It’s interesting to see the different views stirred up by a report of ‘pilot error’.
The ‘new way’ of thinking about human performance urges us to look beyond pilot error, thus in this accident it could be failures in investigation and reporting, and not necessarily of those of individuals which generate debate.
Cook and Nemeth (Refs) discuss error, their views might apply to this accident.
1. A defense against entanglement with accidents – “
As an organizational defense, human (operator) error serves as a kind of lightning rod that conducts the potentially harmful consequences produced by an accident along an (organizationally) safe pathway.”
2. The illusion of control - “
If accidents flow from error and error may be lodged in an individual, then exerting control over the individual may be used to prevent accidents.”
3. A means for distancing - “
Others feel less at risk if error can be ascribed to a practitioner’s deeply seated, but personal, flaws. If accidents arise from forces and circumstances in the environment, then the experience of my colleague has relevance for me and the event increases my sense of hazard and uncertainty. By attributing my colleague’s accident to his inattention or stupidity, though, I make it possible to believe that the accident has no relevance for me. This is because I do not believe that I am either inattentive or stupid. Distancing limits and obscures the deeper examination of the sources of accidents. It marks an area of research interest, but it also sharply limits the value of post accident attributions.”
4. A marker for failed investigations - “
The most important value of ‘‘human error’’ is that it provides an acceptable end point for adverse event investigation. … it forms a ‘‘cognitive barrier’’ beyond which investigators do not make much progress, mainly because it is so difficult to work through the psychology and behavior of human agents. …. ‘‘operator’’ or ‘‘user error’’ is a catchall term for those events that cannot be identified as overt mechanical failure. This is not error by the practitioners who were involved in the accident, but rather error by the analysts who assessed the accident’s source and evolution.”
‘‘Those found responsible have been sacked’’ Observations of the Usefulness of Error. Cook and Nemeth
Perspectives on Human Error: Hindsight Biases and Local Rationality. D. Woods.
The emperor’s new clothes: Whatever happened to human error? E Hollnagel, R. Amalberti.
On "human error"