Sunday, October 13, 2019

5.3 Team-Based Human Factors Challenges

Since man is not perfect and we were not born flying but had to invent a way to do it, failure is inevitable. Yet that is what has driven mankind's greatest achievements; learn from what didn't work and make it better. That said, the term 'human factors' rightly describes the positives and negatives of human endeavor into an unnatural realm, and trying to leverage that information to achieve the most effective method in conquering that unnatural realm.
"In the Federal Aviation Administration (FAA), Human Factors is defined as a “multidisciplinary effort to generate and compile information about human capabilities and limitations and apply that information to equipment, systems, facilities, procedures, jobs, environments, training, staffing, and personnel management for safe, comfortable, and effective human performance” (FAA Order 9550.8A)."

In regards to a team-based activity, in my humble opinion, commercial aviation is just that. No aircraft can get off the ground or land again without a full team of people from different organizations working to make it happen. The video in Module 5.1 for "Crash of the Century" was rife with examples of both positive capabilities and negative limitations. The flight crew of the KLM flight was very rigid in it's team dynamic, the captain not allowing for dissenting opinion and lording his control over not just the copilot and navigator, but the flight attendants as well. The flight crew for the PanAm flight seemed like a cohesive unit, taking cues from each other and working together to figure out how to make it through. The unfortunate terrorist events that led all aircraft to the alternate airfield aside, the Los Rodeos ATC crew in Tenerife did an amazing job trying to fit so many aircraft onto an airfield not designed for that kind of traffic. But with that comes the added responsibility of keeping track of all those aircraft, no matter the weather conditions. Losing the aircraft on the runway in the fog was apparently inevitable given the location of the airport. The choice to deplane the KLM aircraft and then to refuel further compounded the timeline. Once given clearance, aircraft started departing but the ATC lacked clear direction for the PanAm 747 to take the C4 ramp, and then they failed to hold the KLM 747 until the runway was cleared, although there's not much one can do about a pilot who thinks he knows better than anyone else.

Personally, I think the major human factor in this whole tragic story is the infallible hubris of the KLM pilot, not wanting his reputation tarnished by running into a work timeline infraction that would tarnish a "sterling" career. If he had just been more patient, perhaps the whole affair might have turned out differently.

References:
FAA HF definition retrieved from:  https://www.hf.faa.gov/media/RoleOfHF-FAA.pdf

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