For me, the best illustration is the Tenerife airport disaster, the deadliest accident in the history of aviation. Two Boeing 747 crashing into each other on the runway during takeoff.
Circumstances included fog, problems in the control tower, nonstandard phraseology, radio interference and overworked personnel.
For example, let's say a pilot belly-lands because they failed to lower their landing gear, possibly because they were distracted by some other equipment failure, or possibly because sometimes qualified and experienced pilots do this. This error could have been avoided with, say, an automated spoken "gear up" warning instead of a nonverbal warning horn (I have no idea if some aircraft already have this). But it could also have been avoided by longer and more extensive training, right?
Sure, it maybe could, but why risk it? Humans are also humans, and even pilots with endless amount of flight time does mistakes sometimes, because we're all humans. The idea is to work with the idea that sometimes we fail, even if we are well trained, so when failures happen, it's easy to recover.
> Where do you draw the line between blaming the UX and blaming the training process, or the inevitable cases where an irreversible decision made under uncertainty turned out to be the wrong one?
Basically, it's always the UX. If there is a case where the pilot made the wrong decision, something needs to change so if a pilot with similar experience, wouldn't have made that decision with a different UX. Basically force the pilots to do the right decision, always.
I'm not 100% on the history of all of this, so if someone is more familiar with it, please correct me. But I think it started with "Crew resource management" to ensure proper training of the crew. It has gone through many iterations where less and less blame is being made on the crew and more on the equipment. I think the point of the current iteration basically boils down to "Human-error will happen, let's plan for it and if human-error lead to a plane going down, let's fix it so the same error would be prevented".
That's not realistic. If you think it is realistic, please take a look at the investigation report for PK8303. Some pilots will disregard alerts, override safeties and ignore procedures: there's only so much a system can do to promote good decision-making.
https://www.caapakistan.com.pk/Upload/SIBReports/AAIB-431.pd...
If it were possible to do this, we wouldn't have pilots at all.
Generally in this sort of risk analysis there is a hierarchy of mitigation, and the least of them is training. e.g. when you find a potentially hazardous situation, the best thing you can do is design the system so that it can't happen. Failing that, you design in an procedural or workflow aspect that naturally avoids it. Failing that, you put in a system to force the use to confirm or review the action. Failing that, you train around it.
A common sign of a flawed design process is when things get pushed into the "train around it" bucket late in the process, not because they were unavoidable, but because they were looked at too late in the design to effectively make changes.
I view the procedural or workflow aspect as a subset of training. As an example, I always lower the gear and leave my hand on the gear selector until I see three green (gear safe) lights prior to selecting any flaps.
The operating handbook and factory checklists do not require this, but my planning and training has elected this optional workflow/procedure. Why? Because it's incredibly hard to get my airplane to slow down and come down for landing while completely clean (no flaps, no gear). If I use the factory accepted procedure to select approach flaps, I can get it slow enough to land. I've literally never seen a "pilot forgot the gear" airplane sitting on the runway with no flaps deployed.
Example: I have a mechanical system moving fast with enough mass to hurt the operator, so I put the control on the other side of the machine (i.e. machine body between person and the dangerous part), and require the operator to hold a switch "on" for the entire time the machine is moving.
This doesn't make it impossible for the machine to hurt the operator, of course, but it makes it a lot less likely - and it doesn't rely on training at all.
While you can also rely on training aspects like you describe (a good idea!) it's not the same thing.
I don't know aircraft, so I don't know if there is something equivalent but I wouldn't be surprised. Anything you simply have to do with two hands on disparate controls?
The only thing that I can think of that directly work this way are some of the gust locks (to prevent control surfaces from banging about in the wind while parked) are required to be designed so the airplane can’t be started and taxied out with them in place. (That’s arguably a poka-yoke as much as a procedure, but probably still fits.) Mine simultaneously locks the yoke and has a plastic flag that blocks the starter switch when installed.
If the airplane offered a mechanism to inhibit flap operation unless the gear was down and locked (a poka-yoke enforcement of my procedure), I’d decline it/argue against it. In the event of a gear failure or a forced water landing, I want to have the flaps without the gear being safe and, especially for water, I don’t want to have to look up the abnormal/emergency flap extension without gear in a QRH while doing everything else needed while descending for a forced landing.
In my aircraft, it's triggered by ((no gear safe indication) and ((full flaps) or (very low throttle setting))). The presentation is a loud, alternating warning tone and a red "Gear Unsafe" light directly in my field of view on the glareshield. These are not silenceable by button as is common on training aircraft.
Even though a handful are inadvertently geared up every year, I'm not convinced that better warning systems would significantly reduce the rate. Better training would. If I ever do the deed, I'll be the first to admit that I was the primary cause and that I failed not only to follow the checklist, but my own SOPs and flew the aircraft onto the runway with a large red light right in front of me and a blaring horn. Making it a voice seems not likely to help.
If I gear it up after an electrical failure [which some of the inadvertent ones are], that's probably slightly more understandable (and a scenario in which an additional, electrically powered, warning system would presumably also be INOP).