Hi WL
Your post leads to something that I have been looking into this year and that is "Threat and Error Management" - TEM.
"TEM is a conceptual framework that assists in understanding from an operational perspective, the inter relationship between safety and human performance, in dynamic and challenging operational contexts"
The components of a TEM model are;
Threats (usually of the environment)
Errors (usually of people, or latent errors of the system)
Undesired aircraft state (Expensive clanging noises)
Countermeasures. (Happiness)
A threat and/or error can lead to an undesired aircraft state. An examination of threats and errors will lead to "Countermeasures", which are either "Hard" (SOPs, briefings training etc) or "Individual and Team" which covers Planning, execution, and review.
The model can be used in several ways;
1.Debrief of a specific incident, or
2. Reviewing a cluster or trend of incidents,or
3. Review of your safety database
I have used it in all three instances, and this summer ran a series of workshops to tackle some problems we were having in ground operations.
We found out so much that we just did not know about, basically because people don't have the time to make safety reports (in the ground ops/ramp environment)
We were able to come up with a range of contermeasures, suggested by the very people who we initially thought were part of the problem, they actually became part of the solution - how neat is that.
This stuff works in a real world environment.
Have a Google of "threat and Error management" and then put in Capt Dan Maurino.
He has written an excellent paper, which led me to other research, which led to the construction of my own model, which we have used in the company,which gave us answers (countermeasures), and as I look at the ground incident stats, they haven't quite collapsed on last year, but a big positive move in the right direction.
Don't get hung up philosophising about errors and blame, just go and "do the do"
BS