seagull
Well-Known Member
This is still an error, regardless of what we call it - yeah, pulling resilience out of a system is by and large "bad" and systems should be "engineered" to increase resilience to calamity...but ignoring a sink rate alert on approach right as you're breaking out of the clouds is an error. Yes, we "relied upon human performance to fill in the gaps there," but the bottom line is, the last "link in the chain" or "hole in the cheese" or "percolation theory" or whatever model you want to use to describe the accident in this accident was the pilot's decision to continue after the system telling him "GO AWAY FROM THE GROUND!" in no uncertain terms. Yes there are things that lead up to this accident (namely fatigue and confusion in the cockpit) but that's ultimately where conditioned responses to dangerous scenarios are key. Similarly, look at the Asiana accident - yes, I see how this could happen, and I'm certainly not immune, but these guys couldn't fly a visual approach. Yes I understand it's a complicated airplane, complicated airspace, and there were other cultural and linguistic issues that likely didn't help...but if you're not on speed on your approach... you go around - those guys didn't. Pilot error.
We are responsible for our own competency - no one else, not the company, not the FAA, not the engineers who designed the aircraft - us. We are responsible for our actions - it's not the result of a flawed system if you forget to drop the gear. It's not the fault of a flawed system if you CFIT - yes, better systems likely would make operations more resilient and damage tolerant, but it is not a panacea. If there are issues where we have to rely on human pilots to compensate for weaknesses in the system, then it is the responsibility of the human pilots (nay, their ethical duty) to assure that they are able to fill in the gaps.
You miss the fact that under stress people often do not hear warnings and that we have found many cases where humans never heard an audible alarm due to stress or fatigue. Is that an "error" on the part of the pilots, or is that an "error" on the part of people who designed the system who did not consult with actual human performance experts that understood that factor?
Asiana is similar. Eye scans of pilots flying approaches after a few years of autothrottle usage indicates that they drop the airspeed out of their scan, although they, themselves, are sure that they are monitoring it. In that case we have a pilot that had been flying narrowbody FBW Airbus products within Asia for a number of years. The Airbus architecture would not have allowed for the situation that autothrottles can be on yet they not respond (as a sidenote, one of the 787 engineering test pilots almost crashed due to the same issue on a 787, do you think he also "could not fly a visual approach?). There is a lot more, but much of these false ideas of human behavior come from ad hoc simplistic models that lay people put together, and yes, even though someone might be a pilot does not make them experts in all the nuances. So, again, do we have the "error" by the pilots or is the "error" in those that designed the systems and procedures? Do you think the pilots intentionally did not notice something?