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Old 18th Sep 2016, 10:50
  #1622 (permalink)  
alf5071h
 
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Aspects of human behaviour and training discussed in recent posts are like comparing a stone and a bird.
You can throw a stone with some confidence of where it will land, but when throwing a bird there is no control over the destination (a bird has human-like behaviour); where even with training and practice the best can deviate from the intention.
It is possible to make the bird more like a stone, clip its wings, bind it up, (procedures and practices), but then you loose the bird's ability to avoid hazards, especially those previously unseen en-route.
However, a bird might be encouraged to reach the desired destination by suitable placement of birdseed, change or add something to facilitate the desired behaviour.

In this accident an objective would be to apply and check GA thrust. Verification might better be achieved by looking at the engine instruments opposed to relying on feedback from moving thrust levers.
An alternative is to move the thrust levers as part of the GA switch, this also guides the eye to the thrust instruments; feed-forward guidance vice feedback.

Rigorous training and SOPs constrain pilots and will not guarantee appropriate behaviour in all situations, but with thought about the complexity of the task, time constraints, and workload, pilots can be helped to achieve the desired objective. Those who should consider these changes, regulator-manufacturer-operator, must have sufficient understanding of systems and integration - interaction, and the operational environment (professional culture, policies, procedures) in order to form an adequate judgement; they have to resolve complexity, redefine the task, simplify the manoeuvre, and in using their time wisely might benefit safety, perhaps reducing training costs as well.

The industry has to avoid being like a turkey, being cooped up in the office, single focus - overfed, and with little foresight, particularly about the days of the month - beware of, and learn from surprises.

Bird - Stone analogy from "The logic of failure" by D Dorner, ( English version) 1996, 'Recognising and avoiding error in complex situations'.

"... managers need to engage in deeper reflective thinking. This is particularly true about how they manage change. An understanding of systems thinking is necessary to succeed at this. "

http://c.ymcdn.com/sites/www.project...s/mayjun09.pdf

Last edited by alf5071h; 18th Sep 2016 at 16:31. Reason: Typo
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