Blame
lederhosen, et al, why not attribute blame.
We may have different understandings of blame. Blame implies to find fault, to censure, a condemnation, and being responsible for a fault or error; thus culpability.
The alternative is the ‘contributors’ to an accident; items which either pre-existed or were active failures and came together in the event. I would agree that the crew may have contributed to the accident.
In both cases I avoid ‘cause’ as most accidents have more than one cause, although in this instance there may be a unique ‘trigger’ to the final events.
A problem with blame is that it can inhibit understanding which is required to learn lessons and improve safety, because there is no need to look beyond blame. Blame is an easy route to closing down an investigation, it provides opportunity to move on, but without fully understanding the effect of the contributions and thus the issues likely to prevent other, similar events.
Paired with blame is hindsight bias; errors or omissions are easy to see in hindsight and thus support blame.
In agreeing that the crew contributed to the accident, I take care not to define the degree (the effect or proportion) of their contribution. Also, many aspects of the crew’s behaviour might be understandable when considering organisational aspects – items which affect and shape crew behaviour – the crew’s contribution.
This can be represented by an accident model which has both ‘a person’ and an ‘organisation’ channel into the accident. In the flow of events, it is relatively easy for an organisational aspect to reduce people’s capabilities (changing channels) – tight / fast ATC vectoring. However, the person, at this relatively late stage, may not be able to affect the organisational aspect (difficult to change channels) – saying ‘no’ to ATM, or to fly a GA (peer pressure – in a stream of traffic).
Most of the examples of airmanship (#2662), are statements or assumptions without qualification – no reasons why, i.e what supports the conclusion, why should we think this way, why didn’t the accident crew think similarly?
Many posts make the assumption that the crew identified (saw and understood) the malfunction in a reasonable timescale and therefore could have flown a GA at a safe height, but if the crew didn’t see and understand immediately, as indicated by the Captain’s ‘late’ actions, we have to consider why the malfunction could have been overlooked.
We must see the situation as the crew might have done at the time, we should consider what their thoughts might have been, pressures, workload, and evaluate the reasons for their supposed action / inaction.
I suggest that the experienced professionals in this forum are qualified to consider these points, and particularly so if given the same resources as the investigators (e.g. CVR). The process is similar to debriefing – what happened, when, why, - “oh I didn’t see it”, “it wasn’t how I interpreted that”, or “I didn’t think of it”, etc, etc, - all lessons learnt / to be learnt.
The combined wisdom in this forum might provide a very accurate (plausible) sequence of events based on their experiences in similar situations – recalling what has been learned in other operations, and relating these to this event.
The debate could identify the most likely contributions to the accident, yet avoiding the degree of their contribution as without additional information this tends to be biased by individuals’ opinions.
Organisational issues are often dominant contributors to accidents; not withstanding the oft quoted 75% human contribution, which can be offset by organisation/system issues enabling ‘error’. Organisational issues may be easier to identify and fix, and the fixes are probably more reliable and cost-effective than attempting to change human behaviour.
However, I don’t exclude issues of human behaviour and the need for the highest levels of professionalism / airmanship in our industry, but that need does not come from blame, and indeed blame would not necessary improve professionalism.