Interesting article titled "When the error comes from an expert: The limits of expertise"
It uses EK521 as a case study. I hope the people in EK Human Factors dept are making their voices heard.
“It is all too easy to say, because crew errors led to an accident, that the crew was the problem: they should have been more careful or more skilful. This “blame and punish” mentality or even the more benign “blame and train” mentality does not support safety—in fact, it undermines safety by diverting attention from the underlying causes.
Admittedly in general aviation, many accidents do show evidence of poor judgment or of marginal skill. This is much less common in airline operations because of the high standards that are set for this type of operation. Nonetheless, whatever discussion about airline operation could have implications for general aviation.
There are two common fallacies about pilot error:
Fallacy 1: Error can be eliminated if pilots are sufficiently vigilant, conscientious, and proficient.
The truth is that vigilant, conscientious pilots routinely make mistakes, even in tasks at which they are highly skilled. Helmreich and his colleagues have found that on average airline crews make about two errors per flight leg and even more on challenging flights (Helmreich, Klinect, & Wilhelm, 1999; Klinect, Wilhelm, & Helmreich, 1999). And this is, if anything, an undercount because of the difficulty in observing all errors.
Fallacy 2: If an accident crew made errors in tasks that pilots routinely handle without difficulty, that accident crew was in some way deficient—either they lacked skill, or had a bad attitude, or just did not try hard enough.
But the truth is that the most skilful, conscientious expert in the world can perform a procedure perfectly a hundred times in a row and then do something wrong on the 101st trial. This is true in every field of expertise—medicine, music, and mountain climbing just as much as aviation (Reason, 1990).
To improve aviation safety we must stop thinking of pilot errors as the prime cause of accidents, but rather think of errors as the consequence of many factors that combine to create the conditions for accidents. It is easy in hindsight to identify ways any given accident could have been prevented, but that is of limited value because the combination of conditions leading to accidents has a large random component. The best way to reduce the accident rate is to develop ways to reduce vulnerability to error and to manage errors when they do occur.”
(I can't post the link to the full article because I'm 'not an experienced enough poster'. Can someone else post the link? Search for livingsafelywithhumanerror and/or 'when the error comes from an expert')