QF32 CASE STUDY
KEY TAKEAWAY:
While many of the controls identified in the analysis above may already exist in the system, the specific hobbies and interests of the Captain flying QF32, Captain Richard de Crespigny may need to be further systematised for pilots. Captain de Crespigny was an avid follower of aircraft and spacecraft disaster investigations. So much so, he was planning to write a book about it. When it came to responding to the emergency on the day of the engine loss, in 'inverting the logic' to focus on what was still working in the thinking process Captain de Crespigny describes, he was as much relying on what he learnt from aircraft disaster investigations during his reading outside work time as much as his Qantas training. In learning from what went right here, it would be useful to consider whether this aspect that was specific to this pilot's own interests can be further systematised at an organisational level. The question becomes: is there more the organisation should be doing for all pilots to be curious and read/learn about aircraft disasters on an ongoing basis as part of their continuous education?
Serious incidents
What went right in an incident can be just as instructive as what went wrong. By identifying effective control features, they can be replicated across the system. Even if what went right was not a control at all but a "lucky event", an analysis of this may be instructive as to the type of controls that might work as a final barrier to the incident's causal trajectory. Lessons from disasters, instructive as they may be, are entirely superficial. Traditional linear incident investigations have limited ability to impact incident preventions because lightning does not strike the same place twice. Even in serious incidents, there is often something worse that could have occurred because of effective mitigation factors or an effective incident response. It is useful to recognise this in the context of an investigation because it provides recognition of the efforts of the individuals involved. The attraction with asking "what went right?" is its positive character. We know that reinforcement is the most important principle of behaviour and a key element of most behaviour change programs. We also know that positive reinforcement is far more powerful than negative reinforcements. We say someone has received positive reinforcement if a desired behaviour they display has been followed with a reward or stimulus. Negative reinforcement is when someone receives punishment, an aversive stimulus or a withholding of a stimulus after displaying certain behaviour, usually undesirable behaviour.
The focus in the PIM approach adapted to serious incident investigation is two-fold:
Firstly, understanding what could have happened if circumstances were different and recognising and learning from what made the incident less serious, and Secondly, verifying that whatever controls are being implemented would be effective in different circumstances.
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