Firstly, there should be an acknowledgment that if and when the pilot makes a mistake, his will probably be the final enabling one at the apex of a whole pyramid of errors down below. This will, in turn, take the heat off investigations – the ‘we intend to find and punish the culprit’ syndrome.
Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it – faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable.
Research has shown that internally generated thought can block the simultaneous taking up of externally generated information, i.e. that from the outside world. Originally, our ability to blank out too many unwanted stimuli was a survival advantage. But we get nothing for nothing.
The natural adaptations that in past times helped us to survive may now in the technological age be one of our greatest threats. A capacity for conscious representation had survival value for those creatures possessing it, but to achieve its time-saving purposes, conscious experience had to be of very limited capacity.
According to Professor Dixon, formerly Professor of Psychology at University College, London, ‘Conscious awareness is a small flawed barred window on the great tide of information which flows unceasingly into, around and out of the four hundred thousand million neurones and hundred billion synapses which comprise the human nervous system.’ And under stress – the stress of landing, the stress of take off – awareness narrows and the window becomes a tunnel.
A mental ‘set’ is a readiness for a particular thought process to the exclusion of others, resulting in fixation. ‘Set’ is another of the survival characteristics we have inherited. The human brain evolved to help individuals live and survive circumstances very different from our own. It pre disposes us to select our focus on that part of the picture paramount at the time – a vision often so totally focused that it ignores the rest of the environment. The pattern of selectivity programmed into humans by the ancient world is totally obsolete in the present day, where a flexible scanning throughout the visual environment is required. The human beings in the cockpit have to steer a difficult course between too many and too few visual stimuli.
High arousal contributes to ‘set’. The mind becomes tunnelled on a particular course of action. Add to that the ingredient of fatigue or stress and it is not difficult to see that a ‘set’ as hard as concrete can result. Furthermore, ‘set’, particularly in the captain, is infectious. There is a follow-my-leader syndrome. So it is easy to see why most aircraft accidents are caused by ‘silly’ mistakes in the approach and landing phase.
Professor Reason in Human Error (1990) distinguishes between active error, the effects of which are felt almost immediately, and latent error, the adverse consequences of which may lie dormant within the system for a long time. This can clearly be seen in aviation, where pilots at the sharp end make an active error, while latent error lies behind the lines within the management support system. Many of these are already there awaiting a trigger, usually supplied by the pilot. ‘There is a growing awareness within the human reliability community that attempts to discover and neutralise those latent failures will have a greater beneficial effect upon system safety than will localised efforts to minimise active errors.’
As long ago as 1980, Stanley Roscoe wrote that:
The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.
Everyone else, including other crew members, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programmes or procedural
indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident
The operating crew are the last line of defence for every ones mistakes.
Relying on human beings not to be human in a safety related business is insanity
EGPWS (Electronic Ground Proximity Warning System)– Even Good People Will make an error Some day
400Rulz - the above are a collection put together from various professional authors. It is indeed most interesting that your father on hearing of the accident was instantly able to determine its fate. How so? What other holes in the Swiss cheese do you think there may have been, if any? Might I ask what your aviation credentials are?