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( 9adu of 11)
I am very interested in the initial stories and the final report on what happened that caused a plane to crash. I watch the video reenactments in order to try to understand what went wrong, when and how and what could have happened to avoid the crash.
I've watched plenty of videos online and there are one to five common factors in plane crashes. These also apply to many other types of catastrophes, not only related to moving vehicles, but also to many other types of events in life, large and small, such as the FIU bridge collapse and the last Space Shuttle explosion, and may other crashes, accidents and tragedies. Most are avoidable.
Look back at any crash, accident, tragedy, catastrophe or “act of God” and you will most certainly find the common pattern that if a single decision in the chain of events had been different, the consequences could have been avoided or greatly minimized.
1. Mechanical failure by design and/or upgrade. This involves a whole lot of people.
2. Maintenance failure.
3. Procedural failure by anyone involved in the plane's manufacture, approval, maintenance, preparation, flight, air traffic control, training, baggage check, loading of the plane.
4. Weather. Though one of top five common factors, it is the only one that is not controllable, yet is the main factor that is overlooked or ignored because someone made the procedural decision that factors 1, 2, 3 or 5 can compensate for and overcome the weather. Procedurally, weather should be a factor, that by itself, overrules all other considerations. What I'm saying is, if any one of the other four common factors were known in advance to be a problem or unsafe or potentially suspect or potentially unreliable, then, in almost all instances, different decisions would have been made to delay or cancel the flight. However, we tend to think we can overcome the weather with our technology and training. We still haven't learned. Our hindsight is not 20/20.
5. Pilot error. Common causes are impairment due to tiredness or drugs. Lack of untested ability to function in stressful or unique situations. Also a decision to proceed due to being in a hurry, often for pride or monetary reasons. Under-confidence and lack of ability to speak up. Also overconfidence in one's ability that makes the pilot think he can overcome all unfavorable conditions, especially weather. Also being distracted at any point during pre-flight through when the craft is safely landed and at a full stop. This last point is important because crashes have occurred simply because the pilot did not apply reverse thrust upon landing. The most common errors are due to airspeed, altitude, plane's orientation, pilot's orientation.
As you can see, all of these five fall into more than one category and have an impact on at least one other category. These five can be summed up as human error. Human error is the cause of all accidents, even if intentionally caused by attack.
All we have to do is look back at the two recent crashes of the Boeing 737 Max Airplanes (Lion Air and Ethiopian Airlines). 1, 2, 3 and 5 were the chain of events that caused those avoidable crashes. Briefly speaking, Boeing knew the planes were unsafe. Pilots were not trained. Pilots consented to fly the planes without training, even after earlier incidents. This is pilot error.
I repeat: We can also apply the same five chain of events to many other types of “accidents” or catastrophes. Most crashes are accidents that are avoidable.
Here's what can be concluded thus far, based on what we know about the helicopter crash that killed Kobe Bryant and 8 others.
1. Mechanical failure by upgrade was involved. The helicopter did not have a ground warning system which seems like a reasonable device for the area the helicopter was operating in. If operated in a place with no mountains, then maybe not.
2. Maintenance failure – none.
3. Procedural failure – A ground warning system was not required, though recommended by the NTSB back in 2004 for all such passenger-carrying helicopters. Kobe appeared to be a cautious person regarding helicopters. However, that process did not lead to installing a ground warning system. Failure by the tower to clearly instruct the pilot to climb due to the area he was in. Doesn't matter if it was not their responsibility. It is your responsibility if you know better.
4. Weather. The decision to fly in low visibility is also a procedural error by Kobe, by the pilot, by the tower who gave them clearance to take off. Too many people made decisions because of the pilot's experience and because it was Kobe as a passenger who needed to get to something “important.” So important, that logical shortcuts were taken that added up to a dangerous chain of events.
5. Pilot error. Clearly the pilot was disoriented and distracted. He requested flight following, but yet was not high enough for flight following to work. Plus the tower told him he was flying too low, yet he did not climb soon enough and did not seem aware of the need to climb, not only for flight following but because he was in a mountainous region and seemed to have slowly unnoticeably drifted lower by at least 1200 feet as he was in a holding pattern at a lower rate of speed. The pilot was over-confident and was likely distracted by the talk in the helicopter and distracted by being in a holding pattern and feeling time pressure to get his special consideration passengers to their destination. This seems to be corroborated by the pilot accelerating out of the holding pattern at 152 MPH while at low level and before climbing. So as soon as he got clearance to proceed, he gunned the engine and took off trying to “make up” time. Then as he was driving too fast for conditions in low visibility, he realized he needed to climb, then wasted precious seconds notifying the tower instead of simply climbing and slowing down and even trying to go in reverse or hover until he could see clearly. His statement saying he was climbing due to cloud cover seems like a cover-up he made to hide the fact from his passengers that he was nervous because he couldn't see. He already knew he was in cloud cover, because he was in fog. He was trying to multi-task multiple contradictory goals. Use visually flight rules, request flight tracking, get there as soon as possible, speed up, climb, appear calm, not make the decision to abort the flight, show how experienced he was.Let us be certain to understand the other adults on the helicopter also made an error by not using their instincts regarding the flying conditions. It is always every person's responsibility to speak up even if the only one to do so. The other adults also made a form of pilot error because they were each in charge of their own lives. It is important for us to speak up.
Once again, we must remain aware that in our daily lives, there are many things that can be avoided if just one decision in a chain of events is different. We can be certain that we have already avoided many accidents because one decision we made or one decision someone else made helped us out.
I think about another recent example of three teens killed due to a chain of events they initiated through a game of dare. And another example of a death due to deciding to drink alcohol and take other drugs.
What I also want to make clear, is that many decisions related to the five common factors above, are decisions we've made in advance long ago and we rush past the decision because our brain is on automatic. Basic decisions such as this have caused much harm such as I got to get to work, got to get there on time, etc. And so we make a decision that ends up causing partial or fatal harm.
I have used the examples of plane crashes and other accidents but the main point is about the many everyday all day avoidable consequences that take place not because of one decision but because of a chain of decisions. We can look back through our own lives and see how many things could have gone differently for better or worse if one decision had been different by ourselves or by someone else.
We are all connected and all of our decisions affect someone else. The effects don't necessarily show up immediately.
The main chain of events is made of logic which is information used to make decisions.
A decision is a decision to do something.
A decision is a decision to not do something.
