Aviation – John Vincent

Human

It’s good to be able to stand on the shoulders of the outstanding people who have gone before. I’m lucky in having worked with some exceptional people in my engineering career.

That’s not the whole story. To appreciate the good, it’s necessary to experience the bad. There are a couple of people I’ve worked for, and with, who had less than admirable qualities. There’s no way that these experiences warrant the personal touch, naming names or pointing fingers. It’s only by standing back, taking time, letting water flow under the bridge that some behaviours become explainable.

Let’s face it, we are all subject to pressure, on occasions, and there are times when our reactions are not what we might have wished. That’s true of me as much as anyone. Here’s a one or two deidentified examples from the last 40-years of my work.

Hieratical management structures have inherent problems. A reports to B and B reports to C and so one. This way of working was atypical of large industrial organisations for a long time. Then the modern fashion for matrix management[1] swept in.

As a young engineer, working on a major project that involved several subcontractors, the love and terror of the Gantt Chart was familiar territory. This was especially true when key millstones involve an enormous number of components coming together at the same time.

Ever been in an important meeting where your boss throws you under the bus? Then having to pick-up, the pieces the next day. I suspect this is a common experience. The pressure of having to deliver something onetime, and to cost, and having said to the higher-ups that there were no problems, then human behaviour can become unreliable, to say the least. Naturally, after work experiences like this one, it’s easy to promise yourself that you would never do the same. Ho Ho.

Then there’s the case of the senior person who is wrong, or at least that’s what subsequent history showed, and you can’t convince them, at the time, to take a different approach. What makes this harder is knowing that they have the intellect to run rings around you, but they remain adamantly wrong. Times when, at the end of the day, you wander home grumbling like Muttley[2] the character in Wacky Races. Yes, I’ve done that after a few awkward moments.

To add a third one. A smart new boss takes over. A fresh broom with a reinstated mandate. Determine to fix all the things their seniors say needs fixing. Inevitably a period of uncertainty hangs like a mist over the whole organisation. During the first months, everyone has one question; am I part of the deadwood that needs trimming or am I part of the brave new future? My situation was of positivity, lashings of optimism and creative possibilities. Then the realisation kicks-in that this information gathering period wasn’t about renewal. It was about a person climbing the greasy pole.

I will always council against cynicism. Adopting a permanently pessimistic attitude to human behaviour is down-right foolish. Let’s hope this is confined to a few[3]. However, young people entering the world of work do need critical thinking skills, some knowledge of human behaviour and it never does any harm to add a bit of stoicism[4].

[1] https://www.indeed.com/career-advice/career-development/matrix-management

[2] https://wackyraces.fandom.com/wiki/Muttley

[3] https://hero.fandom.com/wiki/Marvin_the_Paranoid_Android

[4] https://dailystoic.com/9-core-stoic-beliefs/

Patch?

Hobbyists built it. So, how come billions are invested by the huge corporations that use it? Only a fraction of their resource was used to create it in the first place. The INTERNET is as much a wonder of the world as the pyramids. I don’t say that lightly. Today’s level of interconnection, intercommunication and interaction across the whole globe was merely speculated about 50-years ago. In historic terms that’s the blink of an eyelid.

Where we are now it’s impossible to imagine a future without the facilities that are at my fingertips. Tap out recognisable words and they can go anywhere, everywhere, or nowhere.

[That part is poor. Keyboards are where my fingertips connect with the world. Surely there will come a better way in the not-too-distant future? Evolution didn’t make us this way.]

Looking at some other major advances of civilisations, they came about in separate ways.

Long distant roads were originally military assets. Getting legions of troops from one place to another in a sprawling empire. Dominating the landscape. Reinforcing even the most remote outpost. Crossing a great distance on land has moved through several phases, waterways gave way to railways and they back to roads, as a primary means of transportation.

The telegraph was more, what I might call, can do technology. Experimentalists like Marconi put two and two together to make five. Scientific investigation provided the possibilities. He, and his like, were entrepreneurs. They saw the piece parts of technology as a business opportunity.

Aviation was more of an evolutionary advancement. A dream that the ancients held and wrote about. Slowly down the centuries theories and experimentation came together until powered flight became viable. Then decade after decade, more technical possibilities were exploited. Warfare, enterprise and adventurers have driven continuous development.

The INTERNET wasn’t seen as a commercial opportunity at its inception. It was a put together simply as a means for scientists to share their work. Maybe more than hobbyists doing the work but technicians with no master plan for world domination. They certainly were not Bond villains.

That is one possible one reason for the vulnerabilities inherent in our global electronic infrastructure. This week, the implications of those intrinsic vulnerabilities are becoming all too apparent. Embedded code that only a few experts take any notice of, that is until something bad happens. Their vital work never especially celebrated or significantly rewarded.

I don’t say it will ever happen but what if there was a practical plan for an INTERNET-2. A whole new set of protocols? An attempt to build-in integrity, expandability, and security from day one. Learning from experience.

The word “patch” is an indication of how crazy the current situation remains. It’s like that silly word “glitch.” Even the word “junk” seems quite inadequate if a crook “hacks” someone’s private account. These words make serious issues seem like minor inconveniences. Distinguishing between annoyances and harmful situations has become muddy waters.

Why is this the case? Is this the only way to communicate what’s going on.

I think it goes back to simple utility. Is the INTERNET, in its current form, so incredibly useful that society can tolerate any number of “inconveniences.” I wonder. Or will the story be like the waterways and the railways. Neither will ever go away but one will dramatically improve on the other. Push past the other. Thus, civilisation advances.

Qualitative and Quantitative

Do I need to define these two? Yes, because they are not words that automatically come up in everyday conversation. Not even in technical conversations.

A qualitative approach to an argument deals with words, meanings, and experiences. Not so much opinions but defensible objective judgements based on best available information.

A quantitative approach to an argument deals with analysis, numbers and statistics. A scientific approach rooted in believable evidence that is reliable, repeatable, rational deduction.

In the aviation safety world, we use both. It’s my view that one is not subordinate to the other. However, the persuasiveness of one is greater than the other. At the end of the day, persuasiveness matters. If a key decision is to be predicated on an argument, then how it is constructed and presented matters a lot.

Many is the time when I have sat in a room listening to a person make a case in as elegant and enthusiastic a way that they can, but the results have been less than impressive. I’ve made the mistake myself. Coming prepared with a barrage load of sound evidence accompanied by a flaky presentation that misses the mark.

That is why the order needs to be thus. Establish a qualitative argument supported by quantitative information. Not the other way around.

In the field of aircraft system safety assessment this is vital. Probabilistic analysis is a powerful tool. Relating numbers to human experience is not so easy. So, detailed charts and logic diagrams sprinkled with numbers are unlikely to be enough on their own.

Stating an objective is met by handing over a pile of calculations is half the job. However impartial and truthful the numbers may be, arguments are not made until they are explained.

Many is the time when I have lifted a large report from my in-tray, studied it and concluded that there’s something missing in that gap between the QED and the statement of compliance.

Maybe this an element of safety regulatory psychology. It’s difficult to approve something if it becomes difficult to explain to others what’s been done. That evidence trail needs to be explainable. And easily explainable to a wide audience.

This doesn’t change with digitalisation. Replacing large piles of paper with large files of results puts the reader in the same position. Impenetrable evidence needs understandable explanation. Presenting a qualitative argument supported by quantitative information is a good way to go.

Servicing the future

Extrapolation is a dodgy game. That is to take a set of figures from past performance and then projecting them into the future. All too often, even in the world of artificial intelligence, a linear projection is deemed sufficient. Having a mass of collected data and then plotting a line that nicely fits somewhere in the middle. Assuming that there’s a value that is atypical of the accumulated data set.

It’s well accepted that predicting the future is fraught with assumptions. Real life is multidimensional and full of combinations and permutations of possibilities that are off the charts. However, everyday there is enough stability to make planning a useful activity.

There’s the phenomenon of the step change. Overnight a new law may be applicable. In the morning a new system may be switched on. In the evening, a major crash may stop transport links for hours. Events, both predicable and unpredictable throw a spanner in the works.

Trying to predict future workforce needs based on current facts and historic trends is something every major industry must do. I say “must” accepting some struggling and pathological organisations survive on a day-to-day basis.

So, if I start with a 100 people and expect a growth of 5% each year, it’s not unreasonable to think that I might need 105 people next year. It’s surprising how often this basic calculation is presented. Same with the predicable response from a chief executive who would prefer an improvement in productivity. Deliver the same output with the same, or less, people.

Predicting one year ahead is a must. Predicting 10-years ahead is nice. However, in certain industries where, say the products have long lives or the demand for services isn’t going away a long-term projection has meaning.

The search for productivity goes on. Digitisation has made inroads into the paper-based world of a couple of decades ago. I remember when I first held a digital camera in the office. In the mid-1990s it was a whizzy bit of kit to be loaned out on rare occasions.

Artificial intelligence, and all the technology wrapped around it, are reshaping business strategy, risk assessments and workforce planning. Everyone is seeking a competitive advantage.

This morning when I woke up, I was introduced to a new word. It was a BBC radio broadcast called: Rethink: manufacturing or services?[1] It doesn’t exactly roll off the tong. It’s servitization.

The premise is that the line between organisations manufacturing products and those who provide services isn’t a ridged one. Progressively, whatever the product, train, plane or automobile, they use masses of data not only to make but to operate. The data flows rapidly backwards and forwards between maker and operator. And lots of it too.

So, if I had to estimate the number of service engineers that would be needed in the next 10-years, I’d better be aware that their jobs are going to change dramatically. Radically.

However, overall will the numbers of people needed by an industry decrease or not? Or is it just that the nature of work will change for roughly the same overall numbers? That’s not so easy as a straight-line graph. Maybe, as productivity increases so it becomes possible to take on new tasks that previously were not viable. The performance of a product continuously improves.

I’d buy a service and not so much a product. I’ll buy 100,000 miles, not a car.

[1] https://www.bbc.co.uk/programmes/m00325dd

Future of Aviation: Enhancing Safety and Resilience

The aim is clear. A safe, secure, sustainable and resilient international aviation system. I’d add to that list an ambition to continuously improve.

And that’s in the face of the challenge that was recognised 30-years ago. With an aviation system that knows how to archives a high level of safety, even incremental improvement is challenging. Factor in projected air traffic growth that’s unabating. What we know is that that continuously improving the global accident rate requires active interventions.

Since here I can only highlight the key priorities, I’ll choose three aspects of active intervention. Back to what I said earlier in my talk. Aviation is still climbing a maturity ladder. Digitisation has facilitated a growth in proactive work. Initiatives and plans identify actions aimed at solving known aviation safety problems. But the next step remains some way off. It’s that ability to anticipate safety problems before they occur. To predict.

We have the notion of safety intelligence. There are Big Data projects that are gathering large quantities of aviation safety data. Today, what might be called prognostics continues to depend on expert judgement. That’s not negative, as such. In fact, that augmented by objective and trustworthy safety intelligence is a route to the next step in maturity.

In my view, here’s the three categories that must be addressed now and, in the next decade.

One is a foundation stone of aviation safety work. It’s the capability and will to react in a timely manner to events. Not just accidents and serious incidents but any event that elevates aviation safety risks above acceptable levels.

Top operational risk that are likely to need immediate actions are those involving loss of control and those concerning runway incidents.

To take timely corrective action the results of investigation need to be readily available. As pointed out by the industry, across the globe, there’s much scope for improvement here. Timeliness matters.

My next category is that of systemic risks. System wide safety risks. People, organisations, processes, procedures, the human factor and human performance issues.

Much is being done to ensure the effective implementation of safety management systems (SMS). The four pillars of SMS have proven to work – safety policy, risk management, safety assurance and safety promotion.

The acceptance, elimination or mitigation of risks is not an act that begins on one day and stops on the next. Digitation can help but there’s always the dangers of the needle in a haystack or even problems sitting in plain sight.

What’s often weak is the communication of what’s discovered. Believable, understandable straightforward communication to decision makers is vital.

Thirdly, what’s ahead of us is an order of magnitude more complex than what’s gone before. And a rate of change that mindboggling.

I’m calling this emerging aviation safety risks. The question arises; are we ready for advanced leaps in technology? Hydrogen, hybrid propulsion, machine learning, quantum computing, complex airspace networks and robotics. Humans as executive manager whilst retaining control only in emergencies.

It’s a famous quote; data is the new oil. We are ushering in extremely large and complex datasets that will be essential to the workings of automated and autonomous systems. Could data be the new quicksand? This is a huge issue in dense airspace where crewed and uncrewed aircraft must share the airspace.

Another emerging aviation safety risks, that industry and regulators are starting to address is the fact that safety and security have become inseparable. In the past, these disciplines were addressed as silos. That’s no longer viable.

Another emerging aviation safety risk is that of the workforce. Aviation has attracted dedicated professionals who acquire experience and train to a high level of competence. A safety culture has been embedded. In this respect the fundamentals of aviation safety remain constant.

The rapid growth of technology is a two-edged sword. Now, there are many opportunities for future generations, but aviation may not be at the top of the list of choices, as it has been. There’s a serious aviation safety risk if serious investments are not made, people are not motivated and able to gain the competencies needed by a rapidly changing industry.

To sum up. Everything I’ve spoken of can only be addressed in partnerships. In the past, the aviation industry and its regulators have proven themselves to be imaginative, resilient and forward looking.

The challenges ahead, dare I say, are even greater. Levels of integration, interdependency and rapid technology adoption are off the charts. Yet, I believe we can continually improve global aviation safety. We can step up.

POST: Farnborough International Air Show 2026. 20-24 July 2026.

Current State of Aviation Safety: Data-Driven

The present day. Today. There will be Press Releases galore at this air show. I expect ambitious and upbeat predictions. More orders. More growth. More developing markets. Demands for more skilled people, more performance, more pressure for the early adoption of rapidly changing technologies.

My subject is safety. Where are we with aviation safety in the present day? There’s a sound legacy. Afterall aviation has a long tail. What we have now, and if I look at the Farnborough Airshow catalogue of ten years ago[1], is digitisation. The ambition to be data-driven. A continuing drive to exploit data of all kinds. Extracting information from ever increasing sources in aviation.

This desire for actionable safety intelligence is not new. On my desk I have a coaster celebrating the UK CAA’s MOR Scheme[2]. That’s been alive for 50 years (1976-2026). Occurrence data has been, and is being, used to construct all sorts of safety performance indicators. These indicators can be useful but it’s not always so. They are fuel for safety management systems.

I used the word “actionable” with purpose. Today, making the results of safety data analysis useable by front-line actors and responsible managers has been a challenge we wrestle. I’ve often heard it said – that’s great but what do I do about it? Too many “greens” on a chart and complacency can set in. Too many “reds” and everyone goes into panic mode.

I have been fortunate to work with a number of safety initiative. One called the Commercial Aviation Safety Team (CAST) in the US. To match its work, on this continent, I set up a European version; ECAST in 2006. The focus was on data-drive analysis. There’re safety teams for Rotorcraft and General Aviation too.

These safety initiatives came about a reactive way. Reporting in 1997, the Gore Commission, was a reaction to dilemmas that is still with us. What to do in the wake of catastrophic accidents. And more pertinent to this talk; what to do when the global accident rate curve looks flat at the same time as predictions are for a significant growth in global air traffic. Reading this report now, the predictions were horrifying. Predictions of one large aeroplane fatal accident every week by now. Luckily, commercial air transport didn’t suffer that fate.

I should NOT say “luckily”. Current safety performance is down to an enormous amount of work done by thousands of aviation professionals over a sustained period. Not only this but shocks, whether they be financial crisis, volcanic eruptions or global pandemics, have tested this industry severely.

Taking on board what was learned over the decades, safety management has developed and matured. Incorporated in aviation’s safety regulatory framework, it’s now practiced across the whole industry. Almost. We don’t just react. We now have Safety Plans. Lists of actionable tasks aimed at continuous safety improvement. On the scale mentioned earlier – we are proactive.

Let me stop. This is not a utopia. I’d say at least half the global aviation industry is struggling with the need to be proactive. So, the road we are travelling on remains a long one. We don’t just need the capability to do better; we need to maintain the will to do better.

[1] 50^th Farnborough Air Show in 2016.

[2] https://www.caa.co.uk/about-us/make-a-report-or-complaint/report-something/mor/occurrence-reporting/

The Evolution of Aviation Safety: A Historical Overview

A quick tour of the history of aviation safety. In a couple of minutes.

As powered aircraft took to the skies it quickly became apparent that, of all the means of transport, aviation was less forgiving than others. Moving at speed in four dimensions, with the necessity to take-off and land safely, has inherent risks. By no means does this mean that flying is an dangerous activity. What it does necessitate is an exercise of sound engineering, preparation, and proficiency. When these are missing, and in cases of misfortune, accidents and serious incidents happen.

In the days between the world wars, aviation moved from the military and a circus-like amusement to a viable means of public transport. Progressively, more passengers had the opportunity to experience the wonders of flight.

Today, it’s not the early days of flight I want to focus on, but we do owe the engineers and aviators of that time a great debt. Much was learned as aeronautics matured. Since the end of the second world war the production, promotion and application of standards has embedded what had been learned. This has established the way that international civil aviation works.

One simple expression of the stages we’ve been through is Prof Patrick Hudson’s[1] model. This model describes five distinct levels of cultural maturity. The steps are pathological, reactive, calculative, proactive and generative.

This model sits alongside steps in the development of technology that have been a hallmark of aviation. Different categorisations exist. AIRBUS[2] has one that’s easily understood in terms of generations of civil aircraft.

First are the “classics” of the 1950s and 60s. Next, the second generation starts down the road of more electronics. More safety critical systems. Third generation starts flying in the early 1980s when automation becomes the norm (early fly-by-wire, glass cockpits, flight management systems). The fourth generation introduces safety systems, which address the major causes of fatal accidents, namely Controlled Flight Into Terrain (CFIT) and Loss Of Control In-Flight (LOC-I). That’s the early 1990s. When I made that move from industry (design and production) to an aviation safety regulator.

Now, I’d say we are well into fifth generation aircraft, with composite structures and integrated modular avionics. In fact, we are well into speculation about what the sixth generation may look like. Machine learning, single pilot operations, hybrid powerplants, aircraft as a node on a network.

Because aviation is a learning industry, and a conservative one, the expectation is of progressive improvement in maturity throughout the aviation system and innovative technology applied to enhance safety.

This is not to say that the potential for error, missteps and recklessness don’t exist. They do. I expect continuity in a way that takes full advantage of advanced methods without scarifying the legacy of an astonishing good global aviation safety achievement.

Later, to cover a lot of ground in a short time, I’m going to condense all the above into three distinct categories. But before that, I’ll talk about the present and a vision of the future.

POST: UK Farnborough Air Show on Thursday 23rd July 2026. Time: 13:00-13:15 BST. Location: Hall 3 Stage. Session title Where Next for Aviation Safety?

[1] https://www.sciencedirect.com/science/article/abs/pii/S0925753507000227?via%3Dihub

[2] https://d10x.airbus.com/generation-of-jets/

Digital Dependency

Here’s a collection of annoying and sometime hazardous events that can happen in our digital world. Digital dependency is growing at an ever-increasing rate. There’s no way we can put our head in the sand and pretend it’s not happening. Yet, I’d say we are ill-prepared for the stuff that can go wrong. Well, anyone over the age of 25 years can be ill-prepared. Maybe the younger ones are ill-prepared too because of the immense trust they place in digital systems.

Last night, the wonderful “smart” TV that sits in our living room behaved in a way that is designed to get anyone’s back-up. Ironically that’s the function that is often missing – back-up.

Do I blame my clever Sony digital TV or the App that’s running on the TV? The many Apps. Anyway, the TV guide displayed but every time a selection was made the TV screen went blank. Me being used to troubleshooting, I tried another App. All worked fine. So, only one App was misbehaving. Ony one App was not doing what it should do.

To most people this would be a shout out to say; my TV is broken. How can it be broken it’s nearly new? It’s not performing its most basic function. To me, my deduction was that the App that provides the digital stream of the live broadcast channels was doing some kind of update but, unhelpfully, not telling anyone about it. The dumb thing is that the screen went blank. No information. Why the developers of this App couldn’t have thought ahead and put up the screen words saying – please wait – I have no idea. Perhaps they like to see our blood boil.

By the way, the above event happened just at the end of a world cup football game last evening.

Believe it or not, this irritating blank screen case has occurred in flight on an in-service aircraft. The main displays in the aircraft cockpit blanked. For those who may not be familiar, the main critical flight information is displayed to pilots on electronic screens in a modern aircraft cockpit. So, when everything goes blank it’s not a nice situation. Because safety is the primary concern there are independent standby instruments. They are only basic and aimed at managing the situation.

The case that I’m writing about above was because of a notorious software error. One that’s by no means new. Most serious and well-trained developers will know the case.

Do a little maths. Have you ever taken any number and divided it by zero? For fun, I picked up a desk calculator, yes, they still exist and did this simple sum. The makers, Casio have that one figured out. A small E comes up on the corner of the screen. E for error. Trapping this potential error is elementary best practice. For flight safety related systems, it’s vital.

What’s my message? It’s to understand what it means for something to be broken.

A vast swath of the population continues to have a, learned from experience, idea of what broken means. It’s basically an analogue notion. If I get a puncture in the wheel of my car’s tyre it’s visible, it’s understandable and it’s fixable. It’s a physical phenomenon.

If my super-duper mobile phone does something strange and unexpected, it might be visible, understandable and fixable but it might not be. In essence I have few ways of knowing. I hesitate to introduce the subject of Wi-Fi connected computer printers to this short article, but I will. Some of the most frustrating, unhelpful and mysterious software has been developed for this equipment. Annoying to a level that is difficult to match anywhere on Earth.

Perceptions of Aviation Professionals

Let’s see what aviation stereotypes look like. There’s a wide selection of free images on-line. There’s a typical view of the crew of an aircraft. It didn’t take long to find one.

I can point out the obvious gender related features of such images, but what first caught my eye were the aircraft engines. They were way to far out on the wings. I suspect our good friend artificial intelligence may have generated such a colourful image.

Now let’s go for an Air Traffic Controller. The image that came up did have plus points. It did give an impression of what a controller’s job is about, at least as much as a simple graphic image can. I did expect to see a radar screen with dots on it as part of the image. A controller sitting at a desk with buttons to press and a window to look out of sums up the basic picture.

Next my on-line search was for an aircraft mechanic. Now, I started this search with low expectations of what might come up. The picture I got was of a hanger with two large aircraft to the left and right. Standing in the middle of this scene was a man in overalls moving an aircraft engine on a trolly. Proportions were off, in that the engine diameter was half the hight of the mechanic. Yes, the stereotype of a workingman with a spanner persists.

So, what have I discovered? Not much really. Or not much that didn’t fit the title of time-honoured stereotype. Images that pigeonhole jobs as done by people who dress in a particular way and are surrounded by the equipment of their trade. Roles, age, race and gender are fixed in a traditional pattern. I do draw the conclusion that, for all the daily hype, artificial intelligence is not going to do anything original when faced with a simple question about specific job.

This isn’t good. If the latest advance in technology is locked into classical and predicable images from the archives, then it’s not so advanced at all.

Why does this matter? Well, there’s a great deal of concern about where the next generation of professional in aviation are going to come from. Our wish to fly is affected by lots of social, environmental, and economic factors. Overall, the trend over coming decades is in one direction – up. More flights, more aircraft, and the need for more people to operate the system.

If the generic images of the professional roles in aviation are stuck in the past, then that’s not going to help. It’s off-putting. There are those young people who may find the traditional professional stereotypes appealing. My guess is the majority are unlikely to think this way.

In an on-line environment where artificial intelligence regurgitates the past this technology may drive us backwards. Not for one moment does the image of a workingman with a spanner need to be demoted. What needs a touch of imagination is a portrayal of images more akin to reality. A changing reality too.

[Yes, the title image is an appropriately prompted artificial intelligence generate one provided by WordPress].

Lessons from Operational Events

For an aviation industry that takes pride in learning lessons from experience and taking timely corrective action, a series of operational events is surprising to say the least.

Today’s large aircraft do look much the same. The tricycle undercarriage has become universal. A set of steerable wheels at the front and a heavy set of landing gear, each side, to the rear. When parked, a nose gear collapse or inadvertent retraction on a large aircraft is not catastrophic. The aircraft can be recovered, inspected, and repaired. This undesirable event can be dangerous for anyone in the vicinity. It has the potential to be fatal. Fortunately, so far, there has been no fatalities.

For an aircraft operator such an event at an airport gate is a massive expense. Putting an in-service aircraft out of action for a considerable time.

To date, several damaging nose gear collapse (and alike) events have occurred to large aircraft[1]. Detailed analysis of these events exists and corrective actions are proposed.

One conclusion is to say that this is about people not following procedures. That is the instruction is to put a pin in one place but instead it gets put in the wrong place. So, this dramatic unintended event is written up as a maintenance error. It’s an outcome that no one intended. That’s fine. There’s no doubt that an error was made. Accepting that an error occurred is not a reason to blame. That is if there are no signs of negligence.

The trouble is the simple question – how easy was it to make that error?

Then we get into that grey area of the gap between aircraft design and operations. In a design office it may be reasonably assumed that a procedure will be followed in an almost robotic manner. No need for the people in operations to think beyond taking the same action day-after-day. This would surely become widespread practice.

As we know the actual environment of aircraft operations can be more demanding than the original equipment manufactures might imagine. Pressure to turn around an aircraft can be high, working conditions can be poor and fatigue can play a part.

There are lines of communication between the aircraft design and operations organisations, and such difficulties are regularly discussed.

Faced with an event categorised as maintenance error then what next? Redesign the aircraft? Change a procedure or require more training? Those are three of the options, there are more.

This is where the possible discussion gets reactive. Now, it would be extremely costly to redesign an aircraft for the sake of an event that is rare or for which the consequences are minor. It is possible to put numbers on each of these. The rarity, the cost, and the impact.

Modifying or rewriting a procedure, on the other hand, can be less costly and it may be quite sufficient as a corrective action. That said, any procedure that can be written can be subject to error. In fact, the original procedure may have been straightforward and well thought out.

Then there is the fall-back position. Give the people in aircraft operations more training. The assumption being that more training means less errors. It is a crude assumption because this is not a linear relationship. So many other factors come into play.

Discussions surround the above possibilities can become protracted. There’s a call for more analysis and more data. There’s the proposal for a study to be conducted. Once in that loop a year can go by as if it was a month.

There’s always the argument that highlights dozens of aircraft operators haven’t had this event occur and therefore the finger is pointed at those who have. This argument gets an outing, but it is foolish. It’s like saying – I haven’t had an accident yet, and therefore I’m safe. Foolish.

There are a lot of detailed discussions and a million and one opinions. Taking the big picture, this is a problem that is solvable[2]. What is surprising is the reoccurrence of the problem.

[1] https://www.gov.uk/government/news/aaib-special-bulletin-g-zbjb-inadvertent-nose-landing-gear-retraction-during-pre-flight-maintenance

[2] https://www.federalregister.gov/documents/2019/12/12/2019-26734/airworthiness-directives-the-boeing-company-airplanes