The culture and mistake (error) based analyses in many posts might represent frustration of being unable to understand the factors contributing the incident, and therefore limiting opportunity to learn. It is unlikely that the precise aspects will be discoverable (not to exclude culture, etc); however, with some well-reasoned speculative analysis it might be possible to identify important ‘learning’ factors.
A contribution to this type of incident could be a ‘mental map-slip’. This is not a loss of positional awareness, just the wrong one, which neither pilot realised. So what else were they doing – mental focus, procedures, radio calls, checks, etc.
Technology is seen as a major benefit – EFIS map, but are the pitfalls and traps in this equipment identified, reported, or just glossed over – ‘it happen to me, a minor slip, it won’t happen again’ – weak safety reporting / dissemination. With EFIS map selected, was the range scale dictated by WXR or a Terrain display – marvellous aids to safety, but the scale might be inappropriate for the airfield position – it appears (mentally perceived) to be closer than it is; have we done this, and with visual confirmation bias to reinforce the positional picture, continue with the approach; - or we able to detect the ‘oversight’ in time, if so how.
Some forward thinking views on human behaviour; for both them and us.
“If we can understand how the participants’ knowledge, mindset, and goals guided their behavior, then we can see how they were vulnerable to breakdown given the demands of the situation they faced.”
“Typically hindsight bias makes it seem that participants failed to account for information or conditions that “should have been obvious” or behaved in ways that were inconsistent with the (now known to be) significant information. Possessing knowledge of the outcome, because of the hindsight bias, trivializes the situation confronting the practitioner and makes the “correct” choice seem crystal clear.”
“… the use of the term “error” is less revealing about the performance of workers than it is about ourselves as evaluators.”
“Fallibility has no bounds in a universe of multiple pressures, uncertainty, and finite resources.”