“There is a tragic abundance of reasons why pilots fail to monitor critically the actions of a colleague, particularly one who is senior to them. Custom, religion and traditional ‘status’ play a strong part. It is forgotten with stunning regularity that cabin staff may find it difficult to use their own initiative–not to mention contradict a captain. Captains who virtually demand to be treated like demigods do so at their own peril. They can engineer a situation where an unexceptional, routine overshoot is seen as a moral defeat and total loss of face. Their ego is read into the careful wording of accident reports.
We trust the pilot—we have no choice. We must live (hope to live) with the assertion that the pilot is a highly trained professional, who can do his largely monotonous job, cope with his own very ordinary human failings, and work in constant readiness to deal with the unexpected. Captain Reist, deputy head of Swissair flight safety, told me: ‘We can change switches and instruments, but not human nature. We’re all just normal neurotics who must be taught to know and live with our problems and weaknesses.’ Heroes? Beware of heroes in the cockpit!’ Which sounds like a reincarnation of a fine definition: ‘Aviation character is the triumph of humility and common sense over arrogance and overconfidence.’ Undoubtedly, the performance and behaviour of the flight crew represent the greatest hazards in the air. But pilot error used to be the easy answer when investigators were baffled by an accident. Though it revealed ignorance and prejudice, it remained the last resort of blinkered investigations until it began to transpire that there must be more to an error than meets even the jaundiced eye. So a new concept was coined: the human factor. It not only sounded much more scientific as well as compassionate, it could also help to explore and interpret even the most complex events. It was therefore probably the most profound innovation in the history of accident investigation.
But in the honest process that followed, has the expression the ‘human factor’ become a bit of a euphemism for unadulterated human mistakes for which pilots should take the blame? Reading through dozens and dozens of accident reports, one senses the emergence of a potentially grave risk. Will the human factor be allowed to be barely an excuse just like the society/upbringing/education complex can serve as a tripartite let-out for the juvenile mugger, granny-basher, and crack pusher? And can the ‘human factor’ deteriorate into one of the numerous causal factors (‘just one of those things’) that may be used to cloud the vital determination of The Cause? Could it sometimes disguise somebody’s fault which turned a containable emergency into an inevitable disaster? Mistakes tend now to be called bad habits, lack of discipline, lack of proper training, lack of supervision. Should it not be admitted that an error is an error is an error? Wouldn’t Reasons of The Cause better describe the road to tragedy?
Anything connected with a flight may be a causal factor. When an engineer’s mistake slips through the net of an inadequate and badly supervised maintenance program, when the resultant malfunction in flight is exacerbated by the weather conditions, and when the pressure not to miss an allocated landing slot combines forces with a mild flu as well as home problems on a tired and relatively inexperienced pilot’s mind, there comes a point where a disaster could or could not be averted, depending on the captain’s abilities. It becomes an accident, even though another pilot could be expected to overcome those particular difficulties, it will be a pilot error – that might have been made easy by several adverse coincidences. Even the most sympathetic and considerate investigator must be firm in differentiating between naming the cause and making recommendations, i.e. the recognition of a mistake (even blameworthiness) and the suggestion of preventive measures against repetition. Fudging the issue will not lead to a cure.
Nobody would denigrate the efforts to treat the cause rather than the symptom. The old attitude, defined sometimes as prescribing rubber gloves for leaky fountain pens is clearly untenable. Yet the pilot who fails to wear the available rubber gloves, however ridiculously makeshift they may be, will still be responsible for not keeping his hands clean. For ultimately, research and noble intentions to eradicate the root of the problems must not overlook the risk of human fallibility. Sadly, this fact seems to be in need of frequent rediscovery as if it has never been heard of.
Those who seem to place more faith in cockpit automation than in pilots’ skill may find that their solution is to air safety what a new underpass or the addition of an extra lane on a five mile stretch is to a busy motorway—it only shifts a perennial traffic jam black spot a little further down the road.”
By courtesy, excerpts from: The Final Call by Stephen Barlay, Sinclair-Stevenson Ltd., London UK 1990