Originally Posted by
alf5071h
‘Blame’ is used as a self-satisfying closure for complex, often indeterminate situations (‘wicked problems’).
Assuming that something was understood as an opening analysis risks hindsight bias, or that everyone will have similar understandings, similar thought processes.
UAS could equally be stick-shaker implying stall, or a range of alternative perceptions according to context. Bounding problems with assumption might aid our after-the-fact understanding, but whatever we conclude is only probability, because we can never know what these crews perceived, what was thought, or understood, or any reasoning for action.
Start with a view that the crew acted as they saw the situation (not our view), that humans are an asset to be used and not a hazard to be constrained; this and the above might provide an alternative analysis. Not fact only probable, but an understanding which might better be used to learn from.
As background see:-
https://www.nifc.gov/PUBLICATIONS/ac...an%20Error.pdf
https://www.ida.liu.se/~729A71/Liter...berti_2001.pdf
https://www.eurocontrol.int/sites/de...ndsight-25.pdf Page 10 -
https://www.demos.co.uk/files/systemfailure2.pdf
[...]
Thank you. I agree completely.
I would add to the list of references any of Sidney Dekker's works, in particular
The Field Guide to Understanding 'Human Error'.
Bernd