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Last updated on 2024年6月21日

Here's how you can incorporate logical reasoning into aviation accident investigations.

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When it comes to aviation accident investigations, logical reasoning is an indispensable tool that helps investigators establish causation, unravel complex scenarios, and ultimately improve safety. It's a methodical approach that requires meticulous analysis of evidence and data, piecing together the events leading up to an accident. By incorporating logical reasoning, you can make sense of the seemingly senseless, transforming raw information into actionable insights. This process is not just about finding what went wrong, but also about providing recommendations to prevent future occurrences.

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Washington Freitas

Especialista em Contraincêndio Aeronáutico | Instrutor OE-SESCINC | Docente na Educa??o Profissional e Tecnológica |…

1 Gather Data

The first step in applying logical reasoning to aviation accident investigations is the comprehensive gathering of data . This involves collecting all available information from the accident site , including flight data recorders (FDRs), cockpit voice recorders (CVRs), aircraft wreckage, air traffic control communications, weather reports, and eyewitness accounts. It's crucial to approach this phase without preconceived notions, ensuring that your analysis is based on evidence rather than assumptions.

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Washington Freitas

Especialista em Contraincêndio Aeronáutico | Instrutor OE-SESCINC | Docente na Educa??o Profissional e Tecnológica | Palestrante
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O A análise do acidente áreeo chamado de "desastre de Tenerife", em 1977, demonstrou a importancia da coleta minuciosa de dados em investiga??es de acidentes aéreos. As grava??es das caixas pretas, destro?os, transcri??es de comunica??o e relatos de testemunhas oculares revelaram falhas de comunica??o, erros humanos e condi??es climáticas adversas como fatores contribuintes. Essa análise abrangente permitiu a identifica??o das causas e a formula??o de recomenda??es cruciais para a seguran?a da avia??o, como a ado??o de fraseologia padronizada e treinamento em gerenciamento de recursos da tripula??o, conforme destacado por Weick (1995), Cushing (1994), Maurino et al. (1995) e Reason (1990).

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2 Hypothesis Formation

Once you've collected the data, the next step is to form hypotheses about potential causes of the accident. This is where you begin to apply deductive reasoning, creating possible scenarios that fit the evidence. It's important to consider all plausible explanations, no matter how unlikely they may seem at first. Each hypothesis should be testable against the data you've gathered, allowing you to narrow down the list to the most probable causes.

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Washington Freitas

Especialista em Contraincêndio Aeronáutico | Instrutor OE-SESCINC | Docente na Educa??o Profissional e Tecnológica | Palestrante
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O desastre de Tenerife demonstrou a importancia da formula??o de hipóteses na investiga??o de acidentes aéreos. Inicialmente, suspeitou-se de erro do piloto devido à pressa em decolar, mas a análise das evidências, incluindo grava??es do CVR e transcri??es de comunica??o, revelou a complexidade do evento. A hipótese de falha de comunica??o, agravada pelo sotaque do controlador e interferência de rádio, ganhou for?a, assim como a influência das condi??es climáticas adversas, como o denso nevoeiro. A investiga??o, seguindo o modelo de Reason (1990), considerou múltiplas hipóteses, incluindo erro do piloto, falha de comunica??o e condi??es meteorológicas, para identificar as causas e formular recomenda??es cruciais para a seguran?a da avia??o.

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3 Evidence Analysis

Analyzing the evidence is a critical step where you scrutinize every piece of data in light of the hypotheses you've formed. You'll need to use inductive reasoning to draw general conclusions from specific instances. For example, if an aircraft component shows signs of fatigue, you'd consider how this could have contributed to the accident. This phase often involves collaboration with experts in various fields , such as metallurgy or human factors, to interpret technical data accurately.

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Washington Freitas

Especialista em Contraincêndio Aeronáutico | Instrutor OE-SESCINC | Docente na Educa??o Profissional e Tecnológica | Palestrante
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A análise das evidências no desastre de Tenerife revelou a interpreta??o err?nea das instru??es da torre pelo piloto do KLM, a falta de clareza nas comunica??es, o comportamento autoritário do piloto e a ausência de procedimentos para baixa visibilidade como fatores cruciais que levaram ao desastre, conforme destacado por Cushing (1994) e Reason (1990).

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4 Logical Deduction

Logical deduction is used to eliminate hypotheses that are inconsistent with the facts. At this stage, you apply rigorous logic to each scenario, determining which can be supported by the evidence and which can be dismissed. This process is iterative and may lead you back to gather more data or form new hypotheses. The goal is to arrive at the most likely explanation for the accident, supported by a clear chain of logical deductions.

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Washington Freitas

Especialista em Contraincêndio Aeronáutico | Instrutor OE-SESCINC | Docente na Educa??o Profissional e Tecnológica | Palestrante
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A dedu??o lógica no desastre de Tenerife permitiu concluir que a combina??o de erro do piloto, falha de comunica??o e condi??es climáticas adversas causou a colis?o. A pressa do piloto do KLM, o mal-entendido nas comunica??es e a falta de visibilidade, evidenciados pela análise das grava??es do CVR e das transcri??es de comunica??o, criaram uma situa??o perigosa que culminou na tragédia, corroborando a teoria de Reason (1990) sobre a convergência de falhas latentes e ativas em acidentes complexos.

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5 Causal Links

Identifying causal links is about connecting the dots between contributing factors and the accident itself. This involves understanding the interplay between human actions, mechanical failures, environmental conditions, and systemic issues. By constructing a timeline of events and identifying where interventions could have prevented the accident, you create a narrative that explains not just what happened, but why it happened.

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Washington Freitas

Especialista em Contraincêndio Aeronáutico | Instrutor OE-SESCINC | Docente na Educa??o Profissional e Tecnológica | Palestrante
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O desastre de Tenerife resultou de uma cadeia de eventos interligados. O desvio dos voos para Tenerife devido a um atentado, o congestionamento no aeroporto e o denso nevoeiro criaram um ambiente propício para erros. A falta de clareza nas comunica??es, agravada pelo sotaque do controlador e pela interferência de rádio, somada à pressa do piloto do KLM em decolar, desencadeou a colis?o. Essa análise dos nexos causais, alinhada com o modelo de Reason (1990), revela como falhas individuais e sistêmicas se combinaram para causar a tragédia, destacando a importancia da preven??o de falhas em múltiplos níveis para garantir a seguran?a da avia??o.

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6 Safety Recommendations

The final step is to translate your findings into safety recommendations. This is where the real value of logical reasoning in aviation accident investigations comes into play. By clearly articulating how each contributing factor led to the accident, you can suggest changes to procedures, training, equipment, or regulations that will enhance aviation safety. These recommendations are the culmination of your logical analysis and are aimed at preventing future accidents.

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7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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Here's how you can incorporate logical reasoning into aviation accident investigations.

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1 Gather Data

2 Hypothesis Formation

3 Evidence Analysis

4 Logical Deduction

5 Causal Links

6 Safety Recommendations

7 Here’s what else to consider

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