To Err Is Human Essay

2470 words - 10 pages

As a pilot I get sick of hearing the term "human error" whenever an accident investigation releases their report. Almost every possible scenario can get traced back to human error in one way or another: pilot failed to initiate proper emergency procedures, pilot failed to stop when he should have stopped, pilot failed to go when he should have gone, and pilot was looking left when he should have been looking right. It is almost too easy to investigate an accident while flying at zero knots and determine that had the pilot done something differently maybe that accident wouldn't have occurred. As long as airplanes are piloted by humans then all accidents will have a cause associated with human error in one way or another. In fact, even when airplanes are not piloted by humans their accidents will still be human error because it is difficult (ok, impossible) to find an airplane that occurs naturally and thus airplanes will always be prone to our flaws. So what is the solution to the "human error" problem? The solution is to take the human aspect out of the equation. Yes, taking the human aspect away will not eliminate all of the errors as I mentioned before, but the difference is when you fix an error in a machine it stays fixed. In theory, if every time a machine makes a mistake you could fix that mistake without incorporating new ones, you could eventually have a perfect machine. Removing the human variable, or automation, sounds like the solution to all of our flying problems - and maybe someday it will be. In this paper, however, we will investigate how automation can and has actually created new hazards with devastating effects.

On December 20th 1995 American Airlines Flight 965, a Boeing 757-223, was flying at night near Cali, Columbia. On board were 2 flight crew members, 6 cabin crew members, and 156 passengers. The aircraft originated from Miami Florida and was just 33 miles northeast of its destination when it crashed into mountainous terrain killing all but 4 passengers. The accident investigation determined that there was no indication of any aircraft systems malfunction, no indication of any unusual meteorological event, no indication of any external hostile force acting on the aircraft, and no indication of any out-of-service condition of any applicable ground based navigational aids (Ladkin). So what was the cause of this accident? Apparently, when the pilot intended to proceed direct to the navaid "ROZO" he entered an "R" into the flight management system (FMS) which defaulted to a navaid over 100 miles away called "ROMEO." The autopilot automatically started steering toward "ROMEO" while the pilot continued his descent for what he thought was the final approach. Unfortunately for everyone onboard, mountains existed in the direction of "ROMEO" and 160 people died (Anderson). Had the pilot not made the error of entering an "R" instead of "ROZO" this accident would have been prevented....what a difference 3...

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