That was believed but reflects an understanding that is now over 30 years old and based on current evidence, false. I know that many believe it still, but the industry is slow to move to new concepts. I suggest reading Dekker, Hollnagel, Leveson, Woods, et al.
I'll look into it...but honestly, I know people who have died because of their own errors - human error is
still the leading cause of aircraft accidents. You are correct in your statement that calling it an error doesn't provide any illumination into how to prevent future errors, but that's what investigations are for. That's
how system safety works. You find a risk, then you work to mitigate that risk. This is no different. I am familiar with the basics of resilience engineering - and it's solid work...but it's not the whole picture. Just because events
can be described by resilience engineering doesn't mean that pilot errors don't occur - nor does it mean that they aren't the leading cause of accidents, it just means we need to develop better tools to help identify and eliminate those errors before they become to big to control.
You are correct in saying that "pilot error" is not exactly informative - but that doesn't eliminate the point that the pilot made an error. If you want to prevent those errors from happening you've got to develop systems (both hardware, software, and human procedures) that reduce those risks, but saying that pilot error isn't the cause of the majority of accidents is a head-in-the-sand approach to safety. Indeed I think the fact that the biggest risk
is pilot error (and is basically non-existent for 121 operations) means that we've done an absolutely marvelous job in developing engineering solutions to the problems of reliability and safety. I mean, look at the BHM UPS accident. From wikipedia:
The NTSB also found contributing factors to the accident included: 1) the flight crew’s failure to properly configure and verify the flight management computer for the profile approach; 2) the captain’s failure to communicate his intentions to the first officer once it became apparent the vertical profile was not captured; 3) the flight crew’s expectation that they would break out of the clouds at 1,000 feet above ground level due to incomplete weather information; 4) the first officer’s failure to make the required minimums callouts; 5) the captain’s performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training, and; 6) the first officer’s fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factor.
Ultimately, in my mind, the real "trigger" event that could have eliminated this accident from happening is hitting guys in the simulator with more CFIT scenarios and training a max performance climb as a "conditioned response" to a terrain alert in the same way that a TCAS RA demands pilot action. Ultimately, the "engineering" solution - ie GPWS, warned them, but they ignored it.
On August 16, 2013, at their third media briefing, the NTSB reported that the crew received two
GPWS alerts "sink rate!" (that they were descending too quickly) 16 seconds before the end of the recording. Three seconds later, one of the pilots commented that they had the runway in sight. Nine seconds before the end of the recording, impact sounds were audible. The crew had briefed the approach to runway 18 and were cleared to land by
air traffic control two minutes prior to the end of the recording. The captain was the pilot flying, and the autopilot was engaged at the time of the accident.
There are so many preventable pilot errors in this accident...like nearly every other accident. Failure to recognize that we can be the cause of errors removes the responsibility from the shoulders of the pilot. This is not a good thing, because ultimately we
are responsible for the actions we take - regardless of how we were pressured or the systems that lead to the scenario that allowed us to make a "bad decision." I'm not saying that we should be looking for "who to blame." In fact, I think casting "blame" is actually counter-productive to safety. We're not looking for fault, we're looking to find the root cause of an occurrence so that we better reduce risk. Still, failure to acknowledge that pilot errors are the majority cause of accidents belies a fundamental misunderstanding of
why accidents occur.
