In my exposure to a handful of news briefs regarding this recent tragic incident, I find it difficult to characterize this photo as a “description error.” Perhaps “chain of death” would be more appropriate.
If you are trying to clarify what a decision error is, a better case might illustrate the consequence of a single error (such as which side of a door to install a caution sign). If you are trying to flag incidences where decision error was a critical factor, then it would be important to include all of the critical factors for context. Since, the incident in the photo was clearly not caused by a decision error, nor would the contributing factors ever be involved by design.
This is an example of a decision error contributing to a root cause, not the other way around.
Like Kegworth it’s an example of a slip (an error of execution) rather than mistake (error of decision). The crews intent was to shut down the engine that was in trouble, but then they incorrectly applied to the wrong engine. That’s the direct (proximal) cause of the loss of the remaining engine. As this slip resulted in a difference between intent and outcome it’s error. When we dig into the ‘why’ of this incident I wouldn’t be surprised if we find a failure trap in the design of the man machine interface, that was triggered by this particular set of events.
With a Bachelor’s of Engineering and a Master’s of Systems Engineering, Matthew professionally consults on system safety and risk. He also teaches and writes on these subjects.
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