Incidents and Accidents - A Breakdown in Human Factors

Aloha and other major accident was preventable and could have been avoided if any one of a number of things had been done differently.                                                                                  In some cases, a number of individuals were involved and the outcome could have been  modified if any one of them had reacted or queried a particular action.                                             In each situation however, the individuals failed to recognise or react to signs of potential hazards, did not react as expected of them, or allowed themselves to be diverted from giving their attention to the task in hand, leaving themselves open to the likelihood of committing an error.
             As with many incidents and accidents, all the examples above involved a series of hf problems which formed an error chain. 

Error chain 

If any one of the links in ‘chain’ had been broken by building in measures which may have prevented a problem at one or more of these stages, these incidents may have been prevented. In accident analysis, a chain of events (or error chain) consists of the contributing factors leading to an undesired outcome.

           The error chain can be just a single link where just one mistake can end in disaster or it can be many links where things all have to line up perfectly for the accident to happen.  
 “For the want of a nail the shoe was lost.” Then the horse and the rider were lost.

     Air accidents or incidents are not a one-off error. It is rather a chain of events or accumulative latent errors, which in a certain point of time and place would come to the fore and confront. 
      At that point, the actions of the crew and their response to such occurrence can be a determinant factor in whether the accident would happen or otherwise be well managed and avoided. Accordingly, human errors can exist well before the time of the accident. 
Operational error done by an individual down the track somewhere in the system might be the cause of the event rather than the actions of the flight crew. 
 Swiss Cheese model - Pr. James Reason 

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