Rotorcraft PPL here: actually assigning blame is a very important part of accident analysis because it's critical to determining whether resolution will involve modifying training curriculum or if there was a mechanical failure. CFIT, engine failure due to fuel exhaustion, flight into wires, low G mast bumping, and settling with power are all sure ways to die from pilot error. And if the pilot did make a serious error their license could be suspended or revoked.
In general we consider that people don't want to die while piloting an airplane. So, even in a major event where all lives aboard were lost, investigating the whole problem and finding opportunities for improvements will make aviation safer, simply saying "the pilot screwed it" won't get anything done.
Of course, if the problem is just a borderline behavior of the pilot or co-pilot, it'll be fantastic if we can get him off the circuit before he locks the captain outside and programs the plane to crash against a mountain. Or not to stretch fuel limits so that he will fall out of gas.
But... if we can also learn how to make a out-of-gas plane land and survive, and the cost is "let's not put this pilot into jail, because it's better to learn how to save more lives", I prefer this approach. Probably you'll be able to get the pilot from some other behavior.
>So, even in a major event where all lives aboard were lost, investigating the whole problem and finding opportunities for improvements will make aviation safer, simply saying "the pilot screwed it" won't get anything done.
Yes, it does. Many aviation crashes are attributed to "pilot error". There's only so much you can do with procedures and such; at some point, the pilot has to be held accountable for screwing up, and investigations do exactly that many times.
Usually, in major events, you're looking at commercial airliners with a pilot and co-pilot and in those cases, it's usually something much worse than a mistake by the pilot, and frequently several bad things happening at once. But in general aviation, where you have one pilot, frequently non-commercial, flying a small aircraft, the cause is frequently just "pilot error". A common example of this is the pilot running out of fuel because they did their calculations wrong. It happens frequently with private pilots, and in a Cessna you can't just pull over when you run out of gas.
I'd argue even that even in cases of "clear cut" pilot error, the goal is to learn and prevent it.
For example, the first fatal 747 crash, the Lufthansa coming down upon departure from Nairobi, happened almost certainly because the flight crew did not extend the leading edge flaps. Clear case of pilot error. If that response had been it, it would have happened again (in fact, it did happen at least twice before, but at lower altitude airports where the aircraft performance was enough for the crew to depart without accident).
Instead, it was acknowledged that the whole system could be improved, and Boeing put in a take-off configuration warning.
Similarly, AF 347 over the Atlantic - sure, you can argue that the pilot in the right seat should not have pushed the stick forward, and that it was entirely his fault, case closed. But maybe one can, instead, improve the whole system, the HCI, etc.
You're talking about big commercial planes. Yes, you can alter procedures here and attempt to prevent the same thing from happening again.
Not in general aviation. You're not going to get all the Cessna 172 owners to modify some part of their plane to make it better and avoid some incident where some yahoo private pilot did something dumb and crashed. It's hard enough just getting privately-owned aircraft to be properly serviced. Many of them are many decades old and quite primitive. You're not going to improve "the whole system", the HCI, etc. in some airplane made in 1940 or whenever.
Finally, attributing an incident to "pilot error" doesn't automatically mean that there weren't contributing factors or that things couldn't be done better.
You are probably right, but I am privately a bit concerned regarding the crashed Air France Flight 447, and the conclusions made regarding pilot error.
I can't shake the suspicion that the Airbus man-machine interface and programming is partly to blame - possibly only when pushed into an extreme configuration, and certainly just as a topping on other factors.
It's clear however, that it's politically and economically impossible to ground all machines made by the European union's prestige project, Airbus.
Fully agreed - shifting all the blame on the pilot absolves Airbus too easily.
Remember the AirAsia from Surabaya, where they got themselves into an upset because of a tiny crack in the rudder-travel limiter unit ("topping on other factors"), then apparently made basically the same mistake as AF 447, one pilot pulling full back all the way down.
> The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are not conducted for the purpose of determining the rights or liabilities of any person.”
49 C.F.R. § 831.4.
(This is on first (non-title) page of any NTSB accident report. [1])
Of course, the NTSB determines "Probably Cause", and makes safety recommendations. But the point is not to blame the pilot. Notice also that enforcement action is taken by a different agency, the FAA, not the NTSB.
Lastly, the whole ASR reporting system is set up to maximise the information gathered and minimise future accidents, while giving some dispensation to pilots that have made mistakes.
Sorry for banging on about this, but the accident report I linked to above is a great example, as it happens. It's about the cargo 747 that stalled shortly after take-off in Bagram, Afghanistan, caught on a spectacular and sobering video.
Cause: cargo was not secured enough and slid back during take-off, shifting centre of gravity, stall, crash. Blame: loadmaster. Done. Or are we?
No: Loadmasters are not FAA-certificated (a gap in the system). The operator procedures were inadequate. FAA oversight over these cargo operations was deficient, one reason being that the FAA inspectors were insufficiently trained. So, suddenly "blame" rests not only with the loadmaster (who perished in the crash, btw), but with the system, the operator, FAA procedures, FAA training, etc.
This is true, but I think the point the parent comment was getting at is that an investigation tends to take a more holistic look at the incident rather than simply assigning blame directly to a single factor. Even pilot error, especially in the context of commercial aviation, is often found to be the result of training deficiencies or cultural issues on the part of the airline.
That's precisely the idea: if a pilot makes errors so grave as to endanger the aircraft, how come the airline training/monitoring in place did not pick up indications earlier?
The people that helped overcome the "pilot error, case closed"-mindset must be thanked (among others) for making aviation today as safe as it is.
Assigning "Cause" is an important part of accident analysis. There have been many cases of a pilot with proper aeronautical decision making processes, and due care and caution, still making a piloting error resulting in a mishap.
Classic example would be TACA 110 [0] Weather related factors, and a flaw in the engine design caused both engines to fail. Rushing the restart procedure resulting in a "hung start" of both engines and subsequent overheat. Thanks to the skillful flying of Capt. Carlos Dardano, and his crew, this 737 made one of the most successful dead-stick landings in history. Capt. Dardano was not to "blame" for the mishap, but he did make errors that were contributing factors.
The 737 needed an engine replaced, but was able to be flown out and fully repaired within weeks of the mishap. Southwest Airlines retired the aircraft in December 2016, with over 27 years of uneventful service.
That's a different sort of blame than what the parent was talking about. This is a sort of technical blame - what needs to be different to not have that sort of incident happen. That's different than "blame" as in scapegoating, where now that you've got a story about how someone fucked up we don't have to feel bad about there being a plane crash anymore.
