My Organizational Accident

My Organizational Accident

On January 06, 1996, Convair 440 N358SA crashed while on approach to Spokane International Airport (KGEG). The aircraft was being re-positioned under Part 91 from Deer Park AZ to Spokane under a ferry permit (special flight permit) due to the aircraft being out of inspection. Recency of experience, fatigue, icing, equipment malfunction, and fuel mismanagement…

Read More

Error-Capturing Strategies and System Design

Building error tolerance, error mitigation, and error-capturing strategies into our systems should be one of the most important outputs of safety management.  These strategies are a hallmark of good system design.  And when system design flaws are discovered, risk controls are implemented. Monitoring of the affected process then helps us see if our strategies are…

Read More

Threat & Error Management

Threat and error management (TEM) is not new; we’ve been practicing it at some level for decades, and it occurs in just about every flight operation, every maintenance operation, and in everything we do hiyo3lg. We just don’t call it that, or think about it in those terms. Back in the 1980’s I was training…

Read More