Aviation is no more the domain of an ‘individual’ pilot. The commercial sector has multiple crew – both flight and cabin. The military operates in formations (and twin-cockpits too), where the pilots are physically separated, yet coordinate their flight to attain a common objective. The errors and accidents here result from individuals failing to perform in the team; whereas the teamwork is essential in reducing, trapping and mitigating or treating errors. In an endeavour to achieve safe mission accomplishment, it is expected that the complete group involved in the mission, whether in air or on ground, works together effectively. This remains the essence of teamwork .
Failures of teamwork in complex organizations like commercial or military aviation can have catastrophic outcome. It has been said that more than two-third of aircraft crashes occurred because of the human error as the primary factor, but a closer analysis invariably reveals that it was the failure of teamwork, in areas such as communication or shared mental models, that was the cause of the accident . Commercial aviation regulations mandate that the flight and cabin crew work together as a team, through the use of standard operating procedures (SOPs) and formal training to facilitate teamwork and communication, including CRM and LOFT. Unlike some of the Western air forces, military aviation in India, especially single cockpit operations are still bereft of this vital human factors advantage – the CRM training. This may hopefully change and CRM for single cockpit operator may come to be accepted in the coming years.
Another area of focus shall be organisational attitude to learn about the human limitations – cognitive and psychological stressors – leading to human errors, besides encouraging the operators to be open about admitting it for analysis by the experts. This shall first require that the aviation sector, both commercial and military, must introspect about the organisational attitude and existing policies on human error and human factors. This has to be followed by a defined policy about human error, specifying that errors should be accepted and not punished; but intentional non-compliance should not be tolerated. Formal preventive and safety procedures, where lacking, must be simultaneously instituted. SOPs were the first countermeasures against threat and error in aviation and remain so till date. Aviation organisations must continue with error reporting systems to uncover threats and sources of error, without fear of victimisation or ridicule. In the same spirit, the reported adverse outcomes and near miss must be thoroughly analyzed and remedial or preventive measures must be disseminated to all operators, aviators and support personnel, to prevent recurrence or a similar incidence turning into a tragedy. More importantly, formal training in human factors and CRM, including human limitations as sources of error, nature of error and error management, culture and communications, decision-making and countermeasure training using specific behaviours and procedures against threat and error must be instituted and nurtured as an organisational safety goal . This approach is highlighted as the organisational quest for safety in aviation, where Aviation Medicine specialist can make significant contributions as team players, with an aim that probably “we will never be ‘safe’ but we can continue to improve”.
The bleak picture of errors continuing to occur shall not deter the aircraft designers and human factors specialist from pursuing their goal of practical research into mission and flight safety. They shall work assiduously for defining human limitations due to cognitive and other psychological stressors. It is likely that human error, especially the decision making errors, would be the commonest cause of accident in both civil and military aviation. So the interventions shall also be focussed at specific aspects of human limitations, based on the lessons learnt from accident investigations and defined strategies for accident prevention.
1. Helmreich RL, Davies JM. Culture, threat, and error: lessons from aviation. Can J Anesth, 2004; 51 (6): R1–R4
2. Boeing Commercial Aircraft. Statistical summary of commercial jet aircraft accidents: Worldwide Operations 1959 – 2002
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