[azalemeth]

Indeed.

Something else I'd like to point out is that it might seem easy to 'blame the Cirrus' pilot or them call out for inattention, but doing so by itself isn't helpful. Aviation is so safe partly because it has managed to turn a culture of blame into a culture of continuous improvement and shared learning: I'd be very surprised if the airport's procedures came out of this unmodified, for example.

[elliekelly]

I’ve probably mentioned this book on HN a hundred times but “Black Box Thinking” discusses the aviation culture of avoiding blame and making sure a problem isn’t repeated and how other industries (like medicine) would benefit hugely from a similar approach. It’s really interesting.

[lbriner]

I'm not sure how scalable this is in modern penny-pinching times. In the old days, airlines had to prove they were safe to attract business and this involved accepting that certain practices were harmful and they were therefore improved.

Once we got to the 1980s, we had so many airlines trying to survive that corners were cut, recommendations were not followed and various accidents were essentially negligent.

Now that lots of smaller airlines have been merged into larger ones, we now have Boeing type problems where the cost of manufacture, safety and development is so much higher than before, no-one wants to put a new plane through the whole approvals process, we just want to re-badge a 737 and get it into service.

Similar things happen on the railways in the UK where we have the RAIB to do a similar "no-blame" analysis of a crash/accident yet still time and time again, the same problems surface - lack of preparation, lack of training and lack of following procedures.

[elliekelly]

I agree and it’s somewhat addressed in the book - if you find the premise at all interesting you should definitely read it, even if you’re skeptical of the practicality of implementing the philosophy (for lack of a better word) it’s interesting and the examples are compelling.

Some of the examples are whole-cloth cultural changes of entire industries (usually commercial flight actually, IIRC), but some are small, simple, changes that can be implemented by one or two people and still have a dramatic impact. One of the smaller-scale examples from the book that really stuck out was the attitude & approach of a surgeon in an operating room. When surgeons approach mistakes from the perspective of “okay, this happened, let’s focus on how we fix it” mistakes are reported to the surgeon quickly, the surgeon gets accurate information quickly, and can respond appropriately. Result: more mistakes are reported but the surgeon has fewer complications and better outcomes.

When surgeons approach mistakes by getting angry or assigning blame to the nurse who did X or the resident who did Y those surgeons have fewer (reported) mistakes but worse outcomes. Why? People don’t fess up because they fear the consequences. And when a mistake is identified, people don’t give accurate and complete information because their primary concern is KYA rather than fixing the problem at hand.

[EricE]

Would also help computer "science" as well :p

[phkahler]

>> I'd be very surprised if the airport's procedures came out of this unmodified, for example.

I'm curious. The airport is at about 5900ft and they were at 6400. If that's AGL for them that seems like a long and high approach. If not, then they were going to do a 3 mile straight in at 500 feet AGL? Either interpretation doesn't fit my (limited, student) experience.

[azalemeth]

KAPA is indeed 5900 MSL, and those heights are also all MSL.

Looking at the FAA's charts, https://aeronav.faa.gov/d-tpp/2104/05715R17L.PDF, this combination of heights and distances isn't totally crazy -- I state without proof (and wait to be corrected!) that the approach is modified because it is a relatively high altitude airport and there may be quite steeply changing terrain underneath. I've never flown there (not even on X-plane) and I'm a low-hours UK person.

I haven't done the trig and meterological lookup to work out what their AGL altitude was on that day, but at the very least it's not crazy-wrong from the published chart...