Accident investigation requires an impartial presentation of the occurrence without allocation either of
pardon or blame; this report is a good example of this. It also identifies many safety weaknesses which can be addressed by a range of people at many operational levels, including individual enhancement as lessons to learn.
Will blaming fellow pilots help us learn; I doubt it. A more likely conclusion is that because ‘we think that we know' what happened (hindsight and a single focus on the outcome), ‘we’ won’t suffer the same, but how do we know that.
This view is similar to considering yourself to be invulnerable or being overconfident, both hazardous attitudes in aviation.
What surprises me is the number of contributors who present an old view of human error and accident causation, which I thought was to be changed with improved training in human factors and CRM. Are these HF initiatives failing to achieve their intent or is the teaching missing some important aspect.
‘Human desire’; try ‘goal’ or the objective of an activity. Seek a second opinion – change the witch doctor:
http://www.scribd.com/doc/224823088/...ective-Crew-DM
Human error
http://www.ctlab.org/documents/PerspOnHumErr.pdf