I generally do not contribute to threads any more, but I am somewhat exercised by some comments and comparison to BA038. I do have something to say about TK 1951 as well (see bottom).
First, BA038 (sorry for thread creep but I do want to be clear on this in a forum in which it has cropped up).
Professor Jim Reason gave an invited talk at the 4th IET Conference on System Safety in London in October 2009, in which he talked about what was known and not known about human factors in safety-critical systems. Many here will be aware that Prof. Reason has been a major influence on human factors thinking in aviation in the last three decades or so, indeed the ATSB (or BASI as the aviation part was known then) based their accident analyses on his classification system for many years. He described two views of operators in critical systems: "human as hazard" and "human as hero". He organised "heroic recoveries" into four categories: "training, discipline and leadership"; "sheer unadulterated professionalism", "skill and luck", and "inspired improvisation". He had six examples of "sheer unadulterated professionalism": Captain Rostrom's action for the Titanic survivors (1911); Apollo 13 (1970); the BAC 1-11 incident of 1990; BA038; and United's water landing on the Hudson River. He said that what it comes down to is "irreplaceable people": "the right person (people)"; "in the right place"; "doing the right thing"; "at the right time".
I agree with Prof. Reason, in his words, that Captain Peter Burkill, along with his colleague First Officer John Coward, is one of those humans as hero, exhibiting sheer unadulterated professionalism, one of the right people, in the right place, doing the right thing, at the right time.
Unknown to Jim at the time, I had invited Captain Burkill to participate in my keynote talk to the same conference later that day. Peter came at lunchtime just after Jim had to leave - Jim asked me to convey his regards.
I had allocated about ten minutes at the end of my talk for Captain Burkill to tell the assembled engineers what it was really like being at the pointy end of all that. The audience was fascinated (Peter is also - obviously - a compelling raconteur) and the session chair, Carl Sandom, let the time run over for about 15 minutes, because of the questions and answers from the audience, not to speak of their rapt attention.
I just wanted to make it completely clear here what people such as myself, Prof. Reason, and my colleagues working in System Safety think of the performance of Captain Burkill and First Officer Coward. We applaud it.
As far as I am concerned, S.F.L.Y. is welcome to remain in his comfortable minority of one.
Second, TK 1951, the topic of this thread.
I am familiar with the human factors investigation and what the conclusions are. The HF investigation was led and the report written by a friend and colleague, who besides having a world-wide reputation and being in my judgement one of the top five aviation human factors analysts is also a practicing 737NG pilot. So concerning TK 1951 he knows whereof he speaks.
It is a fine piece of analytical work, subtle and eye-opening (at least for me) and I recommend that everyone read the report when it comes out. The analysis does not actually fit any specific one of the views aired here (including my original view). There is something to learn for everyone (as there was for me).
I might point out, as many already have, that concepts such as "responsibility" and "blame", the things that people here are suggesting that journalists wrote about the forthcoming TK 1951 report, are not used in ICAO-standard accident analysis and reporting and I sincerely hope that they never will be. It is hard enough to get the causal stuff straight without mixing in the legal as well. Most lawyers I know are equally happy to keep them separate; it makes their tasks easier also.
PBL