Pakistan International Airlines accident (2020) is uncomfortable precisely because the core barriers are well-known:
stable approach discipline
configuration verification, and
“no-fault” go-around culture.
The investigation record describes a sequence involving runway contact gear up, subsequent damage, and a failed recovery.
Through an SToC lens:
Safety: Approach/landing safety gates failed to hold.
Technology: Aircraft state and simple physics became unforgiving once procedural barriers failed.
Organisation: This is where assurance matters. Training, checking, and monitoring prevent drift becoming normal.
Culture: Press-on-itis creating bias and normalisation of deviance become the silent precursors to headline events.
Question: If you looked honestly at your own operation, where does drift show up first—standards, supervision, or culture?
#AviationSafety #SafetyManagement #JustCulture #OperationalDiscipline #HumanPerformance
SToC Resilience Deficit Radar
RADAR Scores
Safety: 0
The core approach and landing safety barriers failed. Stable approach criteria, configuration discipline, go-around decision-making, and landing safety gates did not hold at the critical point.
Technology: 2
The aircraft itself was not the initiating problem, but once the aircraft contacted the runway gear-up, the technological system became unforgiving. Damage to engines and systems reduced recovery margins sharply.
Culture: 1
This is a major contributory area. Press-on-itis, reluctance to discontinue an unstable approach, cockpit authority dynamics, and normalisation of deviance appear central to the accident pathway.
Technology rate of change +RC: 2
Not primarily a technology-change accident. The issue was less about rapid technological novelty and more about failure to respect existing safety procedures and aircraft limits.
Regulator rate of change +RRC: 1
Regulatory assurance appears weak if unstable approach discipline, crew checking standards, and organisational safety culture were not being effectively detected and corrected before the accident.
Corrective Actions
Safety
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Technology
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Culture
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Technology rate of change +RC
Safety Corrective actions
Regulator rate of change +RRC
Safety Corrective actions