“The day I make a mistake like that …, I will hang up my wings.” - Rainboe
The day that you make such a mistake, then if appropriate, you might get a new set of wings from St Peter!
Based on the details available so far, the crew in this accident appear to have crossed the boundary of acceptable professional behaviour as judged by the profession. However, the wider public judgement appears to be still open to the investigation and reporting of the facts, or further deliberation in a legal process.
Many members of our profession are defining, in hindsight, a boundary, which is biased towards the ideals of a safe industry – where ‘safe' (acceptable behaviour) is a relative term often judged in the eye of the beholder. In seeking to allocate blame we focus on the human element, often overlooking the natural fallibility specifically ‘built in’ to enable learning and flexible response when dealing with hazards.
Consider an ‘identical’ crew, behaving exactly in the same manner, in the same situation except that the RA fault occurred at a slightly higher altitude; the small increase in altitude being just sufficient for the aircraft to recover (luck).
Would this crew be judged in the same way?
The contributing factors of a ‘hot & high’ initial approach, the workload and distraction of a training flight, and the inexperience of the handling pilot, are all common occurrences which other crews accept and manage. Yet these crews operate safely (safe enough) even though they exhibit ‘errant’ behaviour; thus are we to judge a particular crew on luck?
No. There is no place for luck in the safety of our industry.
If human behaviour is unreliable (not always safe), then we must look at the environment and the guidance provided for crews’ during operations. This is not to excuse less-than-professionally-acceptable behaviour, but it is to seek an understanding of what led to apparently unsafe behaviour in particular circumstances – a means of determining where ‘the boundary’ of acceptable safety might be.
A major problem is that the eyes of the beholders judging safety, are split between the regulators, the safety investigators, the profession, and the public; each with potential for bias. Also, these viewpoints are in a rapidly changing time frame relative to scenarios (situations), regulations, and training – we (the groups) can change our minds very quickly, often without due thought, which like in many crew operations is a source of error – a mistaken judgement.
What the profession should seek to establish is how often errant conditons arrise, why apparently there are so few safety reports of the the potential for an accident as at AMS. Why aren’t we reporting the hazardous contributing factors (RA faults), weak behaviours, less than ideal training - aspects that are in every day operations. By failing to do so we do not refine the boundary of safe operations and the acceptability of professional behaviour; aren’t all of us exhibiting error, and thus blameworthy?