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Old 7th Oct 2004, 06:30
  #61 (permalink)  
Rongotai
 
Join Date: Oct 2000
Location: Wellington
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MOR

It does seem a pity that you feel the need to try and discount me as a person (about whom you know absolutely nothing except that I live in New Zealand - every other factual thing you infer about me is incorrect) rather than just engage in the debate. I will not debase the important points that you make either by defending myself or attacking you.

I do not agree with you - or rather I think that you only deal with part of the matter.

If we are to learn from an accident investigation we must not only know what happened, but also why it happened. I'll make my point with the simplest possible example.

If a human error incident occurs and it is determined that the proximate cause was that the captain was fatigued and the FO felt unable to challenge the captan because that is the way things are in that company (and there are companies where that is the case), then we can fault both flight crew and invoke whatever sanctions we like, but we have done nothing to manage the underlying risk in most actual cases.

Your argument is valid if it turns out that the captain stayed up all night on his nightstop, and the FO has a personality defect. But even then there should be some follow on questions about selection and training.

But in most cases there will be systemic contributors to do with such things as rosters, organisational culture and so on. If we do not examine the underlying causes and, if necessary, correct them, then the disciplining of the actual flight crew achieves nothing.

It is simply out of touch with how humans perform tasks to assume that because you have lines of authority and comprehensive manuals that failure to adhere to them is solely a matter of individual competence. Your view is supported neither by psychology, organisational research or aviation accident statistics.

I have done work on why people do and do not use CHIRP and other anonymous reporting processes, and how the incident statistics are distorted by relying on such databases. It is fascinating that in some cases cultural assumptions are so embedded that even anonymous reporting processes are not trusted.
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