As you may know by now, there has been a paradigmatic shift in identifying the causal factors that lead to aircraft accidents. Initially, accidents were primarily attributed to proximal factors (in other words, pilot error), while today, many other upstream, or distal, factors are being identified (such as latent organizational threats and errors that may lie dormant in the system for months or even years).
Systemically, it was much easier to attribute an accident to a single cause — pilot error. The train of thought was that pilots made errors solely of their own volition and that there were few, if any, organizational precursors leading to the terminal error. Thus, if the pilot were still alive, the way to ameliorate the problem was with sanctions (such as license suspension or revocation and/or job termination). For lesser infractions, remedial training was another option. Unfortunately, these “fixes” did not prevent the same types of accidents from happening again. A deeper …
