Rongotai
OK here we go then.
But on the face of it your point here seems to be at odds with what seemed to be a linear dependence on the command structure and SOP's.
I wasn't so much talking about the rationale in the cockpit, as the legal framework under which the apportioning of blame, and the quest for compensation, works.
The command structure and SOPs are never going to solve the problem of human error in the cockpit, obviously - they are only as good as the weakest link, in this case the pilots. However they are the best framework we currently have for minimising risk. The "command gradient" is itself of little use, except where executive decisions have to be made. We always viewed the two people up front as the Captain and the Captain in Training.
(a) being regarded as the only intervention necessary (which locates the 'problem' exclusively with the individual); or (b) being believed as having been remedied by re-training when the error was in fact a one off situationally triggered mistake that is unlikely to re-occur, and which anyway has already led to agonised self appraisal by the pilot concerned.
I quite agree, and in fact part of the exercise for me was try and find out the background to the error. It was usually something like life stress or some sort of relational problem. We offered counselling where appropriate.
Often, maybe even usually, but far from always. It sometimes has to do with cognitive overload, unrecognised patterns, or perceptual distortions that have situational origins rather than origins to do with psychological or physical limitations of the individual.
I agree, however these factors aren't really a competence issue either. Someone who is unable to complete a procedure for the reasons above is not incompetent. They are basically overloaded with factors outside their skill set.
In my view risk management of these factors should be about 30% down to individual professionalism and about 70% to organisational management
I agree, but try persuading the airlines!
When we tried to document it by interviewing UK pilots in known incidents that did not appear in CHIRP all we achieved was to increase the mistrust, so we had to give it away. So I'll have to concede that it is an unproven statement.
That is a pity. I thought maybe you had tapped into something from the studies undertaken in some of the Far Eastern carriers, where any form of reporting is officially encouraged, but culturally discouraged.
An example- I was doing some training at Prestwick many years ago, and there were a bunch of Japanese pilots there being type-rated on the Jetstream 31. They had a habit of simply firewalling the thrust levers on takeoff, which is not a good idea as if the limiting system fails, you can overtemp/overtorque the engines. They were told time and time again to just set the required thrust, and did so on their final checks.
They get back to Japan, into a shiny new J31 with only delivery miles on it, and take off on a shakedown flight. Now away from the gaze of the instructors, they simply firewalled the thrust levers. Both engines expired at about 200 feet, and they were lucky to be over the runway and able to re-land. The engines were scrap. The bill was over NZ$7 million.
Why? A senior pilot did it, so they all did it too. The senior pilot was regarded as far more authoritative than all the British instructors...
Anyway, it seems we are in broad agreement. It is a very interesting subject, the more I learn the more interesting it becomes.