Safety – John Vincent

Aircraft Safety and Fuel Starvation

Unsafe. In common language it’s the opposite to being safe. So, take a definition of “safe” and reverse it. Let’s say to be safe is to be free from harm (not a good definition). That would lead to “unsafe” being subject to harm or potentially being subject to harm. The probabilistic element always creeps in since it’s the future that is of concern. Absolute safety is as mercurial or unreal as absolute certainty.

Let’s apply this to an aircraft. The ultimate harm is that of a catastrophic event from which there is no escape. Surprisingly, taking a high-level view, there are few of these situations that can occur.

Flying, and continuing to fly, involves four forces. Lift, Weight, Thrust and Drag. It’s that simple. An aircraft moves through the air with these in balance. Flying straight and level, lift opposes weight and thrust opposes drag.

Yes, there are other safety considerations. If there are people on-board. For example, it’s important to maintain a habitable environment. At higher altitudes that requirement can be demanding. Structural integrity is important too. Otherwise flying is a short-lived experience.

In the recent Air India fatal accident, the four forces of flight were not maintained so as to make a continued safe flight possible. The wings provided lift but the force that was deficient was thrust.

Two large powerful engines, either of which could have provided enough thrust, were unable to do so. The trouble being fuel starvation. Fuel starvation occurs when the fuel supply to the engine(s) is interrupted. This can happen even when there is useable fuel on board an aircraft[1].

Sadly, in the records there are numerous aircraft incidents and accidents where this has happened. Quite a few fuel starvation incidents and accidents occur because of fuel mismanagement. This can result from a pilot selecting an incorrect, or empty, fuel tank during a flight.

Now and then, it is the aircraft systems that are at fault. The pilot(s) can be misled by a faulty fuel indication system[2]. In one notable case, a major fuel leak drained the aircraft’s fuel supply[3].

When there is useable fuel on-board an aircraft, the imperative is to restart and recover. It is not uncommon or unreasonable for there to be a delay in restarting engine(s), especially when a fuel starvation event is entirely unexpected. Diagnosis takes time given the numerous potential causes of a starvation event.

In cruise flight there is time available to perform a diagnosis and take appropriate corrective action. Both take-off and landing have their hazards. Both are busy times in the cockpit. When looking at the worldwide safety numbers, less fatal accidents occur on take-off than landing. The numbers Boeing provide put take-off at 6% and landing at 24% of fatal accidents. Each one only occupies about 1% of the total flight time.

Although these are the numbers, my view is that, even though take-offs are optional and landings are mandatory, the requirements for adequate thrust are most critical during take-off. This is arguable and it reminds me that safety assessment is never simple.

[1] https://www.faa.gov/lessons_learned/transport_airplane/accidents/G-YMMM

[2] https://asn.flightsafety.org/asndb/322358

[3] https://asn.flightsafety.org/asndb/323244

Enhancing Transport Safety

There’re claims that Artificial Intelligence (AI) will make transport safer. It’s to put a positive spin on the introduction of AI. Implying that existing safety deficiencies can be addressed with the power of AI.

It’s difficult to disagree with this simple assertion. There’s a list of risks that continue to be troubling. With directed design effort there are functions that AI can perform that mean it can have an advantage over conventional systems. With good design, no doubt high performing systems can be constructed.

In aviation, for example, if I consider the top five fatality risks, there’s a persistence of specific categories. We never seem to get away from loss of control in-flight (LOC-I) being high on that grim list. Runway related issues persist, and the hardy perennial of mid-air collision remains. Over the years progress has been made addressing controlled flight into terrain (CFIT), but that category of destructive events never disappears.

It’s fascinating to see that the industry thinks that AI itself is a risk[1]. High probability but low impact. This is considering a broad description of risk rather than a safety focus. Here the concern is related to the difficulties of practical implementation of this new technology.

Marketing people will big up the possibilities brought about by AI. This is what’s going on in relation to the most recent mid-air collision fatal accident. With sound justification given how crude elements of air traffic management are in specific locations.

We will never entirely displace “see and avoid” as a means of collision avoidance. Scanning the horizon looking for other air users. In my opinion, relying on this technique in relatively busy traffic areas is unwise, to say the least. This is where airborne AI assistants have much operational safety potential. Sucking up multiple information sources and processing masses of information to give accurate and instant advice. Such systems can be designed to give real-time updates not only to improve situation awareness but give avoiding action guidance, or even automated responses.

Let’s get back to the general assertion that AI will make aviation safer. On this one I’d be more cautious. For example, looking at LOC-I incidents and accidents there’s a complex mix of causal factors, and circumstantial factors. In addition, there’s the complexity of potential recovery actions too. Solving problems in 4-dimentions whatever the weather, whatever any damage incurred and however pilots react. This is where the probability numbers start to stack up.

That catch all disciplines “human factors” makes outcomes particularly difficult to calculate. Accidents are known where pilots and automation fight each other to produce bad outcomes.

AI is a machine. It will speedily crunch numbers in a mechanical manner. An extremely advanced manner but without emotion or, yet, not matching the imaginative capabilities of the human brain. Or for that matter the sophistication of human senses.

Would exceptional capable AI have saved Swissair Flight 111[2], for example? Sadly, I think not. On the day, likely an automated airborne system would have made the same decisions as the pilots. Decision making without the sense of precisely how the aircraft fire was developing would still have been hamstrung. I could raise other cases too.

Will AI make transport safer. In part. Not as a universal cure all.

[1] https://www.iata.org/en/publications/economics/reports/risks-2025-brief/

[2] https://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/1998/a98h0003/a98h0003.html

Tragic Helicopter Crash

The record of sightseeing helicopters is not a good one. In the most recent case 6 people perished as helicopter crashed into the Hudson River in New York City. It’s with a heavy heart that I offer my condolences to the family and friends of those involved. These are devastating events for all concerned.

It’s certainly far to early to say why this helicopter fell from the sky. Eyewitness reports suggest a catastrophic occurrence. Also, that the helicopter tumbled and hit the water inverted. Again, suggesting an occurrence where the pilot had no opportunity to avoid the outcome.

Initially, the indications are that the local weather was not a significant factor in the accident. Also, reports are that no other aircraft was involved. In this fatal accident the US National Transportation Safety Board (NTSB) will be on the scene as they manage the technical investigation. They have already published initial information.

Given the size and nature of operations there will be no Flight Data Recorder (FDR) installed on this helicopter. There is a strong argument for requiring light weight flight recorders on small helicopters. It will be interesting to read of what electronics are recovered from the accident site. Images from a mobile phone may be most useful to the investigators.

The helicopter’s maintenance records will be reviewed for indications of mechanical problems. However, it is highly unusual for a complete rotor system to fall apart in flight. Mechanical failures often have some precursors that give an indication that all is not well.

The list of Bell 206 type helicopter accidents and incidents is long[1]. That’s not an indicator of their relative safety. This is a popular single engine small helicopter with a long history. Both civil and in other variants, military. First flight dates to 1966. It’s going back a while, but I clearly remember a sightseeing flight I took on such a helicopter back in the 1980s.

This type of small helicopter is often operated in difficult conditions. They have the advantage of being highly maneuverable. However, there are maneuvers that can case serious problems. The term “mast bumping” was used by the US Army[2]. In the worst cases this results in catastrophic occurrences.

One of the factors in such accidents and incidents is a significant change in the helicopter’s center of gravity and an inappropriate response to that condition.

POST 2: Pictures of the recovery of the rotor system from the river suggest structural failure. It’s as if the rotating mechanical parts ripped themselves from the body of the helicopter. Bell 206 L-4 helicopter crash, Jersey City, New Jersey (April 10, 2025) | Flickr

POST 1: Social media is littered with theories, as per usual. One seems highly unlikely. Namely, fuel exhaustion. Another, concerning a strike of a flock of birds over the river is worth investigation. In that possible case evidence will surely be easily uncovered.

[1] https://asn.flightsafety.org/wikibase/495847

[2] https://youtu.be/_QkOpH2e6tM?si=AtMfqztc_cjrUOSm

Safety Analysis

In discussions about safety one model is often called up. Its simplicity has given it longevity. It also nicely relates to common human experience. The model is not one of those abstract ideas that take a while to understand. If you have been on a safety training course, a lecturer will give it couple of minutes and then use it to draw conclusions as to why we collect and value safety data.

On illustration, and it’s a good one for sticking in the memory, is a picture of a big iceberg. Most of an iceberg is underwater. One the surface we only see a fraction of what is there. This is the Heinrich pyramid. Or Heinrich’s Law[1] but it’s not really a law in the sense of a complete mathematical law.

The logic goes like this. In discissions about industrial major accidents, there are generally a lot more minor accidents that precede the major ones. Although this was drawn up in the 1930s the model has been used ever since. And we extend its useful applicability to transport operations as much as workplace accidents.

Intuitively the model seems to fit everyday events. Just imagine an electrical cable carelessly extended over the floor of a hanger. It’s a trip hazard. Most of the time the trips that occur will be minor, annoying events, but every so often someone will trip and incur a major injury.

What we can argue about is the number of precursor events that may occur and their severity. It wouldn’t be a simple universal ratio, either. Heinrich said there were generally about 30 accidents that cause minor injuries but 300 accidents with no injuries. A ten to one ratio.

Forget the numbers. The general idea is that of the iceberg illustration. Underlying that example of the pyramid is the notion that there are a lot more low severity events that occur before the big event happens. Also, that those low severity events may not be seen or counted.

It’s by attempting to see and count those lesser events that we may have the opportunity to learn. By learning it then becomes possible to put measures in place to avoid the occurrence of the most destructive events.

In British aviation I will reference the 1972 Staines air accident[2]. A Brussels-bound aircraft took off from London Heathrow. It crashed moments later killing those onboard. One of the findings from this fatal aircraft accident was that opportunities to learn from previous lesser events were not taken. Events not seen or counted.

Thus, Mandatory Occurrence Reporting[3] was born. Collecting data on lesser events became a way of, at least having a chance of, anticipating what could happen next. Looking at the parts of the iceberg sitting under the water.

How many fatal accidents have been prevented because of the safety analysis of data collected under MOR schemes? If only it was possible to say.

[1] https://skybrary.aero/articles/heinrich-pyramid

[2] https://www.bbc.co.uk/news/uk-england-surrey-61822837

[3] https://www.caa.co.uk/our-work/make-a-report-or-complaint/report-something/mor/occurrence-reporting/

Safety Defined

I found myself saying the words: “the fundamentals remain the same”. A nice phrase that promotes the idea that there are some bedrock ideas that are immune from the winds of change. It’s as easy as saying that 2 plus 2 will always equal 4. Except I wasn’t taking about a mathematical relationship. A traditional set of rules that are so established that it becomes incredibly difficult to think differently. That is unless I get terribly esoteric and argumentative about what do we mean by plus and equals.

Safety is freedom from harm. That’s one of the simplest definitions of “safety”. Simplicity has merit but there’s one or two weaknesses in that basic definition. Although, it’s one that I’m happy to use. It communicates well. Theres a lot to be said for brevity.

The human condition is such that we are never ever free from potential harm. Such is the sheer complexity of our situation that the combinations and permutations of stuff that can harm us is immense. Every tiny cell in our bodies is doing something that it needs to get right. Yet, we exist relatively healthily with a myriad of flaws. Unfortunately, or fortunately, our awareness of the flaws that can harm us is often non-existent. Perhaps we have the freedom of ignorance.

Safety is freedom from harm with these caveats. Generally, even invoking the word “safety” implies that the stuff that can harm us is substantial and tangible. It’s something we might know and understand. Likewise, the word “harm” in this context doesn’t mean trivial or non-consequential actions. It’s something undesirable where effort would be made to avoid.

To compound my kicking away at what seems like a perfectly reasonable simple definition, the well-known dictionaries who publish their wisdom each have different variations on a theme.

Each definition has at least two parts for the abstract noun “safety”. Yes, it doesn’t have a physical form, in of itself but “safety” is a condition. The negative stuff to be avoided comes up as harm, danger, hurt, damage, injury, death, loss, and even risk. The act of avoidance of a negative outcome comes up as a condition of being free or protected.

Another dimension not explicitly mentioned in the common definitions is the dynamic nature of safety. It is not a static condition. Theoretically, the transition from a safe to an unsafe condition can take an infinite number of paths. In reality, some pathways are more probable than others.

This is where the discussion moves away from grammar to the substantial experience of safety. It’s locked into our thinking, and not often expressed that the dynamic nature of the subject means that probabilities always come to bare.

Today, I may not be the least bit concerned that a meteor would crash through the roof of my house without warning and injure me. That is even if I am not entirely free of the possibility of such an event happening. I will take the possibility of tripping on a loose stair carpet much more seriously. Both safety jeopardising events are possible but one is more probable than the other.

Next, I come to what’s conceivable and what’s not. In a universe of an infinite number of possibilities there are lots that are just plain inconceivable. The meteor case above is conceivable. Governments take practical actions to monitor space rocks.

Even to speak of something that is inconceivable is stretching the boundaries of our imaginations. It’s often taken as obvious that certain threats are out of bounds. Yet, the inconceivable occasionally happens and our boundaries are thus expanded. A pilot chooses to fly a perfectly airworthy aircraft into a mountain. As we know it has happened.

I’ll stop here. What’s clear is that a simple definition isn’t simple at all.

Tragic VoePass ATR72 Crash

2024 was going so well. Looking at the indicator of worldwide fatalities in commercial aviation for the first six-months of this year, and it is exceptionally low. The time between major fatal accidents across the globe is another indicator that my team once looked at on a regular basis. Aviation is an extremely safe mode of transport but when accidents happen, they can be devastating.

Yesterday, the situation changed in Brazil. A VoePass ATR72-500 aircraft[1], registration PS-VPB, flight number PTB2283 crashed in the Brazilian state of São Paulo. The twin-engine aircraft crashed in a residential location.

Yet unknown events resulted in a loss of control in-flight. On-line videos of the aircraft flying show a dive and then a spiralling decent to the ground. The aircraft was destroyed on impact, and it is reported that all lives were lost.

The publicly available flight data shows a sudden decent from a stable altitude[2]. The aircraft was about and hour and twenty minutes into its flight.

Looking at the video information it might appear that local weather may not have been a factor in the accident. However, there was known to be severe icing conditions at the altitude that the aircraft was flying.

It’s speculation on my part but unrecognised severe icing is one of the conditions that can bring about a catastrophic outcome for such an aircraft. It is sad to have to say that there is a record of a major accident to an ATR-72 that has some of the characteristics of this new accident.

In fact, it is one fatal accident that is etched on my mind given that it happened in late 1994, when I was still fresh in my job with the UK Civil Aviation Authority as an airworthiness surveyor. It’s known as much by its location as by the name of the aircraft, namely Roselawn[3]. The accident was extremely controversial at the time.

Crews are told that they may be operating in severe icing conditions but there is no specific regulatory requirement for on-board advisory or warning system on this generation of turboprop aircraft. An ice detection system can serve as a final warning to alert a crew that ice protection is needed.

Work to update the technical document; In-Flight Ice Detection System (FIDS) Minimum Operational Specification EUROCAE ED-103 is completed. Issued in April 2022, ED-103B – MOPS for In-Flight Icing Detection Systems is available[4].

In the case of the current accident, it is a matter for Brazil’s highly capable independent accident investigators to determine what happened. Anything I have written here is purely speculative.

POST 1: Reports of statements made by Agência Nacional de Aviação Civil (Anac) say that the aircraft was in good condition.

POST 2: Accident flight recorders have been recovered from the accident site. Flight recorders retrieved from crashed Voepass ATR 72-500 | Flight Global

[1] https://asn.flightsafety.org/wikibase/409335

[2] https://www.flightaware.com/live/flight/PSVPB/history/20240809/1450Z/SBCA/SBGR/tracklog

[3] https://www.faa.gov/lessons_learned/transport_airplane/accidents/N401AM

[4] https://eshop.eurocae.net/eurocae-documents-and-reports/ed-103b/

Turbulence

Turbulence is the result of atmospheric or environmental effects. Afterall, aircraft are craft that fly in the air. This is a hazard that is inherent in flying. Clear air turbulence (CAT) is common. However, extreme examples experienced in commercial aviation are rare. For one, aircraft operators and their crews do their best to avoid known potential atmospheric or environmental upsets, namely bad weather.

En-route turbulence accounts for a substantial number of cabin crew members injuries, and can occur at any time and at any altitude[1]. As far as I know, the UK Civil Aviation Authority (CAA) does not hold detailed data on turbulence injuries occurring on foreign registered aircraft. Numbers of injuries to passengers and flight crew on UK registered aircraft resulting from turbulence are recorded. However, it is not always known whether those injured in turbulence encounters were wearing seat belts.

Nevertheless, I can confidently say that the more passengers that are wearing seat belts during turbulence encounters the less the number of injuries. Deaths in these circumstances are rare. As might be expected fatalities are more likely to results from a combination of multiple causes and factors.

This subject is not immune from airline economics and competition. International flight routes can often be highly competitive. Fought over. So, the route taken, and associated fuel costs, can have an impact on the likelihood of a hazardous weather encounter. In fact, choosing to take routes for the benefit of picking-up specific winds is a common practice.

A high percentage of cases of turbulence events come about by flying too close to active storms[2]. Here there is often visual cues, reports, forecasts and feedback from turbulence encountered by other flights. This all helps crews avoid the worst weather encounters.

With very few exceptions, flight turbulence does not result in fatalities, permanent injure, or structurally damage commercial aircraft. However, turbulence is recognised as both an aviation safety and an economic issue, and it has been steadily increasing. Speculation and some research cites climate change as a reason for this increase. Also, there is the international growth in air traffic and development of new long-range routes.

One thing to say is that until recently, with INTERNET connections now in both in the cockpit and cabin, it could be the case that a passenger could access better real-time weather information than a flight crew. Now, SATCOM connections providing up-to-date weather information are more common on modern civil aircraft types.

There is still more that can be done to reduce crew and passenger injuries during turbulence encounters. There will inevitably happen despite any policy to avoid hazardous weather. The greatest threat to life exists to cabin crew. The cabin is their place of work.

There is potential to develop and employ better airborne detection systems to assist crews. That maybe by enhancing existing weather radar systems. It maybe by new means of turbulence detection using LIDAR, and possibly AI/ML. There is research and innovation that could be done to develop algorithms to better predict turbulence hazards.

Avoidance remains the best strategy.

[1] NASDAC Turbulence Study, August 2004

[2] US CAST briefing in 2004.

Harmonisation

There’s an example in of itself. I’ve used the British English spelling. Perhaps I should have standardised on the American spelling, namely Harmonization. Or does it matter at all given that the definition of the word remains the same, whatever. Oh, I can’t resist the temptation to say; you say Tomato, I say Tomato.

“You say tomato, I say tomato.

You eat potato and I eat potato,

Tomato, tomato, potato, potato,

Let’s call the whole thing off.”

Naturally, in the voice of Fred Astaire[1]. Nice though this is, my subject is not pronunciation.

Aviation is a highly regulated business. It’s been that since its potential for transporting huge numbers of people around the globe was recognised. Safety must be number one. Although, it’s not if you read the first few words of the all-important Chicago convention.

Article 1: Every state has complete and exclusive sovereignty over airspace above its territory.

In the minds of those who signed the convention it was sovereignty that took first place. That didn’t mean abusing the word “sovereignty” as has to often been done. Afterall, the whole basis of the Convention on International Civil Aviation was international cooperation. It still is.

Let’s put that to one side for a moment. One of the challenges of international aviation has been the different rules and regulations in place in each country. There’s a level of harmony in the standards of the International Civil Aviation Organization (ICAO). But ICAO is not a regulator and it’s for each country to interpret agreed standards within their domestic law.

Europe, or at least the European Union (EU) is different in this respect. Since there’s European law and an active European regulator then there’s common rules and regulation set for a regional grouping of countries. So far, Europe is the only region to go this far.

When it comes to aircraft airworthiness this has been a topic of a lot of discussion in the last four decades. In the 1990s, that discussion centred around the idea that a single worldwide code was a desirable achievement. That the time the two major entities engaged in the business of aviation rulemaking, and the maintenance of rules were the FAA (US) and the JAA (Europe).

A single worldwide code could greatly facilitate the movement of aviation produces around the globe. That done to ensure that common safety standards were maintained on every occasion. It proved hard to get to this utopian condition. That said, a great deal was achieved in the harmonisation of existing civil aviation codes. Today, we benefit from that work. I’d say we even take it for granted.

In around 2000, after much study, countries concluded that it was fine to seek some form of equivalence between respective rules rather than having to write done one single set of rules. Mutual recognition has flourished in the form of agreements between countries that has smoothed the path for the aviation industries.

That last major study of the pros and cons of harmonisation is now nearly a generation old. A lot has moved on. For one, in Europe the JAA transition to the EASA.

At the same time the manufacturing countries worked closely together to agree on measures to ensure that there was no great divergence in rules and regulations. Now subjects, like Safety Management Systems (SMS) became codified. However, sovereign countries continued to develop and maintain their own aviation rules and regulations.

International working groups often achieve remarkable commonality and convergence on detailed technical topics. Often because the few people who were deeply embedded in a technical subjects all knew each other and shared information relatively freely.

Discussion as to the viability of a single worldwide code has not completely faded into the past. In fact, there’s some good reason to breath life back into this historic debate. Here’s what’s added to the dynamics of the situation:

Ongoing moves from prescriptive rules to more performance-based rules,
Entirely new products in development, like eVTOL aircraft,
Interdependency, interconnection, and integration all increased since 2000,
Security and safety are becoming inseparable,
Digitisation is changing the ways that we ensure that an aircraft is airworthy.

If you have knowledge of, and thoughts on this subject, I’d be happy to hear from you.

[1] https://youtu.be/LOILZ_D3aRg

Electrics & Mechanics

Yesterday, I wrote on LH2. The potential fuel for electric aircraft of any size. Yes, I’m not just talking about smaller commuter class transport aircraft.

Let me take some anecdotal evidence from the transition that is going on in road transport. Repairer turns up to fix an electric car that will not start. It’s a simple matter given that the car has been standing unused for a long time. The battery had discharged. A quick charge from another battery pack and all is well. Meantime in conversation it’s clear that the repairer hates working on electric cars. I could say, no surprise, they were trained on combustion engines and have been forced to make a transition in technology.

What’s evident here is the apprehension of a person who likely has a mechanical bias towards their work and the necessity to take on fixing powerful electrics. Mechanics, those who love working with moving parts, often have a dislike of electrics and electronics. It’s an engineer’s “feeling” expressed to me casually over the last 40-years.

In fact, it can be the reason that a design or maintenance engineer took the career path that they did. There is a dividing line between mechanical engineers and electrical engineers that is embedded in our institutional, educational, and training systems.

So, there’s two practical human issues to grapple with in a transition:

Propensity of one branch of technically capable people to find mechanical work less fearsome and more satisfying than electrics or electronics, and
Streaming that is embedded in our institutional, educational, and training systems. Qualifications and recognition are often not so multi-disciplinary focused.

I’m not for one single moment making a luddite argument that mechanical engineers[1] and electrical engineers[2] are two tribes that must be kept apart. Far from it. What’s more important is to recognise that transitions are hard.

New electric aircraft are going to demand technical people with a multiplicity of both mechanical and electrical knowledge. The way the engineering world has been divided up in the past doesn’t cut it. Some of our most cherished niches will need to be challenged.

Transitions of this nature always take much longer than is originally anticipated. In a way, that should be such a surprise. It’s a generational change for a community that can be conservative with a small “c”.

This is NOT business as usual. For example, handling powerful 1000-volt electric technology is not for everyone. Removing and replacing cryogenic plumbing is, again, not for everyone. The hazards are clear. The skills needed are clear.

Reorienting the aircraft maintenance engineering world is going to need new plans and programmes. Better start by enthusing people about the change rather than just forcing it.

[1] https://www.imeche.org/

[2] https://www.theiet.org/

Culture

Yet again, Boeing is in the news. The events of recent times, I feel are immensely sad. Now, it is reported that the FAA has opened an investigation into a possible manufacturing quality lapse on the Boeing 787 aircraft[1]. Concern is that inspection records may have been falsified.

A company that once had a massive professional engineering reputation has sunk to a place where expectations are low. It’s not so much that the company is having a Gerald Ratner moment. Unfortunately, the constant stream of bad news indicates something deeper.

It’s interesting to note that Frank Shrontz[2] passed away last Friday at the grand age of 92. He was the CEO and Chairman of Boeing, who led the company during development of the Boeing 737NG and Boeing 777 aircraft. In the 1990s, I worked on both large aircraft types.

A commonly held view is that, after his time and the merger with McDonnell Douglas the culture of the organisation changed. There’s a view that business schools graduates took over and the mighty engineering ethos that Boeing was known for then went into decline. Some of this maybe anecdotal. Afterall, the whole world has changed in the last 30-years. However, it’s undoubtably true that a lot of people lament the passing of an engineering culture that aimed to be the best.

A famous quote comes to mind: “Culture eats strategy for breakfast.” Those sharp 5 words get discussed time and time again. Having been involved in a lot of strategic planning in my time it’s not nice to read. How wonderful intent, and well described policies can be diluted or ignored is often an indicator of decline. It’s that cartoon of two cavemen pushing a cart with a square wheel. One says to the other: “I’ve been so busy. Working my socks off”. Ignored, on the ground is an unused round wheel. If an organisation’s culture is aggressively centred on short-term gain, then many of the opportunities to fix stuff gets blown out of the window.

We keep talking about “performance” as if it’s a magic pill. Performance based rules, performance-based oversight, and a long list of performance indicators. That, in of itself is not a bad thing. Let’s face it we all want to get better at something. The problem lies with performance only being tagged to commercial performance. Or where commercial performance trumps every other value an engineering company affirms.

To make it clear that all the above is not just a one company problem, it’s useful to look at what confidential reporting schemes have to say. UK CHIRP is a long standing one. Many recent CHIRP reports cite management as a predominant issue[3]. Leadership skills are an issue.

[1] https://aviationweek.com/air-transport/some-787-production-test-records-were-falsified-boeing-says

[2] https://www.seattletimes.com/business/boeing-aerospace/frank-shrontz-former-ceo-and-chairman-of-boeing-dies-at-92/

[3] https://chirp.co.uk/newsletter/trust-in-management-and-cultures-is-the-key-to-promoting-confidence-in-safety-reporting/