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2011.09.30 18:38 |  医療事故  |  映画 / 音楽 / 読書  |  その他（一般）  |  おかだ  | 推薦数 : 1

後出し

　日航ジャンボ機墜落事故の記憶は、私の中ではまだ色あせていません。アナウンサーが興奮した口調で「生存者が見つかったようです」と言ったときには、本当に驚きましたっけ。ただ、その直後のヘリコプターでの釣り上げは、いかにも不慣れで装具も専用のものではなさそうで、「ヘリでホバリングしながらの救出」を日本ではこれまで想定していなかったんだな、と思いましたっけ（あの複雑な気流が起きそうな危険な地形でエンジンに負担がかかるホバリングをやっていたヘリパイロットの腕には感服しますが）。
　あのとき、現場（御巣鷹の尾根）は本当に悲惨な状況だったそうですが、遺体や散乱した部品などが山から降ろされたところも、悲惨だったそうです(*1)。

　事故原因は、尻もち事故での修理が不十分だったために後部隔壁が破壊されて機体尾部と垂直尾翼が破壊され、さらに４系統ある油圧パイプがすべて破壊されたために操縦不能になったため、と事故報告書にはまとめられました。
　ただ、操縦不能のために123便はダッチロールをしていましたが、実は、油圧装置が効かなくても左右エンジンの推力を変えて機体を安定させることは理論的にはできたのだそうです。ただし、そのことを、当該機のパイロットは知らなかった……というか、日航の誰もそのようなことは訓練されていませんでした(*2)。そもそも「“複線化”してあるすべての系統の油圧制御装置が破壊される」ということ自体が“想定外”ですから、その原因とそのことへの対応法が即座に頭に浮かぶことを期待するのは、人に「神の視点」を期待するのと同じことでしょう。

　で、医療裁判で医療者に無茶な要求や判断をする人たちの同類が、もしもこの「油圧装置が効かなくても左右エンジンの推力を変えて機体を安定させることはできた」ことを墜落事故直後に知っていたら、「飛行機の挙動や全油圧装置の破壊という“症状”から、後部隔壁が破壊されたという“診断”を即座につけるべきだった」「たとえ現存する一番強烈なジェットコースターをしのぐ上下左右への揺さぶりがあったにしても、エンジンの推力を調節すれば飛行機の微妙なコントロールは可能だったはずなのだから、安全な着陸または着水も可能だったはずだ」と平気で主張するんじゃないか、と思いました。少なくともリクツは通っているでしょ？
　私の反応にも、医療事故や医療裁判と同じスジを通しておきます。「机上の空論を弄んで喜んでいるのではなくて、現実的に可能かどうかをきちんと判断してよね」「できるのだったら、シミュレーターでやってみせて。ただし、後出しできないようにパラメーターはあらかじめいくつか変えておくけど、即座にきちんと判断してね」。

*1)『墜落遺体　──御巣鷹山の日航機１２３便』飯塚 訓 著、講談社、1998年、1500円(税別)
*2)『ブラック・ボックス　──航空機事故はなぜ起きるのか』ニコラス・フェイス 著､ 小路浩史 訳､ 原書房、1998年、1800円（税別）


※蛇足
　「左右エンジンの推力を変えて機体を安定させることは理論的にはできた」で私が思い出すのは、戦艦ビスマルクです。大西洋の通商路破壊のために出撃したドイツ海軍の最新鋭艦ですが、英海軍の巡洋戦艦フッドを撃沈したものの英空母アーク・ロイヤルから発進したソードフィッシュ雷撃機の魚雷に舵を破壊されて進路変更ができなくなってしまいました。そこでも「理論的」には、左右のエンジンの出力を変えることで進路変更はできるはずでしたが、破壊されてねじくれた状態で固着した舵が抵抗となって結局思うようにいきませんでした。ビスマルク艦上では様々なアイデアが検討されましたが（潜水夫を使って舵を取り除く、艦上から爆薬を落として舵を爆破する、など）、当時は荒天、しかも英海軍の艦艇や飛行機と戦闘をしながらの状況で、さらにフッドとの交戦で損傷を受けて前部燃料タンクが使えない状態、という“悪条件”がいくつも重なったために、結局何もできませんでした。「理論的には可能」でも「現実」が“邪魔”をすることはよくあるのです。

蛇足の参考図書
『巨大戦艦ビスマルク　──独・英艦隊、最後の大海戦』ブルカント・フォン・ミュレンハイム＝レッヒベルク 著､ 佐和誠 訳、早川書房、1994年、2200円(税別)
『戦艦ビスマルク発見』ロバート・Ｄ・バラード　著、　高橋健次 訳､ 文藝春秋、1993年、5825円（税別）
『孤独の海』アリステア・マクリーン　著、　高津幸枝・高岬沙世・戸塚洋子 訳、 早川書房、1987年、1500円

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