PPRuNe Forums - View Single Post - "To err is human": differing attitudes to mistakes in EK and Turkish accidents
Old 5th May 2009, 17:32
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bjornhall
 
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My simplistic understanding of rule based behavior goes something like this: You are faced with a situation, you analyze it (more or less subconsciously) to identify it with some category for which there is a rule, you recall or choose that rule, and you apply that rule. The process is not rational in the way it appears in writing, but it nevertheless follows a chain or a cyle of "identify - choose - apply".

IMHO, if that is the way one manages speed control on final approach, then there is something seriously wrong. My view is that it should be a skill based, not a rule based behavior. Admittedly an amateur pilot's view, but am I really that far off the mark?

Skill based behavior on the other hand is an automatic, ongoing process. Importantly, it is far harder to get distracted from a skill based activity than it is from a rule based activity. Distraction means the "identify" step never occurs, and then the "apply" action is never taken; furthermore, one does not realize that something important was missed, until the indications become overwhelming (e.g., stick shaker).

Transforming an ability from a rule based to a skill based behavior is the role of training; maintaining it in the skill based category to prevent a relapse into rule based or even knowledge based is the role of recurrent training.

I like to think there are few professional pilots who make Type 3 errors because they fit in the "wrong stuff" group; i.e., that they could not perform to an acceptable standard no matter how well they are trained. I think they make such errors because they are insufficiently trained, and that with sufficient training they could perform as required.

My tentative conclusion then is that the mere existence of Type 3 errors indicate training problems.

Type 2 errors, on the other hand, are precisely the type of problems where what can now be referred to as "classical human factors issues" and the traditional solutions to such problems can be applied (read: J. Reason, Swiss Cheese, System Failures and so on).

EDITED to add: On the other hand, "someone should always mind the shop" seems to have its correct place in the rule based category. It would be interesting to understand if that step failed? Did nobody realize that nobody was minding the shop? Or did the person who was doing so get distracted and failed to perform it properly?

Last edited by bjornhall; 5th May 2009 at 17:42. Reason: thought of something else
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