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Old 30th Jul 2011, 19:36
  #1068 (permalink)  
safetypee
 
Join Date: Dec 2002
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whenrealityhurts (#1064) “… it was pilot error. ...people screw up.

I aspire to more modern views of human error, even those which suggest error is a meaningless term, and particularly unhelpful in accident investigation.
The industry, your friends, and even you, might benefit from an understanding of why the crew behaved as they did.

Focussing on error looks at negative aspects and fails to look for positive human contributions, and possibly why they were not employed.
We all make errors (variations in human performance); most are identified and corrected. It’s the ones that aren’t which can hurt; we need to know why they weren’t seen.
It’s not the error itself that is important, but consequences of the error, which more often depend on the culmination of many contributing factors.
Error is always tainted by hindsight, thus always a biased view.
Error directs attention to the individual the sharp end, which may overlook a chain of events or contributions from technical and organisational sources.

Aspects from all of the above are in this accident. However, because it is impossible to know precisely what the individuals thought at the time, any views we might have as to what was seen, understood, or reasoned, can only by supposition; but at least by determining such views it enables us an opportunity to learn.

Concluding ‘pilot error’ as a cause is like closing an investigation without benefit; like closing the mind without learning, and thus preventing opportunity to help avoid similar human responses in similar demanding situations.
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