Lantirn, I agree with the sentiment, but offer an alternative view of
"SOPs are the only reason behind those thousand successful tasks by humans".
Pilots have been successful
despite SOPs because they are able to adapt by using their 'expertise' in situations which are not as assumed by SOPs. Unfortunately in some situations the adaptation does not work, leading to the blame and train cycle.
An increase in SOP violation was forecast by Amalberti *. As an industry approaches a high level of safety there will be more violations due to a tendency for over regulation as adding more regulations and procedures because they are an easy safety response for rare complex accidents.
My take-away point from the BEA study is that in situations where human performance is limiting then it's the situation which should be changed, opposed to more training, as blame and train may not achieve any improvement.
Alternatively changing the situation could be more effective, and also cover a wider range of human issues.
The situational aspects aspect in the study were noted by several pilots; they identified complex navigation routing, unnecessary ATC calls or re-routing, and complexity and workload when using workload 'alleviating' automation. The study also noted that some crews focussed on the FMA and achieving the correct sequence of call outs as required by the SOP, opposed to flying or monitoring the aircraft flight path.
The safety investigation and responses in this incident, both from the operator, and presumably the regulator, focused on even more training, which could imply some blame or failure to learn from the incident.
This was a training flight, the supervising pilot like many instructors was faced with the difficult judgement of how far to let the other pilot continue, if too late, more training (blame), but train for what.
The 'student' might benefit from more training, but the essence of the event was the difficult conditions requiring adaptive judgement, both from the instructor and the operator, who perhaps expected training to be completed irrespective of conditions.
Several aspects of aircraft certification refer to an average pilot (no definition given), the assumption might be that with two crew both would not be below average (having a bad day) in a given situation. Of course this is a probabilistic assumption, but rarely considered in increasingly high pressure operations which may assume the best performance from everyone all the time. Amalberti also noted this - slide 20 in
http://ihi.hamad.qa/en/images/Keynote_Haraden.pdf
Ref: * Amalberti:
https://www.irit.fr/SIGCHI/old/docs/...g.book2000.doc