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Human error or system error: Are we committed to managing it? Key Dismukes We have now posted the slides and notes from a presentation Key Dismukes recently made to three audiences: the Pacific Northwest Business Aviation Association Safety Day (Seattle), the Air Force Reserve Command CRM Conference (Ft. Worth), and the Aviation Human Factors and SMS Conference (Dallas). This presentation - Human Error or System Error: Are We Committed to Managing It? (PDF 8.9MB) - draws on our group's research over the past several years to provide a perspective on why even the most skilled and conscientious of human operators are vulnerable to error, arguing that these errors are the consequences of system vulnerabilities, and in most cases do not represent personal shortcomings of the individual operator involved in an accident. The complex and partly random interplay of diverse multiple factors leading to accidents is discussed as necessary for understanding accident causality. Some of the most common patterns of interplay are described with accident examples. Interruptions, deferring tasks or performing them out of the normal sequence, and attempting to juggle several tasks concurrently substantially increase vulnerability to forgetting to perform flight-critical tasks, such as setting flaps to take-off position. The talk concludes with practical measures pilots, flight organizations, and the overall industry can take to reduce vulnerability to operator error. |
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