Accident investigations yield useful information. But is all this information actually being fed back to the system and acted upon?
The primary objective of accident investigations is to determine the causal factors and to use that information to prevent that type of accident from occurring again. However, the same types of accidents still occur.
Through no fault of the accident investigation agencies around the world, the industry is not doing a very good job of assimilating their findings into effective training examples in the classroom.
Although the sequence of factors leading up to an accident may be complex, the final triggering mechanism itself often is simple — such as taking off with ice on the wings or intentionally descending below landing minimums when a go-around should be conducted. In most cases, these triggering events can be ascribed to fundamental decision errors by the crew.
These are what I label thematic accidents. Four such thematic accidents, with almost id…
