WHY Aviation lessons unlearned?
Since the 1908 investigation into the death of Lieutenant Thomas Selfridge, the focus of aviation accident investigations was to improve aviation safety. Investigatory reports from aviation organizations from around the world, have documented efforts of investigators who have given us lessons learned.
but what happens when the accident investigation reports got the investigation wrong?
Like anything else that was taught in error, the lessons have to be unlearned. Facts must be sifted from opinion; the experienced must teach the unqualified; the obvious cannot be ignored; the incidental should be kept in its place.
The root cause mUST replace the probable cause.
once unlearned, the mistakes can be corrected. But until then we continue to be unsafe and are employing the wrong solutions. we unknowingly act in error while the problem - or problems - continue to exist.