PPRuNe Forums - View Single Post - AS332L2 Ditching off Shetland: 23rd August 2013
Old 25th Sep 2013, 06:35
  #1899 (permalink)  
DOUBLE BOGEY
 
Join Date: Dec 2006
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SuperF - nice post and I agree with you. We should not ignore errors made by the crew of course as long as we are determined to understand how these errors have happened.

In the worst case it may be that a pilot is just not skilful enough, or deliberatley transgressed from the rules, but we tend to assume that in CAT, a trained and checked pilot has demonstrated sufficient skills and discipline to do the tasks he is doing.

Deconstructing complex events is our best way of trying to identify why a crew made a particular error. This can only happen in a "No Blame" culture and this should be the default status of such investigations as we assume the crew did not want the event to occur to them.

With this approach it allows the investigators, even when a Pilot has maybe been transgressing rules deliberately, to widen the net and look at "culture" that has allowed him to believe what he is doing is acceptable. The internal military inquiry into the Australian Army Blackhawks crashes is a good example of this approach.

In my experience as a pilot, instructor/examiner and regulator, we can change the rules, we can change procedure, we can even change the pilot. However, the hardest thing to change is culture!!

I am not sure Hummingfrog meant to isolate our US brethren with his comments but I agree with you SuperF, they are not appropriate.

DB
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