wileydog3;
I may have posted this but I like Dekker's comment that cause is not found, it is constructed and to even construct a plausible cause, we have to get inside the 'tube' to try and ascertain what the crew was seeing, what the crew was thinking and how they were responding to the events.
No doubt, some one will come along and say they should have 'connected the dots' but that short changes the process and is afforded the bright light of hindsight. I also like the observation that during the evolution of an event, the process is fairly opaque and afterwards starkly evident
Precisely - I think Dekker's work has much to contribute generally in terms of how humans interpret the world and history, but in both accident prevention and investigation specifically. His 2nd latest, "The
Field Guide to Understanding Human Error" 2nd ed, (his latest, "Just Culture: Balancing Safety and Accountability", January 2008) are both worth reading and not just for aviation professionals and accident investigators.
I would commend many of the contributors here to these books alone, for comprehension of the investigative process and a more thorough understanding of human nature, and not only in aviation.
If nothing else, Dekker makes clear the strong human motivation to re-write experience to be in accord with post-event learning, while those involved in the event are only faced with perhaps dozens of avenues in terms of choice and dozens of "cues" which afterwards assume are so clear.