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Old 18th Apr 2014, 14:10
  #706 (permalink)  
safetypee
 
Join Date: Dec 2002
Location: UK
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‘The more lofty words like "foresight" or "tolerant of misuse" the more meaningless they are’.
This depends on your viewpoint; you can choose the ‘person view’ or the ‘system view’, both adequately described by James Reason et al.

With the person view, often biased by hindsight, blame is an easy solution but does little to provide deeper understanding of the safety issues. What value is there in concluding that you or your operation would not suffer the hazards of human / system / situational limitation; self-satisfaction does not equate to safety.

A system view might not provide a uniquely packaged primary cause, where new SOPs / training etc can be applied (but to what effect in scenarios differing from this accident); but such a view could provide generic indicators of weaknesses or opportunities for error in higher workload situations where crews are expected to manage unusual environments – monitoring when training, descending/decelerating without ILS, poorly identified system failures (737 AMS) or systems intolerant of misuse (777), - simultaneously.

Life is understood backwards, but it has to be lived forwards where foresight might help avoid the pitfalls which are so easy to identify with hindsight.

‘Without knowing the 777… …’; recognising individual limitations, knowledge, operation, might help avoid or resolve difficult situations, but labelling professionals who might have may have learnt from their mistakes, as fools, might suggest that it takes one to know one – FLCH that is.
How many 777 pilots have been caught out by Boeing FLCH … is the mode the same in all models?
How do operators train or guard against the differences between A or B when changing type; ‘first learnt best remembered’?
What avoidance strategies are used when flying types with particular ‘weaknesses’ (people also have weaknesses); … how have people adapted to crossing the road in the UK vice the USA? At least we might consider taking care and looking both ways – considering other people’s points of view.
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