Re “I wondered if anything changed in training after that’, #303 (also #297, #300)
It might be better to consider if we could have expected any change in training.
While investigators and regulators continue to spout a ‘need for more training to improve decision making, judgement, etc’, but fail to provide guidance as to what and how should be trained, the industry is left to its own ideas.
This should not be surprising as there are few accident/incident reports which identify specific aspects of decision making – to continue or discontinue an approach – that have weaknesses and might be addressed by training.
At the time of deciding all decisions are good (valid), as judged by the decision maker; only subsequent events might classify the decision – good, less-so, poor, ‘wrong’, but all of this is in hindsight, and based on the judgement of the reviewer.
A significant problem in low visibility approaches is determining what the decision maker actually sees – perceives, and then how this is used, which may depend on training and experience. This point identifies a weakness in safety thinking, such that even if the decision maker is a highly trained / experienced pilot, the perception of an ‘incorrect picture’ can result in choosing an inappropriate action. We cannot assume that training and experience will always provide adequate perception and thus accident avoidance.
Vice-versa an inexperience pilot, perceiving a ‘correct picture’, can equally choose an appropriate course of action based on minimum training and experience.
The industry should heed the thoughts of James Reason where improving human performance – training, etc, is difficult and cannot be assured to be used in every situation. Solutions offering greater safety benefit can come from improvements in working conditions – the wider working environment, and protecting humans from their own fragility.
In low visibility this could be improving what might be seen, to perceive the visual scene (approach accuracy, guidance and autos, approach lighting), and/or ensure that pilots are not exposed to conditions where a decision could be unacceptably wrong (revise the approach minima). The point about ‘acceptability’ considers that the decision process is continuous and that choices of action can be changed, and even poor decisions are not necessarily ‘unsafe’, because the risks are contained.
The industry should stop trying to improve the human. Instead look at the working environment and pressures of operation; reconsider the assumptions made about operations, how operations, infrastructure and equipment have changed since regulations were formulated and minima published.