|Quoting GPHOTO (Reply 63):|
Fact is, most accidents ARE caused by pilot error.
That's a pretty drastic over-simplification, GPPHOTO. Suppose you're driving a car in snow and ice, and you skid and have an accident? There's an element of 'driver error' in that - for a start, you decided to get out of bed that morning; then you decided to go driving; and if you'd kept your speed down to 5 mph all the way, you probably wouldn't have skidded at all....
Virtually all aircraft accidents are the result of a 'cascade' of events, which COMBINE to produce the accident. And that is exactly what the NTSB concluded; three main causes, pilot error, Airbus rudder systems, and AA
training. Three additional possible contributing causes that it didn't mention in its final conclusions were the level of departure separation allowed by the ATC controllers at Kennedy, the fact that the controller actually directed both the previous JA
flight and AA587 on exactly the same course on climb-out, heading straight for the George Washington Bridge ("Fly the Bridge Climb..")
, and of course the turbulence itself.
Beyond that, you have to look at the role of organisations like the NTSB. It is not to apportion blame; it is to analyse the causes of an accident and (as its name implies) make recommendations to increase future safety. And it wouldn't be practical for it to cause the whole industry to grind to a halt - by grounding whole marques of aircraft until they have been modified, stopping entire airlines from operating until they have retrained their pilots, closing whole airports until they have re-jigged their ATC arrangements. Or to destroy public confidence by indicating that all these matters probably played a part. So a conclusion that the 'main cause' was 'pilot error' suits pretty well everyone - except, of course, the pilot, but he/she is usually dead and past caring.
As aeroplanes get more complicated, there's an additional factor creeping in now; that the pilot is supposed to understand the way the various systems work, and in what circumstances they may overrule his commands; as well as the structural limits of each aeroplane type. Suppose Sten Molin had survived, to undergo hours of cross-examination by three or four sets of hungry lawyers?
"So, Mr. Molin, you applied left rudder. Why?"
"The plane was banking sharply to the right, the nose was dropping, and I could feel a sideslip, and that the aircraft was losing more height. I also pulled the column back, applied left yoke to try to level the wings, and called for full power."
"Please could we just concentrate on the rudder movements for the moment; those are what we are examining at the moment? Now, less than two seconds later, you applied RIGHT rudder - why?"
"The turbulence had caused the aircraft to begin rolling the other way, to the left. So I reversed the rudder - not just the rudder, all the flying controls....."
"Please concentrate on the rudder. Were you aware at this time that the manufacturer had recommended that abrupt movements of the rudder were to be avoided in conditions of turbulence?"
"I'd heard something about that. But this was an emergency, we were losing height fast, the aircraft was in danger. I suppose.....er....I suppose I had to disregard that......"
"I SEE, Mr. Molin - you CHOSE to disregard the manufacturer's safety recommendations? Is that what you're saying.....?
[Edited 2005-08-25 08:23:58]
"Once you have flown, you will walk the earth with your eyes turned skywards.." - Leonardo da Vinci