I have been thinking today.....a scary thing for me to do some of you might agree.
My pondering got around to the concepts of Pilot Error, Crew Error, Operational Error, and humans making errors in general as they relate to aviation.
This accident cannot be attributed to Pilot Error in the least.
The Crew was confronted with a serious mechanical problem and as it turned out....it was in fact a serious mechanical failure. That in itself rules out Pilot Error as the aircraft was lost to a mechanical failure.
The Crew were presented with unusual indications initially and those were indication abnormalities. There were no signs of smoke, fumes, fire, vapor trails, grinding noises, or other physically viewable signs of a problem. All they could see were the unusual indications of warning lights, caution lights and gauge indications.
The Crew sought and got technical assistance from their Operations. There was a back and forth discussion of some sort regarding the indications, possible causes, and options to be considered in the wake of those indications.
Thus the Crew did not act independently. That rules out Cockpit Error in my view. The Crew exercised good CRM as evidenced by taking action to descend then report the problem. It appears they consulted their Emergency Checklist, and at least initiated the proper response as indicated by the immediate descent and reduction in airspeed. They sought the counsel of their Operations and Engineering staff who provided what guidance they thought right.
That brings us to Operational Error.
If we define this to be a systemic error and not a Pilot or Crew Error and one that involves other individuals from the system including Engineering and Flight Operations then perhaps this is the category we should begin to call this accident.
Plainly Human Error played a role....a very large role in this accident.
The substantial risk of the failure of the Oil Filter Bowl retention studs was under estimated by a host of people and organizations. Perhaps the Emergency Procedures in place at the time did not adequately address the situation the crew encountered and management decisions did not effectively deal with the situation before the flight and during the actual emergency itself. If the crew had not made contact with their Operations Office, would they have been more likely to have landed the aircraft and thus avoided the result of that effort to continue flying?
Others have mentioned the NASA experiences with the loss of two Shuttles and the near loss of a third. We could add the loss of three astronauts in a launch pad fire when the capsule used an oxygen enriched atmosphere.
Was this crew not in the same situation as the astronauts aboard the shuttles? Were they not as much Victims as were the passengers?
They were professionals in the true sense of the word.