Posts by user "Bergerie1" [Posts: 5 Total up-votes: 33 Page: 1 of 1]¶

To Senior Pilot , T28B and all the other nameless Mods who have been moderating this and the previous thread, may I thank you all most sincerely for your excellent work. As an ex-senior flight manager, now long retired, I know from experience how thankless these tasks can be. I am sure other readers of these two threads will join me in thanking the whole team.

I think we need to be really careful about how we think about human factors.

To all of you who have talked about ‘muscle memory’ or ‘brain farts’ may I refer you all to post No. 183 by MaybeItIs. In it, he writes about the interactions between the cerebellum and the cerebrum – in effect, we have two brains; the cerebrum being the ‘conscious thinking part’ and the cerebellum being the ‘unconscious automatic part’ of our brains.

All of us have done very strange inexplicable things at some time or another in our lives, you only have to read about human factors to know how common such things are – even by highly trained flight crews . I know I have made mistakes like these, and I ask you all to examine your own lives and acknowledge that you may have done the same.

In my own experience, when I was a very new co-pilot, I was involved in a very nasty incident in a VC10 in which we all did inappropriate things, with the best of intentions . We very nearly ended up crashing. After that experience, I began to read books on psychology, brain structure and human behaviour. You will be surprised how easy it is to do the wrong thing and then, afterwards, to wonder why.

Later, I spent much of my career as a training pilot and as a training manager. Despite all the safeguards built in by designers and manufacturers, despite all the safeguards included in our crew procedures, and despite all the training we undergo during our careers, we are all still vulnerable to error, including the so-called ‘sky-gods’.

James Reason wrote about the Swiss Cheese model. Sometimes, one of the holes in the cheese can be our own totally improbable actions. What MaybeItIs has written in his post may help to explain such seemingly inexplicable events.

We all need to have some humility – There but for the grace of God go I.

May I refer you to MaybeItIs' post 183 and my post 351 . I think that tdracer has laid to rest most (if not all) of the electrical theories that have been put forward on this thread. And I find the accusations of malicious operation of the switches by one or other of the pilots to be repugnant.

This leaves the so-called 'muscle memory' and 'brain fart' theories. Those who work in the field of psychology can show quite clearly that we are all liable to seemingly inexplicable mistakes, both in normal life and in the cockpit. MaybeItIs wrote about the cerebellum and the cerebrum in his post 183, his words are very wise.

Those of us who have worked as instructors will have spent many hours embedding in our students essential habit patterns, most of which are life-savers. But, equally, habitual actions can very occasionally go wrong, despite our best intentions. I have a strong feeling that the root cause of this accident will be found to be psychological.

Some may simply try to put this down to 'pilot error' which, in a way, it is but it is not a culpable error . It is simply a result of being human.

Agreed, but may I recommend reading the whole of 'Human Error" by James Reason - there is a lot more good stuff than just the Swiss Cheese model, particularly the sections on the various types of human errors, the circumstances under which they are likely to occur, and some of the mitigation strategies.

Pilot DAR , Thank you for your very reasonable post regarding the moderators' position. I agree, and would go even further and suggest that this thread is closed until some new and authoritative information comes to light.