It's strange how in the aviation community, people (and especially managers with no knowledge of aviation, only financing it or supposedly managing the 'sharp end personnel
) have only in fairly recent years come to realise what human factors engineers have known for years.
As far back as 1947 Fitts and Jones studied the behavious of pilots in the cockpit and showed how systematic failures in interpreting instruments and operating controls produced misassessments and actions not as intended.
The implicit assumption was that the person closest to the failure was the cause. Investigators saw that the aircraft was in principle flyable and that other pilots were able to fly such aircraft successfully. They could show how the necessary data were available for the pilot to correctly identify the actual situation and act in an appropriate way. Since the pilot was the human closest to the accident who could have acted differently, it seemed obvious to conclude that the pilot was the cause of the failure.
Fitts and his colleague empirically looked for factors that could have influenced the performance of the pilots. They found that, given the design of the displays and layout of the controls, people relatively often misread instruments or operated the wrong control, especially when task demands were high. The misreadings and misoperations were design-induced in the sense that researchers could link properties of interface design to these erroneous actions and assessments. In other words, the “errors” were not random events, rather they resulted from understandable, regular, and predictable aspects of the design of the tools practitioners used.
The researchers found that misreadings and misoperations occurred, but did not always lead to accidents due to two factors. First, pilots often detected these errors before negative consequences occurred. Second, the misreadings and misoperations alone did not lead directly to an accident . Disaster or near misses usually occurred only when these errors occurred in combination with other factors or other circumstances.
In the end, the constructive solution was not to conclude that pilots err, but rather to nderstand principles and techniques for the design of visual displays and control layout. Changing the artifacts used by pilots changed the demands
There's a lot of interesting in this paper published a few years ago by Ohio State University:
http://csel.eng.ohio-state.edu/woods..._hand_chap.pdf