Effect of the term 'Pilot Error' by media & investigators on future flight safety

Rick Heybroek (LOFTwork_at_CompuServe.COM)
Sat, 17 May 1997 17:09:59 -0400


Hi Gary,

I'm unclear what the topic is really asking for - an argument that use of
the term WILL have such an effect, or an investigation of the use of the
term and its relationship to flight safety.

I would think a good baseline example is the Dryden crash, which
effectively rewrote the book on the meaning of "Pilot Error" into its
present organisational context. "Pilot Error" prior to Dryden was still
generally understood in the context of single-cause blame attribution.
After Dryden, any HF accident investigation worth its salt included some or
all of the Reason Model taxonomy. A good example is the BASI report on the
Ansett 747.

I may be exaggerating the significance of Dryden for simplicity - there
were earlier cases where organisational factors were officially faulted,
including the Erebus crash. It is significant that in both these landmark
cases an official inquiry was required to allocate blame off the flight
deck.

As to the understanding of the term "pilot error" by the popular press, who
knows? There are certainly great concerns that accidents deemed to be
"pilot error" which are associated with any new training approach - such as
CRM, AQP, LOFT substituting for checkrides etc. - could cause enough
political smoke to seriously jeopardise attempts to improve flight safety.
I suspect the usages by media and investigators are entirely different and
require separate treatment, but it's an interesting and slightly hirsute
question.

All the best,

Rick Heybroek
LOFTwork limited