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Comment by songzme | Hacker News Reader

I've heard this anecdote before and it never sat well with me. Forgetting to fuel a plane as a plane mechanic exposes a serious character flaw that could lead to something devastating if allowed to continue (perhaps next time he forgets to oil the engine? Grease the brakes?). Sensationalizing this story could actually do alot of harm. The plane mechanic should have been fired for failing such an important task. If he showed incredible remorse and was responsible enough to own up to his mistakes, he should still have been striped of all his other responsibilities and only fuel planes until he has proven himself enough to take on more responsibilities again.

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When people are afraid to loose their jobs if they make an error you can be pretty sure they will do everything in their power to hide the fact that they made an error, which is the exact opposite of the behavior you want. To allow process improvements it must be absolutely clear that errors will not be punished, but used to help everyone to learn.

It must be coupled with processes that guard against errors though. Defense in depth. I'd imagine the pilot has a tick sheet to go over before takeoff and fuel is an item on that sheet.

You imagine right. It's on every checklist: check fuel quantity and type.

The JAL 2 mishap is legendary in the aviation world. Learning from mistakes is a big part of aviation safety

https://en.wikipedia.org/wiki/Japan_Airlines_Flight_2#The_.2...

The Captain basically got up before the NTSB and when asked what happened, he responded "I F__ked Up!" instead of trying to deflect blame onto an unforeseen system glitch or other excuse. Its since been known as the "Asoh Defense"

They also have the NASA ASRS for reporting near misses, and incidents without fear of FAA enforcement.

https://en.wikipedia.org/wiki/Aviation_Safety_Reporting_Syst...

I think you highly underestimate the number of mistakes like this on the flight line.

By an order of magnitude it sounds like from your comment. Even if you get 99.99% reliability (good luck with humans involved) think of the number of flight movements per day multiplied by the number of tasks that must be completed.

This is why there are redundant checks and checklists and systems in place. To catch human errors, as absolutely everyone in the business will eventually make a trivial yet critical mistake.

Demanding individual human perfection is great, but you'll find you will end up with no workforce.

The aviation industry recognizes and accepts that people make mistakes, and that this is a simple fact of being human. Firing that mechanic without fixing the process wouldn't have done any good in the long run. Someone else would just make the same mistake. Maybe not the following week, maybe not the following month, but eventually, it would've happened again. The right answer is to fix the process.

Agreed. Point in case, the recent death of nearly the entire Chapecoense football team:

> According to the preliminary report, several decisions of the flight crew were incompatible with aviation regulations and rendered the flight unsafe. Insufficient flight planning (disregarding necessary fuel stops) and not declaring an emergency when the fuel neared exhaustion caused the crash.

https://en.wikipedia.org/wiki/LaMia_Flight_2933

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