Swish 266: Is this rush to find a criminal (humans to blame) driven by the compensation society that has evolved? Is it there in comparable industries, I wonder? Is it caused by the massive payouts that can be achieved in aviation, and has it been driven by the legal profession not the legislators? Until we know the cause of the change we can not start to find an antidote. Can the legislators reverse the trend? I'm sure that in the search for truth and prevention the same attitude of blame-free reporting/investigation, as is found in many airlines, needs to feed across into the public arena. Surely any accident should be investigated as just that. They do happen, in innocence, but it is likely there was a trail of minor events that culminated in an unforeseen accident that was outside the scope of the humans involved.That finds a cause. In doing so the root cause is found and addressed, and may indeed involve a mixture of humans & systems. Should negligence, or other culpable human factors be uncovered, then further action might be taken; but to start assuming someone is for the chop is counter productive and could cloud any judgement as to finding real cause. Just look for the finger on the wrong button and, hey presto, a winner. Mega bucks please.
I have come across an attitude supporting rigid SOP adherence. It was not good communications; any crew can fly together philosophy, but rather a back-side covering attitude. "The SOP's are approved. I followed them; S*!t happened. Not my fault. Ask the company and authority." I wonder what will happen when this attitude is questioned after a survivable accident. "Surely, you as an experinced captain, should have realised that the situation called for a different response? Surely you should have realised that the SOP was not appropriate at this time?" "I was only following orders, guv." I wonder.
In history, we have seen too many accidents, especially where the pilots have not survived to defend themselves, where, perhaps for expediancy, perhaps for compensation reduction, pilot error has been the verdict. The trail of little things, including fatigue, lack of or inadequate training/checking, lack of total experience in the cockpit, etc. etc. has never been fully investigated. Maybe touched upon, but given little importance. Perhaps lack of time or resources? I have marvelled at how some accident investigations have unearthed the most minute and bizzare causes. I applaud them. It was years of hard graft and eventually they found the tiniest grain of truth. Real Silent Witness stuff, but usually mechanical, not human failure.
The process needs to change, as does the incessant removal of the pilot from the flying loop, otherwise we'll become earth astronauts on a computer controlled trajectory with TCAS as the final safety net. Afterall, the only thing missing is automatic taxy & takeoff, and taxy after landing. For 20 years, from 400' up to landing, it has been able to pre-program it. However, I suspect the ball will roll much further in its present direction before someone puts their foot on it and looks around to pause and makes a back-pass.
As our friends in ATC and engineering are commenting, it is not isolated to the sharp end. Our world is part of a chain of many links. I wonder if they are all evolving in a coordinated manner? I wonder if isolated technocrats & accountants are too inward looking at their own territory? It is not impossible to imagine an incident being created by one link working out of sinc with another down the chain and catching the latter by surprise. However, I'm sure blame would be attached to the final culprit. It's an extremely complex area for discussion, and as always 10 experts will have 10 opinions. Who decides?