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Old 15th March 2010 | 12:08
  #5 (permalink)  
turbocharged
 
Joined: May 2008
Posts: 150
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From: Kettering
Hugel,

I would have thought that the 'blame the pilot' fallacy is well-recognised in most 'enlightened' territories even if not always fully endorsed through the actions of society, management and investigators.

I think the problem with Root Cause Analysis is the title. As I said in my previous post, it isn't a single technique and it doesn't necessarily get to 'root cause'. You need to use the appropriate selection of techniques to get past 'proximal' cause in order to get an accurate understanding of why things happened.

We can, in fact, get to a single factor that causes an accident. Usually that single factor is the action sequence of the crew immediately prior to impact. A different action sequence would have resulted in a different outcome. However, first, we need to avoid 'blame' and second (most importantly) we need to understand why the crew through that their actions were appropriate under the circumstances. This is what the 'root cause repertoire' is supposed to clarify.
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