Pre-Accident Investigations: An Introduction to Organizational Safety by Todd Conklin

Author:Todd Conklin [Conklin, Todd]
Language: eng
Format: epub
Publisher: Ashgate Publishing Ltd
Published: 2012-10-27T21:00:00+00:00

DISCUSSION

Let us identify some of the conditions that, although normal, combined to create this DFEO:

• Weather

• Skills of crew

• Warning and notification systems

• Quality of operational information

• Surprising outcomes happening simultaneously

• Design features of the wings—which create clear fuel efficiency

• Emergency response systems

• Operational leadership

• Normal system responses up to the point of the failure

This event is “classic” in the unexpected combination of relatively normal aviation performance variability, which produced a clear, and potentially life-threatening, deviation from an expected outcome—in this case a safe and on-time departure from the Denver International Airport. All of the conditions listed are extremely beneficial in creating the context for this failure. Keep in mind that this by no means is a complete list. The problem is that all of these conditions are also incredibly normal.

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