While we wait for the full analysis of the accident, it is disappointing to see possibly hasty punitive action taken in an industry that strives for a ‘just culture’ and the avoidance of blame. If nothing else, the industry deserves some public explanation, as without it the operator could be criticized for pre-judging the AAIB investigation or possible not conducting a thorough in-house investigation and thus overlooking any organizational contributions.
From a crew error viewpoint, I recall an interesting test – the substitution test.
CAP716 Aviation Maintenance Human Factors P159
www.caa.co.uk/docs/33/CAP716.PDF
The “substitution test” is good rule of thumb when illustrating where blame is inappropriate. If an incident occurs, ask yourself whether another similar individual (with the required skill, training and experience) in the same circumstances would have done anything different. If not, then blame is definitely inappropriate.
“Do blame and punishment have a role in organisational risk management?”. Johnston, N. Flight Deck. Spring 1995, pp 33-6.
In addition, I would suggest that those who use this test require the appropriate level of ‘skill, training and experience’ in applying the human factors associated with error.
Applying the substitution test to the assumed initiating error - a ‘momentary lapse’ (a failure of execution – J. Reason) e.g. the disconnection of the autopilot vice use of transmit button, then it would be interesting to hear how many other 737 pilots have made or nearly made a similar mistake. Is the AP DISC button proud or guarded, is it easily depressed? Of course, any specific circumstances in this incident would also have to be considered, e.g. why it was necessary to transmit during the latter stages of a Cat3 approach, which could be a mitigating factor.
It is possible that many crews would judge the initiating factor as an error and therefore not blameworthy. However, if the test was applied to the subsequent autopilot re-engagement then a different judgment might be made. The crew action would have to be balance by the level of training given and understanding acquired about the use of the autopilot, the pressures of time, fuel, or fatigue. Alternatively if there was a clear cut company procedure that states – do not reconnect the autopilot in ‘these’ circumstances, then the ‘error’ could be judged a violation. But even violations have categories that require understanding and explanation, with many contributing factors originating from the organization.
And finally do you blame a crew for a violation that was precipitated by an error? The answer to this question requires both organizational judgment and wisdom.
I hope that the industry is not deprived of the opportunity to learn from this accident either by the operator’s opaque activities or by a limited investigation that does not delve into the human and organizational background to error.
If anyone has the document
“Do blame and punishment have a role in organisational risk management?”. Johnston, N. ‘Flight Deck’. Spring 1995, pp 33-6. I would appreciate a copy.