PPRuNe Forums - View Single Post - "To err is human": differing attitudes to mistakes in EK and Turkish accidents
Old 5th May 2009, 15:57
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biscuit74
 
Join Date: Mar 2009
Location: UK
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I think Blacksheep's description is excellent.

The TK issue was apparently very a much a Human Factors, classic distraction, case. Described at length by James Reason and others. The cultural aspect may be that if others in the crew noticed something wrong, perhaps they felt inhibited about mentioning it in time. In which case the holes in th Swiss Cheese start to line up. Training activity + distraction + cultural inhibition. Any one of those could happen anywhere. We'd like to believe they should not all line up at once.

I think that is why this for many pilots seems to hover between Gibon2's Type 2 & Type3. For myself I view it as a Type 3, because loss of situational awareness in what was not an apparently high stress environment should not happen to a well organised & competent pilot. This is part of what we teach people as basic airmanship. But I am an (now ex-) instructor not an airline pilot.

The EK event sounds to have been an oversight and a failure, presumably, to follow procedures. Since I understand it is quite common for departure routines to be interrupted - not unusual, in most professions the 'ideal' and the actual worlds are quite different - an error like this is easier to visualise and I suspect that is why rather more folk have the 'there but for the grace.....' feeling about that one, hence leaning towards Type 2.

Interesting discussion. I don't see any way to totally avoid these things, because of the way human beings operate.
Maintaining awareness of the pitfalls and snags in any activity does help. However we all get complacent, in all activities. Every so often, at the very least someone gets a nasty surprise. If we are lucky, we learn from that 'incident' and the general awareness threshold are back up higher for a while. That seems to be a consistent pattern in most pursuits, not just aviation. In theory, if we could graph the awareness curve, intervention at the right moment can help improve safety. The services used to do this with extra supervision at the various high risk flying hours points.
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