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You trust that the pilots made the best decision they could given the data they had, and you find a way to give them better data next time. If they took a known risk, you ask why they thought it was ok to take that risk.

If you think they were truly acting in bad faith, you have other issues.



"The pilots were at fault" does not mean the same thing as "the pilots were acting in bad faith", not even remotely.


Sorry, maybe I wasn't being clear. I don't think they are the same thing, my point is more that if you think someone is acting in bad faith you should fire them, but assuming they aren't, you shouldn't assign the fault to them, because then the only solution is "just do better next time." The organization learns nothing if you assume the pilot is at fault. The entire point here is that the pilot is not at fault, which leaves the door open to fixing the system. It's all about enabling organizational learning.


That makes no sense. Assigning fault to the pilot could mean that your training is inadequate, or that your rules for rest or drugs aren't sufficient, or that they need to be more explicitly empowered to resist external schedule or financial pressures, or any number of other things.

There's a wide range of reasonable "it's the pilot's fault" judgments which don't involve firing them or just shrugging your shoulders and saying "do better".


I guess maybe this is just an issue of semantics. I don't view the pilot being at fault if the training is inadequate, I view the training as being at fault.


Two sides of the same coin. If the engine explodes due to a manufacturing defect, is it the engine's fault or the factory's fault? Both.

What really matters is what the fault implies. Finding the pilot to be at fault does not imply that people just give up on figuring out a fix.




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