TC
I think your last line would have had David Beaty (the Naked Pilot) turning in his grave.... and Emil Zotov (The Zotov Error Map) chortling in his borsch.
The guy who created the Heindrich Pyramid theory based his calculations on 1930's data and methodology and his recipe for the reduction of accidents was to focus on the individual and the errors he/she made. Modern analysis recognises that accidents are a product of a process and the design of the process should be one that minimises the opportunity for error (accidents). The design of a process is a management responsibility and they must NOT escape from the investigation without an examination of the role their input or lack of input played.
The question to be asked is: "who chose the equipment for the helicopter?", then, "who designed the pilot training for that equipment?" then, "who approved the equipment and the training?"
You might go on to ask "who did the risk assessments", who designed the "change management" for the new equipment/procedures?"
When all has been analysed you may then point the finger at the operative - Joe Pilot.
G.
PS. Perhaps it is worth pointing out to those that are not aware that designing a better/safer system does not remove a 'hazard' - in the short term it actually creates a hazard and the risks associated with changing to a new system must be fully understood before making the change. Upgrading to a new sophisticated type brings a whole host of these issues but how many operators tested their internal systems to see if they could cope BEFORE taking delivery?
Last edited by Geoffersincornwall; 13th Nov 2013 at 23:48.