FE hoppy I hope that you agree that a central theme of modern flight safety is that human error cannot be completely eliminated; it can only be minimised or the effects mitigated.
At some point an error will occur. A key aspect of TEM is to ensure that this error is detected (if it cannot be avoided), or does not occur in combination with some other critical feature, or that the outcome is manageable.
I agree that checklists can help, but why only checklists, why not use technology to prevent / detect an error in parallel with the crew. Why not increase normal takeoff speeds so that an inadvertent flapless takeoff might be controlled? These, like most things in aviation, are judgement calls, and are generally in the process of certification – communal experience.
The crew appears to have suffered an error – why; this aspect has yet to be revealed.
Our commercial industry chooses to crew with two pilots, where one might monitor the other. This accident involves one of those rare situations where both pilots suffered simultaneous, or near simultaneous error – there was a safety time span from checklist action until takeoff to detect the error, why were there failures in these aspects?
In this accident it is not up to us to determine if the crew (or others) did all that they could have done in the prevailing circumstances, we should not – we cannot determine negligence. It might be impossible to establish the mental processes which the crew employed; it is difficult to establish intent, knowledge, perception, bias, or belief, etc, which could have affected behaviour from a FDR or CVR.
However, we can at least consider other aspects which could affect the circumstances which might have influenced the crew.
It was not my intent to identify excuses, only the circumstances, which based on current information point towards weaknesses in the TOCW system.
Was it just chance that the crew encountered error provoking circumstances at the same time as the TOCW was at its weakest; if so the danger is that we might ‘blame’ chance, because as has been stated other crews have suffered checklist errors (flaps) without an accident. Chance is not good enough for our industry, thus there is the need to search deeper into the communal experience – the ‘model’ of safety, which like in the financial crash, might be flawed.
Perspectives on Human Error.
Punishing People or Learning from Failure?
Human error: models and management.
Human reliability.