Linate, 8 ottobre 2001, 15anni dopo: ancora su un scenario contromano intenzionale!

Era una opzione applicabile e/o da investigare anche a Linate? E' un riscontro nodale!

Dopo tanti anni la verifica dello scenario di "violazione intenzionale" di una SOP - Standard Operational Procedure, ovvero della procedura standard di rullaggio, andando contromano verso il punto attesa della pista 36 di Linate è ancora solo una ipotesi investigativa. Senza adeguati rilievi, riscontri sui tempi di rullaggio degli aeromobili che in quella tragica mattinata hanno rullato dal piazzale dei parcheggi (Piazzale Ovest ex ATA) dell'aviazione generale.

La responsabilità del pilota del Cessna immatricolato D-IEVX, autorizzato a muoversi intorno alle 07.48 dell'8 ottobre 2001, parcheggiato nel piazzale Ovest - ex ATA dell'aeroporto di Linate, ovviamente, non è in discussione. Ma la chiave dell'indagine è rappresentata dalla opzione: è stato un errore umano e/o un atto intenzionale deliberato e per quali, magari evidenti, evidenti ragioni?

Ma come, innanzitutto, definire e distinguere tra "Human Error" e "Violazione":

"Errors and Violations

In everyday language, the term “error” is used in a very broad sense. For a more detailed discussion of the topic, more precise definitions are needed. The classification used here is in line with James Reason’s definitions.

Errors are intentional (in)actions, which fail to achieve their intended outcomes.

Errors can only be associated with actions with a clear intention to achieve a specific intended outcome. Therefore, uncontrolled movements, e.g. reflexes are not considered errors. The error itself by definition is not intentional, but the original planned action has to be intentional. Furthermore, it is assumed in the above definition that the outcome is not determined by factors outside the control of the actor.

Violations are intentional (in)actions, which violate known rules, procedures or norms.

The fundamental difference between errors and violations is that violations are deliberate, whereas errors are not. In other words, commiting a violation is a conscious decision, whereas errors occur irrespective of one’s will to avoid them. Cases of intentional sabotage and theoretical cases of unintentional violation (breaking a rule because the person is not aware of the rule) are outside the scope of this Flight Operations Briefing Note.

Therefore, it is important to realize that within the scope of our discussion a person committing a violation does not intend the dramatic negative consequences which sometimes follow a violation - usually it is belived bona fide that the situation remains under control despite the violation.

It is worth noting that many sources, even in the domain of aviation safety, use the term “error” in a wider sense, covering both errors (as defined here) and violations.

Ma perchè inoltre i piloti - nel corso di talune operazioni e procedure a terra e in volo - deviano volontariamente e/o intenzionalmente dalle SOP - Procedure Operative Standard?

"Why do Pilots deviate from procedures?

Why do well trained, motivated and professional operators deviate from an SOP?

Individualism

Pilots and engineers are individuals at the end of the day and generally they want to impose some form of their own character on a procedure, this is in part what differentiates us from computers. Whether it be a different technique to break the boredom, or to apply some form of critical thinking to a procedure, generally these deviations do not adversely affect the outcome. Gone unchecked however, it can break down standardisation and bring confusion to a flight deck if a co-pilot does not understand the deviations in procedure of his Captain.

Complacency

This is the dropping of your guard during a repetitive task or the introduction of humour by deliberately mispronouncing words in a critical standardised task. The backstop to this is reinforced in CRM, where a pilot can correct repeated non-standardised responses to a checklist, preventing a deterioration in responses.

Frustration

Being forced to conform to a seemly ridiculous procedure can provide justification to alter or amend the practice of a procedure. There are several ways to approach this problem; either raise the issue with management and have the policy or procedure changed or have training provided to explain why a procedure is conducted in a particular way so it no longer seems ridiculous.

Conclusion

As we all know without procedures it would be difficult to maintain effective and safe operations of aircraft due to the complicated nature of the systems involved. The process of designing procedures from both an organisational as well an operational perspective is a long and tedious process. How effective these procedures are can only be determined by constantly monitering how much procedure deviation takes place once it is put into place. There will never be a perfectly designed set of SOPs due to the ever changing factors in the environment and thus changes in procedures."