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Thread: Pilot Error ?
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Old 18th Oct 2015, 11:28
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Teddy Robinson
 
Join Date: May 2004
Location: Bear Island
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An interesting question. My personal and professional view is that whilst a high proportion of accidents / incidents may be directly attributable to the crew, the systemic model (aka the Swiss Cheese) may demonstrate that the dice were loaded towards of a set of potentially negative outcomes.

At one end of the scale, there is the accident alluded to:

Aircraft hits flock of birds, loses power and and accident occurs.
As most of us will appreciate, you can read and re-read the NOTAMS regarding bird activity but a) there is little that can be done once away from the protected airport environment, and b) the inescapable fact is that birds do not read NOTAMS.

Risk mitigation such as managing local populations will help, but when the hazard comes from migratory birds the nature of the problem has shifted.

The incident did happen, and the last layer of cheese was the outcome achieved by the crew.

The driving force behind safety culture is to reduce the holes in the cheese to an acceptable level, although in reality, zero risk is not achievable.
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