Originally Posted by
MurphyWasRight
Totally agree that this is an effort to build the public opinion case for pilot error.
I find it quite remarkable that it takes such a long windup to finally conclude that the crew did not do everything perfectly. Duh. No human ever does.
And then it just stops. What is the point of finger-pointing? How can that help anyone in any way? (Except perhaps Boeing's reputation, but even that is doubtful.)
A finding of "Human Error", can never be the end of an analysis, rather it must be the start of asking questions such as:
- What was the exact situation the operators were in?
- What was the information they could get?
- Was some information maybe ambiguous? Even contradictory? Hard to find?
- How much time did they have to find it?
- How much time did they have to analyse it?
- Were they trained to evaluate the information properly?
- Were there perhaps multiple anomalies requiring different, possibly even contradictory procedures?
- Was there perhaps cognitive overload?
- Did they (could they?) have an understanding of why the system did what it did?
- What additional information do we have now, that the operators at the time did not have? (The easy one: we know that what they did eventually led to an unrecoverable situation. They didn't. Or else they wouldn't have done it.)
- Which again leads to: why did they do what they did?
- How can we prevent:
- ... crews from doing the same things again, or better still:
- ... anyone from getting into the situation in the first place?
I repeat here the image I posted way back that makes these ideas very clear:
From
The Field Guide to Understanding 'Human Error' by Sidney Dekker
Bernd