PPRuNe Forums - View Single Post - Boeing incidents/accidents due to Thrust/Pitch mode mishandling
Old 15th Oct 2018, 04:20
  #73 (permalink)  
Dan Winterland
 
Join Date: Jun 2001
Location: Fragrant Harbour
Posts: 4,787
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Accident reports are variable in quality, but are generally improving. Very seldom do we see the term 'root cause' used and some investigation agencies have gone away from using the term 'cause' altogether. Accident reports should never apportion blame, so you should never see "the cause of the accident was the pilot doing xxxxx " wriiten. Investigation of human factors is changing for the better too, particularly in the field of human/machine interfaces. I have recently qualified as an accident investigator and the main emphasis on my course was human factors. Based on the premise that people don't go out to do a bad job (if they did then this becomes sabotage and a deliberate act - therefore not an accident), the investigator has to try and understand why an action made sense to the operator at the time. The factors which lead up to an accident are numerous and varied - and never simple. One basic statement such as "The pilot didn't understand the auto-thrust modes" is neither accurate or helpful. You have to look at the reasons why they were misunderstood.

It's a fascinating subject and those who wish to understand this topic more could do no better than to read 'The Field Guide to Understanding Human Error' by Sidney Dekker. It's not an expensive book, and will change your opinion on human actions, and may well change the way you act as an operator yourself. It's a 'must read' for accident investigators.
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