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Failed Barriers owe their failure to stop the accident from happening to an Active Failure that can easily
be spotted. The important part of the Investigation commences with the “hunting” after Preconditions,
environmental, situational, psychological
‘system states’ or ‘states of mind’ that promote Immediate
Causes. The necessity to distinguish Preconditions while investigating is the “whistleblower” speaking
up about the Organizational Cultures involved into the accident. Therefore, not only can we reach the
underlying Causes behind the failure more efficiently
but also we have enough hints and raw data
about corporate cultures that definitely need change.
Back to “HELIOS Accident”
The First TRIPOD
While the formation of the first TRIPOD, from the maximum five that we can manage in an Accident
Analysis, might be easy, all the rest require effort and a definite knowledge of who requested the
investigation, since his array of interests we need to take into account upon examining the accident’s
data.
Soon after HELIOS take off, the flight crew faced a challenge as they had found themselves faced
with the task of dealing with multiple warnings, a combination of at least two of the elements of the
Warning System of the aircraft (either OFF & Intermittent Horn or Aux Fail & Intermittent Horn) as
they had been active in short time intervals or almost simultaneously. That challenge had been the
change agent of this first in session TRIPOD while the Object that had been chosen to be guarded is
“The Boeing 737/300 integrity of the design over time”.
According to Sidney Dekker (unknown), the EICAS (Engine Indication and Crew Alerting System)
technology was available at the time that Boeing 737/300 came out but still it is unknown why this
system had never been applied on the prototype. Sidney Dekker argues that for that reason “B737
lags behind the industry standard on warning and alerting systems”.
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