UNDERSTANDING HUMAN ERRORS IN AIRCRAFT ACCIDENTS

INTRODUCTION

Committing errors by man has a historical back­ground. The first ever error committed by man, perhaps, was Adam eating the apple in the Garden of Eden. He was then forced to look for a scapegoat and found one in Eve!! Since then, whenever accidents have occurred, it was assumed that some man had committed an error and a scapegoat had to be found. From the time the Wright brothers took to air in 1903, aircraft have been involved in accidents. More often than not, the cause of the accident was attributed to the pilot essentially because there was no one else on whom the blame could be attached. This attitude stemmed from the belief that aviation as a skill was difficult to master or acquire. Further, it was the pilot who dared to go against the laws of nature, and in his quest to attain parity with the birds, was prone to committing errors.

PILOT ERROR

The term pilot error, as has been mentioned earlier, was derived from the belief that in an aircraft accident the only human who could cause a crash was the pilot. This belief gained momentum during the Battle of Britain when pilots in their exuberance beat up the homes of their girlfriends and crashed, or forgot to lower the undercarriage after executing victory rolls at hair- raising altitudes. With instances of ‘pilot errors showing an alarming rise, Air Marshal Dowding, the Air Officer Commanding-in-Chief of Fighter Command, Royal Air Force was compelled to issue instructions that pilots who behaved irrationally should be punished with the utmost severity. Indian Air Force inherited these instructions and has been following it most rigidly ever since.

It was in the late 1970s, after a thorough examination of aircraft accidents in the United States Air Force, that it came to be believed that aircraft accidents are caused because of failure of some human: it could be the designer who made a faulty design, a Met officer who did not appreciate the rapid changes in weather; the technician who overlooked an essential check, the Air Traffic Controller who gave incorrect instructions, or the pilot who failed to follow instructions. Lack of flying skills or judgments was other reasons attributed to the human. Hence from pilot error, the world of aviation moved to the era of human error.

HUMAN ERROR

Psychologists have assessed that the brain is one of the-most complex organs in the human body which, at times, defies logic. Prediction of human actions or reactions is, therefore, quite complex. It would, indeed, be a miracle if two humans were to react identically to a situation in identical conditions. Since the human brain is central to all acts of omission or commission by an individual, it stands to reason that the causal factors need to be studied in greater detail. Paradoxically, we tend to find a scapegoat rather than dig into the accident to realize the cause.

Lloyd and Tye in their book ‘Systematic Safety suggest that ‘an accident or serious incident is a systematic failure of the overall system. Or, as Professor KR And­rews of USA puts it, ‘Every accident is a failure of the organisation. Hence, the system or the organization itself needs to be investigated in an aircraft accident to determine probable failure zones. For example, a technician goes to the accounts section to collect his pay at 10 am. He must collect his pay for he has to proceed on leave next day at 5 am to attend to his ailing mother at his village. The accounts officer tells him to come back at 11 am because as per section orders no payment is to be made before this time. The airman gets back to his Squadron and is told to carry out Turn Around Servicing on an aircraft. His job entails tightening a nut in one of the flap connections. While tightening the nut, he frequently keeps glancing at his watch so as to be in time to collect his pay. In the bargain he cross-threads the nut, signs the Form 700(aircraft log book) and rushes to the Accounts Section. The aircraft gets airborne and the pilot is unable to lower flaps. He attempts a flapless landing but is unable to control approach speed adequately for a safe landing. The aircraft engages barrier and sustains damage. The verdict: the pilot erred in executing a safe flapless landing. After an in-depth analysis the errant nut, dislodged due to cross-threading, is located. Now the question is who is to blame? The pilot, the technician, the accounts officer or the system?

Errors are a part of human nature. It would be naive to think that we can produce a human, or condition a human who commits no errors. In activities connected with aviation there is a tendency to state that there is no room for error, or in other words ‘errors are forbidden’! Subconsciously, we tend to expect perfection from those who work intimately with aviation safety. A pilot is considered a hero in case he excels in a dog-fight with the enemy, but if there is a landing accident on his return, the pilot is invariably exposed to untold rebuke or reproof. This, in spite of the air traffic controller or the technician is found to have made a mistake. Many a time, a small molehill of an incident is turned into a mountain of an accident.

It is not being suggested that human errors are irrelevant to aircraft accidents. What is being brought out is that instead of homing on to an individual, it would be necessary in the best interest of flight safety, to determine the cause of the accident. If all evidence points towards willful negligence or disobedience of orders, then the individual must be held guilty and suitably punished. If not, then examine the organizational failure(s) that have led to the accident and attempt to eliminate the causes. The urge to blame a human, perhaps, could be an urge to find an outlet for our grief and dismay, to blame somebody. A better and scientific: approach would be to eliminate emotional reactions which attribute blame and responsibility on an individual. If we can establish a gap between the effects of errors and our emotional reactions, then errors would not appear to be a shameful disease but as normal consequences of the performance and character­istics of the human brain.

During a presentation on the Accident Prevention Programme it was amply brought out that errors are an integral part of life. Error is not only universal but is inevitable. Hence one cannot engage in human performance of any form without human error.

CONCLUSION

  Over the years, there has been an appreciable shift in the field of aviation to consider human factors more humanely. Understanding of the human mind has become an important facet in investigations; to accept certain accidents and incidents as an inherent inevitability of a human being. While cases of honest acceptance of failure or lapse by an individual must be handled with a degree of leniency, cases of willful failure must attract disciplinary actions, for in the words of Gen George S Patton, “There is only one kind of discipline – perfect discipline”.

  • By Air Cmde AD Chhibbar, AVSM (Retd)

INTRODUCTION

Committing errors by man has a historical back­ground. The first ever error committed by man, perhaps, was Adam eating the apple in the Garden of Eden. He was then forced to look for a scapegoat and found one in Eve!! Since then, whenever accidents have occurred, it was assumed that some man had committed an error and a scapegoat had to be found. From the time the Wright brothers took to air in 1903, aircraft have been involved in accidents. More often than not, the cause of the accident was attributed to the pilot essentially because there was no one else on whom the blame could be attached. This attitude stemmed from the belief that aviation as a skill was difficult to master or acquire. Further, it was the pilot who dared to go against the laws of nature, and in his quest to attain parity with the birds, was prone to committing errors.

PILOT ERROR

The term pilot error, as has been mentioned earlier, was derived from the belief that in an aircraft accident the only human who could cause a crash was the pilot. This belief gained momentum during the Battle of Britain when pilots in their exuberance beat up the homes of their girlfriends and crashed, or forgot to lower the undercarriage after executing victory rolls at hair- raising altitudes. With instances of ‘pilot errors showing an alarming rise, Air Marshal Dowding, the Air Officer Commanding-in-Chief of Fighter Command, Royal Air Force was compelled to issue instructions that pilots who behaved irrationally should be punished with the utmost severity. Indian Air Force inherited these instructions and has been following it most rigidly ever since.

It was in the late 1970s, after a thorough examination of aircraft accidents in the United States Air Force, that it came to be believed that aircraft accidents are caused because of failure of some human: it could be the designer who made a faulty design, a Met officer who did not appreciate the rapid changes in weather; the technician who overlooked an essential check, the Air Traffic Controller who gave incorrect instructions, or the pilot who failed to follow instructions. Lack of flying skills or judgments was other reasons attributed to the human. Hence from pilot error, the world of aviation moved to the era of human error.

HUMAN ERROR

Psychologists have assessed that the brain is one of the-most complex organs in the human body which, at times, defies logic. Prediction of human actions or reactions is, therefore, quite complex. It would, indeed, be a miracle if two humans were to react identically to a situation in identical conditions. Since the human brain is central to all acts of omission or commission by an individual, it stands to reason that the causal factors need to be studied in greater detail. Paradoxically, we tend to find a scapegoat rather than dig into the accident to realize the cause.

Lloyd and Tye in their book ‘Systematic Safety suggest that ‘an accident or serious incident is a systematic failure of the overall system. Or, as Professor KR And­rews of USA puts it, ‘Every accident is a failure of the organisation. Hence, the system or the organization itself needs to be investigated in an aircraft accident to determine probable failure zones. For example, a technician goes to the accounts section to collect his pay at 10 am. He must collect his pay for he has to proceed on leave next day at 5 am to attend to his ailing mother at his village. The accounts officer tells him to come back at 11 am because as per section orders no payment is to be made before this time. The airman gets back to his Squadron and is told to carry out Turn Around Servicing on an aircraft. His job entails tightening a nut in one of the flap connections. While tightening the nut, he frequently keeps glancing at his watch so as to be in time to collect his pay. In the bargain he cross-threads the nut, signs the Form 700(aircraft log book) and rushes to the Accounts Section. The aircraft gets airborne and the pilot is unable to lower flaps. He attempts a flapless landing but is unable to control approach speed adequately for a safe landing. The aircraft engages barrier and sustains damage. The verdict: the pilot erred in executing a safe flapless landing. After an in-depth analysis the errant nut, dislodged due to cross-threading, is located. Now the question is who is to blame? The pilot, the technician, the accounts officer or the system?

Errors are a part of human nature. It would be naive to think that we can produce a human, or condition a human who commits no errors. In activities connected with aviation there is a tendency to state that there is no room for error, or in other words ‘errors are forbidden’! Subconsciously, we tend to expect perfection from those who work intimately with aviation safety. A pilot is considered a hero in case he excels in a dog-fight with the enemy, but if there is a landing accident on his return, the pilot is invariably exposed to untold rebuke or reproof. This, in spite of the air traffic controller or the technician is found to have made a mistake. Many a time, a small molehill of an incident is turned into a mountain of an accident.

It is not being suggested that human errors are irrelevant to aircraft accidents. What is being brought out is that instead of homing on to an individual, it would be necessary in the best interest of flight safety, to determine the cause of the accident. If all evidence points towards willful negligence or disobedience of orders, then the individual must be held guilty and suitably punished. If not, then examine the organizational failure(s) that have led to the accident and attempt to eliminate the causes. The urge to blame a human, perhaps, could be an urge to find an outlet for our grief and dismay, to blame somebody. A better and scientific: approach would be to eliminate emotional reactions which attribute blame and responsibility on an individual. If we can establish a gap between the effects of errors and our emotional reactions, then errors would not appear to be a shameful disease but as normal consequences of the performance and character­istics of the human brain.

During a presentation on the Accident Prevention Programme it was amply brought out that errors are an integral part of life. Error is not only universal but is inevitable. Hence one cannot engage in human performance of any form without human error.

CONCLUSION

  Over the years, there has been an appreciable shift in the field of aviation to consider human factors more humanely. Understanding of the human mind has become an important facet in investigations; to accept certain accidents and incidents as an inherent inevitability of a human being. While cases of honest acceptance of failure or lapse by an individual must be handled with a degree of leniency, cases of willful failure must attract disciplinary actions, for in the words of Gen George S Patton, “There is only one kind of discipline – perfect discipline”.

  • By Air Cmde AD Chhibbar, AVSM (Retd)

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