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Old 9th Dec 2003, 02:43
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Rongotai
 
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Amos - Continued discussion Erebus is still valuable - see below.

Prospector - your points are valid, but........


For me the issue of Erebus - still unresolved in attitudes to attribution of cause in aviation accidents - is that a simple 'pilot error' conclusion is frequently used to let everybody else of the hook despite a false premise.

For me the false assumption in blaming Collins (and many crews since) is that all that is required to avoid human error accidents is for pilots to follow standard operating procedures as documented in their manuals and instilled in their training. This is a false premise for three reasons:

(a) real life situations are invariably more complex than those predicted in manuals and training:
(b) manuals and training never predict every possible situation; and
(c) pilots, just like everybody else, are human beings who can occasionally be put under pressure by contradictory requirements between technical performance and social, cultural and business expectations.

In this case, as in many others, all three were operating at some level. If we want someone to blame then we can choose the crew (Kippenberger) or the company (Mahon) and there is a defensible position in either case. But if we want to reduce accidents then we must recognise that there is a correlation between cultural and business practices of airlines and errors committed by aircrew. If, in such situations, we simply attribute blame to the aircrew without addressing any underlying corporate behaviours or practices that contributed to that error, then we may have cause some sort of emotional catharsis but we have done absolutely nothing to reduce the frequency of critical incidents in that company.

Erebus is one of the first, and still one of the most striking, case studies about such matters. That is why it still merits study and discussion. Everybody acknowledges that Collins was a top class pilot. Everybody recognises that in strict procedural terms he should not have been where he was. If we consider how a pilot of such quality could nevertheless place himself in that situation, we have the possibility of drawing lessons that might make commercial aviation safer in the future. If we simply blame the pilot, we deny ourselves that possibility.
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