Originally Posted by
FullWings
I think that’s the core of the issue that divides the “pilot’s fault” crowd from the “aeroplane’s fault” one.
First, I'll have to say that I really don't like using concepts like "blame" and "fault" when it comes to discerning important safety lessons in aviation. The blame game tends to get too emotional and too defensive with everyone picking sides. On the other hand, I am very much interested in all the contributory causes, whether they be technical, environment, regulatory, or human factors. Some have referred to this as the "chain of causation", and I think it is important that we learn everything we can from every link in this chain. Structuring the debate around an either/or proposition such as "Boeing screwed up" vs "pilots screwed up" risks missing some important lessons.
There is pretty much unanimous consensus that MCAS was poorly designed and implemented. Behind that process, however, were numerous decisions made at numerous levels - including some made by people with completely benign intentions who are likely now horrified by whatever role they played in this tragedy. As much as some might like to find a clearly defined group of bad actors at whom we can point fingers, I just don't think that is possible. I'm not saying here that Boeing didn't produce an ill-thought design, but that's different than saying it was done with intent or malice. Despite Boeing's attempts to minimize their financial liability (as one might expect from the legal side), it does appear that there is a serious attempt to examine and change their internal processes. Time will tell.
Attempting to jump from Boeing's to the pilots' roles skips over an entire body of causal factors which ought to be examined as well. As I have said before, pilots do not create the hiring process, the training syllabus, the regulatory structure, the operating environment, or the corporate culture. However, their responses in the cockpit will reflect all of these factors. The discussion around the pilots' actions tends to revolve around the discrepancy between what they did as opposed to what they were expected to have done. In safety culture language, this gap is sometimes referred to "work as imagined" and "work as done." When looking at the flight crew responses, I think the objective should be to identify all those things that contributed to this gap and takes steps to mitigate those factors. I have seen nothing in the evidence that indicates that the pilots were incompetent. On the other hand, I see evidence that they were not provided with the proper tools and training to deal with such a complicated malfunction. It appears in this area there are also sincere attempts to identify and correct some of these deficiencies, but again, it will take some time to see if there is proper follow-through.