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Administrative mitigation like pilots are usually the least preferential ways of mitigating hazards. Humans are often the least consistent, most fallible part of a system. If there were engineering solutions available I would hope Boeing would implement them.


There are many examples of automated systems not accounting for novel or rare situations that the original designers didn't plan for or ignored. This is why manual override should always be available as a last resort if possible. No automated system we can design today is perfect. While protections and automatic mitigation should be implemented, taking away agency from pilots or whoever else is a recipe for disaster.


I wasn't implying that humans should be taken out of the loop. I was more referring to the hierarchy of mitigation. Most preferable are to design the hazard out of the system, followed by engineering controls, and lastly procedural/administrative mitigation.

Too often systems are designed with procedural mitigation as the primary way of controlling a hazard without realizing all the human factors that come into play. Maybe the pilot is distracted because she just had a fight with her spouse. Maybe her co-pilot a bad night's sleep. Or maybe he isn't physically capable generating the force necessary to move the trim wheel.

I think too often designs can over rely on administrative mitigation because the engineering controls seem too costly or difficult to implement. In some cases, this rationalization that a person "just" has to do XYZ activities to control the outcome falls short because we don't acknowledge all the factors that person is dealing with in the moment.

In this case, to someone like me without intimate knowledge of the Boeing process, it looks like they failed at their hazard analysis. They did not design the hazard out of the system (airframe design), the engineering controls were inadequate (MCAS), and the administrative controls were poorly managed (pilots did not understand the procedures for disabling MCAS or the procedures were not capable of being executed effectively). In other words, they did not apply appropriate hazard analysis and mitigation. Hindsight is easy, I know, but when schedule pressure hits a lot of these processes are rushed.




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