Awesome thread. Much kudos to Orange Anchor for name-dropping Sidney Dekker! We used his theory of "Drift Into Failure" as the basis for our Recurrent CRM program in 2007.
In respect to doing it right 100% of the time, I remember hearing a quote somewhere that said, "A true professional pilot is one who always attempts to fly a perfect flight, all the time knowing that feat is impossible." As professionals, we should try to get it right 100% of the time. However, we are human beings, so that is practically impossible. That is why the airplanes we fly, and the environment we operate is, is filled with "checks and balances." Whether it is a takeoff configuration check built into the airplane, or the paper checklist, we have procedures and alarms that should help correct the mistakes that we do not catch ourselves.
However, the system we operate in is defenseless again blatant disregard for those safeguards. In the case of NWA Flight 255, the pilots ignored the checklist (safeguard one), and also removed the airplane configuration warning by "possibly" pulling the circuit breaker (safeguard two). So, they removed all opportunities for the "system" to correct their mistake of not setting flaps properly for takeoff. Could the same have happened in the crash in Madrid? Possibly. The actual cause remains to be seen.
Thing is, it is never
one thing. James Reason came up with a "swiss cheese" model which is great for analyzing accidents like this. Any crash (even with NWA Flight 255) is never
just pilot error. Sometimes it can be organizational influences, training issues, the pilot group culture, and so on. So in the case of the Spainair accident, maybe the pilots did override the system safety by pulling the circuit breaker. But they likely did not do it just that one day, and they likely did not come up with that themselves. Just like the Captain of the Garuda crash in Indonesia... That Captain is not likely a rogue who decided to "push it" to "make it work."
Great commentary from Orange Anchor about "Captain Ace Dazzle." There was a great quote in our Recurrent CRM program that asked the definition for Murphy's Law. In aviation, it seems we have re-written it to say, "What can go wrong usually goes right, and we draw the wrong consequences."
For those of us in the airline industry, soon you'll be seeing safety being analyzed from this angle, since we are all beginning to move towards SMS (Safety Management System) in 2009.
You can read about it here in AC 120-92:
http://rgl.faa.gov/Regulatory_and_G...6485143D5EC81AAE8625719B0055C9E5?OpenDocument