PPRuNe Forums - View Single Post - "To err is human": differing attitudes to mistakes in EK and Turkish accidents
Old 6th May 2009, 12:55
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alf5071h
 
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Error is a very complex subject. An interesting view is given by Woods & Cook in Perspectives on Human Error. Error could be a categorization after the accident (hindsight bias), or considered as a process generating the accident. The references to knowledge in this paper, IMHO are important both to this discussion and aviation safety.
Other error categorizations are given by Reason in GEMS (generic error modeling system) which includes Skill, Rule, and Knowledge based behavior (note that rule in this instance refers to the ‘rules of mind’ not SOPs); there are similar categorizations in HFACS.

A more practical view is given in Errors in Aviation Decision Making (Orasanu et al). Here decision error is broken down as a failure to understand the situation, or with correct awareness, an incorrect choice of action; these definitions appear to relate to the TK and ET accidents respectively.

A cultural view of situation assessment (or accident review) might come from New Scientist “East meets west: How the brain unites us all.”
My very simplistic interpretation of this is that a traditional ‘Eastern culture’ might perceive a situation holistically – a wider view including the relationships within it, whereas the ‘Western culture’ perceives a situation analytically – a narrower logical view.
These views would not be restricted to national culture, thus organisation and professional cultures (independent of nationality) should be considered, possibly with the largest divide amongst the ‘professionals’ e.g. commercial pilots / GA.

Relating the above to the original question, then the different views might indicate to how the situation preceding the accident is judged in hindsight. In addition, there could be bias due to different understandings of human factors (beliefs, myths, experience, knowledge of error) and the expected professional standard; see my post at http://www.pprune.org/4904796-post2429.html

Thus the mode of thought (or capability for measured thought) might account for the differing views of the accidents.
If this is relevant then a focus on our thinking skills could open opportunities for safety solutions. Crews should be trained how to perceive situations and assess their own performance (self awareness - thinking). i.e. we cannot train-out type 3 mistakes as they are inherent in human behavior, but we could train crews how to think more effectively instead of relying on rules, procedures, and guidance, which have limited applicability.

A form of ‘self’ TEM, or ‘self’ LOSA, but aren’t they the basis of airmanship?
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