict between things that have been proven to work and the selfish ideology of some throughout this site makes me wonder where some have been taught and how they have been taught . This thread is nothing more than a pilot (who likes everyone to know that)promoting his take on policy adopted by the aviation industry and his wish for it to be adopted in the world of driving.

No recognition of the complexity involved, no understanding of any of the differences between aviation and motoring wholistically, no awareness that much he promotes happens withing the motoring world anyway,little understanding that its human nature to report something with the hope something is done to correct it and where error/mistakes are concerned there are enough people and enough science to discover. But the biggest show of ignorance is the lack of understanding that things like manipulation, cohersion, intimidation and threats are used every single day along with encouragement and praise in many different ways by almost all human beings. Threats are used all the time, threats can be self manifest throughout any culture, the threat of embarrassment for example. I am really really surprised with some people in this site, you have allowed PC type of behavior along with cuddling up to those you feel akin to your views ,close your minds almost completely .

Making quotes about such things as the swiss cheese model and like children try to ridicule me as if I dont know what it is, when clearly you havent understood what I said, who is ignorant here, me for not getting my message across, or you for only understanding a preferred way something is published or simply siding with someone you see as an idol or preferred companion and accepting regardless?

There has been little discussion in this thread just a lot of self promotion, ridicule, abuse and ass licking. I wont be contributing any longer to that CULTURE as it has had its day a long time ago, only the less enlightened dont see that. It is and always has been a waste of time debating or discussing anything with a majority of ignorant people who clearly think themselves superior. It is so easy to discover such people without any difficulty at all, you just have to present them with the written word for them to use interpritation, a bit like letting people read a novel, 10 people will have different views of the subtleties within the pages they read, its the same in here only people can then interact with the story, everyone having thoughts as to who is a hero to them, who is the clever one and who knows what then they can take sides in the story. awww!

I cant see much debate of benefit in here as I have seen hardly any debate at all. goodbye! .........you may now gather togeather in the playground as the bell has just gone.

Herbie

As I said in viewtopic.php?p=183185#p183185 , I reiterate - a shame to see you go if you do - and a shame I've only just caught up with this as I cannot see what you put as you've chosen to wipe out your contribution, leaving only the snipes made in response.

I have respect for your posts and points of view, but I do recognise in both your posts and those of several others, as things get fractious, the heat gets.. hot!

I hope some day you return with your wisdom.