Lessons in Process Safety Management from aviation incidents

Two air accidents that I have been tracking closely is the Air India express Mangalore air plane crash and the Qantas Airbus superjumbo incident in Singapore. Details of the CVR recordings from India express crash now reveal that the pilot had slept for 90 minutes during the flight and was suffering from “sleep inertia” when he was attempting to land. How many of you consider your poor shift crew in this light? When I was working in shifts, I have experienced this sleep inertia even though I had slept well during the day.
A news article about the Qantas Superjumbo Rolls Royce engine incident it was a “worst case scenario” when one of its four engines exploded. The article reports that the crew were inundated with 50 error messages. However for the pilots, luck was on their side, there was no fire, and they managed to land the plane safely.
''It could have been much, much worse,'' says Richard Woodward, a Qantas A380 captain and a vice-president of the Australian and International Pilots Association. ''It could probably be termed a one-in-100 million event with bits and pieces going everywhere.''
Smith, a two-time chairman of Australia's aviation watchdog, says it was lucky QF32 did not become a repeat of the Concorde crash in 2000.
Smith says that the public has come to expect the impossible - aircraft being fail-safe. ''It is almost like people believe that flying in the air is perfectly safe. Even the most disciplined person can make an error - it is the same with design.''
''One of the things in aviation safety is 'hindsight bias'. It is so easy after an accident to say they should have known,'' says Thomas Anthony, the director of aviation safety at the University of Southern California.
''It is part of the problem of new engines and new aeroplanes. Change is a frequent precondition to error,'' Anthony says. ''When you are changing things you really do need to have a very robust change management process to identify potential problems.''
The above accidents had direct parallels to process safety. Learn lessons from them!
Read the articles in these links
Air India Express Crash
Qantas Superjumbo incident
PS: I have a deep interest in aviation safety as my Dad was a pilot and I have spent many days in the cockpit with him when I was young!