Mansfield, Bergerie, “compliance” reflex. AF447, yes, correcting an apparent height loss of 400ft, or complying with the loss of airspeed procedure – box items; both actions relating to ‘trained’ memories (pull up), or acquired beliefs and biases.
A similar viewpoint of other accidents might identify the same behavioural patterns; Colgan, where both crew’s actions were consistent with the recently learned tail stall procedure; or resetting cbs in flight, engaging the autopilot to resolve misunderstood situations.
The hazard in this behaviour is not necessarily the actor, but the source of the ‘norm’.
Inappropriate training, ill-conceived SOP’s, reliance on SOPs – fit the SOP to the perceived situation vs the need to assess the situation first.
How might we identify the source, avoid these aspects, create barriers or mitigations?
In most accidents we are unable to ask the pilots for their view of the ‘norm’, i.e. the origin of the ‘reflex’. Of greater concern is that even with crew recollection they might not know because the ‘reflex’ comes from subconscious memories; thus the problem of identification would include how these aspects became to be embedded in the subconscious memory.
A further thought from modern ideas of cognition is that all of our thoughts and actions come from the fast acting subconscious process, and that slower conscious thought is only an error checker / detector. If so, then an inappropriate reflex action could be seen as a by-pass or failure of error detection, which could also be a function of the appreciation of time – another contributor to these types of accident.
A wider view of these accidents and the previous hypothetical example (#116), is that these accidents were ‘designed’ by others just for these crews, all the holes lined up, human variation peaked, limited attention resources, … , but no one identified these future circumstances.
Centaurus, CRM, agreed; “everyone knows what CRM is for, but no one knows what it is”, (it’s like an inverted bidet in English humour).