ABSTRACT

Indignation means one is upset or angry or annoyed at something that seems unreasonable. It is understandable that one would get disturbed at the sight of apparently stupid behavior. Especially if it has tragic consequences. But the problem is that such indignation serves so little. The problem is that anger and indignation at a sequence of events that led to trouble is not the answer to making progress on safety. Interestingly, even the 737 story pulls out to a wider perspective, and starts looking for a context in which the performance of the pilots could have made sense. The reasons the report offers include the 'mindnumbing effects of the event itself', and then it proceeds to talk about different kinds of attitude instruments in aircraft that show, in different ways, how the aircraft is pitching and rolling relative to the horizon. It talks about fatigue and about instruments that are not co-located, robbing pilots of the ability to cross-check.