Thoughts on Human Error

Humans are amazing inventors, capable of envisioning a “possible” for every “impossible”, creating incredibly complex feats of engineering, in the name of Hughes and Learjet and McDonnell Douglas and Lockheed and a hundred others whose names won’t be forgotten. Even amazing inventors can engineer lemons, or fail to see every possible contingency. But the possibility of error goes beyond human error. Humans are not responsible for the fact that rust exists. Do you blame Einstein for the fact of relativity? It’s the dichotomy of reality: for every up there’s a down. Everything creates its own opposite. “Fixed” allows the possibility of “broken” to exist.

Thinking logically along those lines…we can speculate and plan, study and test, polish and revise, but does that make our planning and scheduling invincible? Even if it were perfect (and I’m not saying it is, because I am speaking of things in general), things fall apart. The nature of reality is change. Change happens. Plan for contingencies 1-3000 and the one that will happen is contingency # 3001.

We have to be careful sometimes when we start talking about human error. Unfortunately the container where the human error begins is life itself, because in theory EVERY thing can be blamed on human error. The patient died, blame the doctor. Nevermind that the patient was 112 and suffered every illness known to man.

In aviation, gunnysacking the humans happens too. Maybe they didn’t cause the lightning but they flew through it. We humans are pretty amazing creatures but we don’t control nature. We can plan and schedule all we want, but if you are going to fly during rain, you’re going to encounter thunderstorms. So let us say that the storm is responsible for the event. Do we blame the pilot for flying through the storm? Do we blame the arrogance of the plane manufacturer who claims the plane is invincible and can fly through anything?

Pilots are human. We have the full range of the spectrum, from the sublime, Sully, to the ridiculous (Colgan Air’s Marvin) Renslow. The problem that a hero like Sully presents is that it creates the philosophy is that well trained pilots should be able to solve any emergency.

But take for example Air France 447… could the pilots have been able to cope with flight speed problems caused by the performance of flawed parts?

Is the failure to recover from an unexpected event (wind shear, potential conflicts with other planes, broken planes) pilot error? If we put human beings in an easy chair of an automated job in some point-and-click fly-by-wire captain seat, when the crisis happens, the built-in redundancies in flight systems fail and the pilot can’t snap out of humanness to turn into Superman when the wire breaks, is that pilot error?

Our pilots now have to deal with cost-cutting industry practices causing fatigue and poor training.

Even if the ultimate safety device in the airplane is the well-trained, pilot, guess what? Pilots are human. Humans are capable of mistakes. They are capable of mistakes when operating planes.

Let us not forget that pilots fly planes that were crafted by humans, maintained by humans, orchestrated by human ATC, landing on airports designed by humans.

There is no one single answer. I have seen it a hundred times, and each case is unique unto itself, with one generality that can apply.

Human error occurs at all levels, and rarely alone.

Originally Posted by George Hatcher Sunday, February 14, 2010