The Essence of Safety podcast

“At 1:43 and some odd seconds, I felt the first shudder… a loud bang. Something was gravely wrong.”

The story of Greeneville — a U.S. Navy submarine, a routine drill, and a tragedy that shocked the world.

🎙️ Listen to the full episode now:
open.spotify.com/episode/1Tgb...

In 1968, a Japan Air Lines DC-8 landed in San Francisco Bay. No one died, but the captain’s blunt confession became legendary: “I f*cked up.”

But did self-blame help aviation safety - or hide the real lessons?

🎧 The Essence of Safety — new episode out now:

open.spotify.com/episode/1Tgb...

Guilt, Blame, and the Lessons We Miss

When a JAL DC-8 lands short of the runway in San Francisco Bay, its captain admits fault with disarming honesty. Decades later, a U.S. Navy submarine collides with a Japanese fishing vessel, and another captain shoulders the weight of guilt...

open.spotify.com/episode/1Tgb...

Exactly!

That's the one :)

Close, but not quite it.

A DC-8 airliner ditched in shallow waters. In front of it, a small patrol vessel.

After many months of research, I finally finished the write-up for the next episode - and started recording it. Unforeseen circumstances aside, I should publish it next week.

The first part is about this ⬇️ accident. Fortunately no-one got seriously hurt. Any idea what it was?

Crashing in a helicopter while on a crocodile egg gathering mission - only in Australia! 😄

YouTube video by Air Accidents Investigation Branch Shoreham Airshow Accident, 22 August 2015

#OTD 2015 Shoreham youtu.be/u20-oh5Wblw #flightsafety #aviationsafety

Embraer 195 probe: captain pressured first officer to accept incorrect take-off calculation after wrong-runway taxi Serbian investigators have revealed that the captain of an Embraer 195 pressured the first officer to accept an incorrect take-off calculation after taxiing onto the wrong runway intersection at Belgrade.

Embraer 195 probe: captain pressured first officer to accept incorrect take-off calculation after wrong-runway taxi - More on hype.aero

Absolutely agree. Although I have used AVherald in the past, I have become increasingly concerned. That's why I was criticising this particular quote.

Fully agree on the first bit. As for any operator being willing to take the risk, I am not so sure. Ju-Air tried very hard, but looking at the obstacles they were facing in maintaining/regaining airworthiness, you realise that they are almost unsurmountable.

In 2019 the evacuation of a burning Aeroflot Sukhoi Superjet was hampered with fatal consequences. Why are passengers still taking hand luggage with them? #avgeek #aviation #safety www.aerosociety.com/news/a-bag-f...

I made the first ever episode of the Essence of Safety podcast about the terrible accident of HB-HOT, another Ju-52 operated by Ju-Air. I believe that it was this accident (and its investigation) that led to the grounding of the remaining Ju-52s.

the word fin is written on a black background . ALT: the word fin is written on a black background .

That’s it – the end of my very first thread.
Did you like it? What are your thoughts?
I’d love to hear from you.

Asking those questions reveals the deeper story: about systems, conditions, decisions, and pressures.
And that’s the insight we need if we want to prevent future accidents.

Instead, finding human error is the starting point.
The real questions are:
Why did the error occur?
Why this time – and not the countless other times when everything went fine? Or did it occur previously, but didn't cause an accident? Why not? That's how you learn about the accident causes.

So where does that leave us? How do we deal with human error in an investigation?

One thing is crucial:
Human error must never be the *ending* point of an investigation.
If you are an investigator and your only conclusion is that human error occurred, you haven’t done your job. At all.

I’ve heard of surgeons saying a *good* surgeon can still operate flawlessly after a 24-hour shift (i.e you need to be 'good," then you can do it). Most pilots would never consider flying after being awake that long, because they know that fatigue will affect them, no matter how "good" they are.

Human performance is shaped by many factors: fatigue, design, commercial pressure – just to name a few.
This doesn’t mean humans have no agency, but it does mean they’re not as fully in control as we like to think. As an example:

So the interesting question is *not* whether there was human error – but:
Why did it lead to an accident THIS time, and NOT on previous times?
Why did things go right all the other times, until they didn’t?

And one more thing: you’ll always find human error.
Todd Conklin, a safety guru, once said: “Looking for human error is incredibly boring – because it’s always there.”

Every system has human involvement. And wherever humans are involved, some form of error is inevitable.

Nothing was technically “wrong,” but today, that design would probably never be certified.

Design matters. Context matters. Humans make errors, but those errors are shaped by the systems they're working in, and how tolerant the systems are to human error.

A famous example: During WWII, US B17 pilots often mixed up flap and gear levers, causing accidents. Were they poorly trained? Overwhelmed? Or is there another explanation?

As if it turned out, the flap and gear switches looked alike, felt alike, and were close together.

Engine failures shouldn't happen – and crews train for them.
So was it technical or human error? The answer: both. You can't reduce it to one aspect. Any accident is usually both.

You also can't understand human error without understanding the technological and sociological context.

A common misunderstanding: that you can clearly separate technical failure and human error. People think it's either one or the other. But reality is messier.
Imagine an airliner suffers an engine failure during takeoff. The crew mishandles it and the plane crashes.

Sometimes, the same crew can perform worse than expected and then better than expected – even on the same flight.
Example: Air Astana 1388. They failed to detect the flight control issue before departure – but later managed to regain control in flight, against all odds.

One key concept in understanding human performance is human performance variability. Human performance isn't steady – it can be worse than expected (many accidents show that) but also much better than expected (think Sioux City or the Hudson ditching).

Please note that this thread is not going to be about suicidal actions and mental health. These are important topics, but they deserve their own discussion.

A pictogram symbolising human error, using the head of a person and an aircraft

Recently, the topic of pilot error / human error / human factor has come up a lot again, and I thought it might be useful to start a 🧵 summarizing how modern safety science views the human role in safety-critical systems – and particularly in accidents. It's going long, but worth it, I promise!