Don't rush MH370 probe

At the moment, we still don't know what happened to the plane carrying 239 passengers and crew from Kuala Lumpur to Beijing.

All we have is Malaysian Prime Minister Najib Razak's announcement that the plane is now believed to have crashed with no survivors.

But the urge to make sense of it all and to find a scapegoat is a human tendency. It's also natural for the travelling public and those who are awaiting news of their loved ones on board the plane to seek answers.

The goal of any safety investigation is to understand what happened, identify any lessons learnt and implement any safety actions needed to prevent a tragedy like this happening again.

The systems safety perspective teaches us these three important lessons for this investigation that counter that initial urge to find answers quickly.

The main principle of a systems safety perspective is that several contributing factors may be found. They could be in the technology and crew operating close to the accident. They could also be in different organisational elements whose decisions and actions are further removed from the accident, both in time and place.

Part of what went wrong with Flight MH370 may be a symptom of underlying issues in the wider system. If these elements remain unaddressed and only people and technology operating close to the accident are looked at, the safety issue may occur again for another crew or plane.

The major rail accident in Santiago de Compostela, Spain, on July 24 last year was shaped by factors across the rail transport system, most of which were beyond the control of the driver.

But initial reports focused heavily on the driver, who was speeding. The driver was readily blamed and blamed himself for this accident.

From a systems safety perspective, this accident was waiting to happen. For example, that particular bend in the rail track was known to be dangerous but nothing had been done about it.

The route the train was travelling on was equipped with an automatic speed control system (European Rail Traffic Management System), but this system was not in place at the part of the track where the accident happened.

If these systems safety factors across the rail system remain unaddressed, the accident may happen again to other drivers.

The systems safety perspective also reminds us that accidents may not have been caused by one single failure. Rather, it may have been an unlucky concurrence of events and behaviour that have happened many times before in isolation.

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Consider the Air France Flight 4590 which crashed on July 25, 2000, just minutes after take-off from Charles de Gaulle airport near Paris, on its journey to John F. Kennedy airport in the United States city of New York. All 109 passengers and crew were killed. Four others died on the ground.

But this accident had no single cause - the investigation found it was such an unlucky concurrence of events that led to the crash.

Tyres had exploded in the past. False alarms had gone off before in the cockpit. But on the day of the Concorde crash, it all happened at the same time and all during the time-critical take-off phase of the flight.

The Concorde ran over a metal strip left on the runway by a Continental Airlines airplane that had just taken off.

The Concorde's tyres exploded and this explosion led to a fuel leak. As a result, fuel entered the engine and this caused a fire.

The false alarms led the pilots to shut down engine No. 2 rather than engine No. 1, which was losing thrust.

The events all combined rapidly at take-off and soon the pilots entered a scenario in which they lost control of the plane.

If the events had happened in isolation or in different combinations, we may not have seen this accident occur. Continental Airlines was found criminally responsible for the crash but later cleared on appeal.

It is tempting to reassure the public that air travel is safe by quickly "finding and fixing" each factor found to have contributed to the accident.

If the fate of Flight MH370 was an unlucky concurrence of things that have happened in isolation before on other flights where nothing tragic has happened, then any improvements should not compromise the safety of future flights should the same thing happen again in isolation.

The systems safety perspective should also remind investigators that if whatever happened to Flight MH370 was shaped by factors across the aviation system, then safety improvements will influence operations across the whole aviation system.

That is why it's important to take time in any investigation into Flight MH370.

Once complete, the entire suite of safety actions recommended and their potential impact on the whole aviation system (people, technology and organisations involved) should be carefully considered before anything is finalised.

The writer is lecturer in aviation safety at Griffith University, Australia.

This article first appeared in The Conversation (https://theconversation.com), a website which carries analysis by academics and researchers in Australia and United Kingdom.

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