In the world of air accident investigations, finding out what led to a crash is followed by finding out why. Why is critical. That’s one reason I often write about the fallacy of attributing an accident to “pilot error”. Pilots (mechanics, designers, schedulers, dispatchers, flight attendants, etc.) will make mistakes, that is inevitable. Tracking those errors upstream to see what in the system led to those mistakes is how aviation gets safer. Or, as Key Dismukes, one of my favorite human factors scientists once told me, “The airplane, the designer, and the pilot are part of a complex system. Under certain circumstances, things happen that… Read More…