Unfortunately, plane crashes are a frequent occurrence, and they take away the lives of hundreds of people at once. The danger of such accidents is that the conditions in which the aircraft is located, precisely high speed and altitude, significantly reduce the likelihood of rescue and survival. At the same time, the human factor, or mistakes made by aviation workers, are the most common cause of air crashes (Earl et al., 2012, p. 3). However, an assessment of the impact of the human factor in aviation began only in the late 1970s as well as the development of measures to reduce it. The reason for the development of this science was the collide of Pan Am and KLM’ Boeings 747 at Tenerife Airport, which killed 583 people (Smith, 2017, para. 33). Although one of the reasons for this collide was adverse weather conditions, the main causes were the human factor that influenced the decisions of the pilots. Consequently, this paper will examine the human factors aspect that caused the accident at Tenerife Airport, as well as the approaches and measures that were taken to address them and prevent other accidents.
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Human Factors in Tenerife Accident
Aviation is a complex system that is based on various mechanisms of interaction between people, structures and technology. Aviation is also often defined as a system of systems, since air traffic requires the cooperation of different internal and external elements, such as the work of aircraft designers, pilots, air traffic controllers and other professionals who analyse and create safe airspace conditions. For this reason, the modern Just culture system is aimed at assessing all the factors that develop accidents to eliminate them (Civil Air Navigation Services Organisation, 2016). Besides, most of the modern approaches consider the human factor as a symptom of the system’s internal problem. Therefore, one may note that the planes crash at Tenerife Airport was the result of a combination of events, which belong to a group of internal, external and organisational human factors by considering it in a socio-technical system.
There are various approaches to assessing human factors causing errors in aviation; however, modern science recognises that one agent cannot be responsible for an unintentional accident. In Vlaming, Jan de Boer, and Boosten’s classifications (n.d., p. 1), human factors are divided into internal, external and organisational. In the case of the planes crash in Tenerife, the first group includes the unintentional deafness of the KML pilot and the complacency of both pilots and controllers. These internal factors are also associated with elements of the second group, such as stress, fatigue, and lack of communication (Vlaming, Jan de Boer, and Boosten’s, n.d., p.3). KML and Pan Am pilots were stressed and tired, since they were on the flight for a long time due to a bomb explosion on the place of their initial arrival (Smith, 2017, para. 4). The controllers also experienced a significant load as they were forced to guide more aircraft than usually, including Pan Am and KML simultaneously. For this reason, the pilot of Pan Am missed a turn to exit C3, and could not leave the runway, and the controller could not react to the situation on time.
The actions of the KML crew revealed a more significant number of human factors. Due to problems with radio communication, as well as fatigue and an uncritical approach to his skills, the pilot did not hear reports that the Pan Am’s plane had not cleared the runway (McCreary et al., 1998, p. 24). Irritation and impatience prompted him to begin moving, although the controllers did not permit to take off. This decision can also be explained by “false hypothesis” of the pilot, since he creates environment according to his regular or routine image, since he had not had enough information due to limited vision (Allnutt, 2002, p.371). Thus, he believed that the runway is clear and controller, as usual, permit take off.
In this case, the decisive factor was also a problem with radio communications. Simultaneous signals from Pan Am and controllers cut off the vital part of the message for KML: “Stand by for take off, I will call you” (McCreary et al., 1998, p. 24). Besides, the controllers spoke a language that was not native to them and had to control the movement of two aircraft at the same time. Thus, they misunderstood the KML’s message “we are now at take off” and accepted it as a signal that the aircraft was at take off position (McCreary et al., 1998, p. 24). This misinterpretation is also explained by Allnut (2002, p. 372) as he emphasizes that errors occur in the communication itself, since it based on individual mental of sender and receiver. Thus, this feature also relates to external human factors.
More specific external factors are the lack of communication and the high authority gradient, which prevented other team members from challenging a decision of the aircraft captain. From the internal communication between the KML team, one can hear that the engineer and officer have heard Pan Am tell the controller that they will let them know when they clear the runway (McCreary et al., 1998, p. 24). However, the lack of communication due to stress or fear to doubt the decisions of a senior officer made them silent. As a result, a collision occurred when a KML plane cut off the upper part of the Boeing Pan Am, which led to an explosion of both aircraft but with few minutes delay for Pan Am. Consequently, the combination of poor visibility and the human factor led to tragic consequences.
However, it is also worth noting the influence of organisational and technical factors that influenced the development of fatal mistakes. In this situation, a series of events led to the crash. The first aspect was that the Tenerife airport was not ready to receive a large number of aircraft, and the controllers were faced with an enormous load. The limitations of the airport led to the fact that due to the location of the Pan Am Boeing in the parking lot, the plane could not leave the airport earlier because it was blocked by the KML Boeing (McCreary et al., 1998, p. 23). Besides, the airport was not technically equipped with traffic monitoring radars or other means to increase visibility in adverse weather conditions. For this reason, the pilots and controllers relied only on radio communications, and the simultaneous signals from Pan Am and the controller created interference that blocked part of the vital message for KML pilots.
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Therefore, a combination of factors demonstrates that aviation is a socio-technical system or system of systems. The combination of human factors in this situation led to a disaster that claimed hundreds of lives. However, this accident also has positive consequences as it pushed scientists to study human factors in the system to reduce the likelihood of their occurrence, leading to new plane crashes.
Measures and Approaches to Manage the Effect of Human Factors
The crash in Tenerife and its further analysis have demonstrated to society and scientists the importance of the human factor influence in aviation and other industries. Sydow and Berends (2019, p. 131) note that the incident in Tenerife marked the beginning of introducing aspects of the human factor in mandatory pilot training. For this reason, psychologists working in aviation and pilots jointly developed the Team Resource Management (CRM) system, which is aimed at training non-technical skills for aviation personnel. This program has various approaches and measures, as well as plans for different categories of workers; however, its primary goal is to train staff to deal with errors related to the human factor.
CRM training allows team members to better interact and respond to threats and errors in routine work. Earl et al. (2012, p.3) that mistakes are common and constant, but most of them are only lapses, while others become fatal; however, they are easily manageable. For this reason, CRM is more focused on skills that allow staff to deal with errors such as leadership, teamwork, communication, decision making, situational awareness, stress and fatigue management (Rosenthal, Boin and Comfort, 2001, p. 115). At the same time, CRM training is repeated and has different features for controllers, flight crew and cabin crew members, as well as joint training for different teams (Dahlström et al., 2008). This aspect provides them with skills to establish interaction and avoid fatal errors. For example, if the KML team had a higher level of communication, and the officer challenged the decision of the pilot, then he would have said about Pan Am message and avoid colliding. Therefore, the measures for training non-technical skills of staff are necessary for aviation.
In addition, CRM is an extensive system, and it also consists of approaches and methods that allow professionals to identify problems and direct efforts to their elimination. Threat and Error Management (TEM) is one of these approaches that aims to study how and why accidents occur by dividing the process of making fatal mistakes into three parts, namely threats, errors and undesired aircraft state (Earl et al. 2012. p. 3). Threats are events or conditions that arise by external reasons but not fault of the team and are divided into environmental and airline risks. If a team does not respond or does not cope with these threats, they turn into errors, which are also divided into groups such as aircraft handling, procedural and communication errors. Failure to correct errors leads to undesired aircraft states, which are displayed at such groups as aircraft handing, ground navigation, and incorrect aircraft configuration (Dahlström et al., 2008, p. 25). At the same time, the team has many opportunities to avoid accidents by correctly managing threats, errors or even an undesired aircraft state; hence, the teams undergo CRM training to find and use these chances.
A comparison of the TEM classification and the collision of the KML and Pan AM aircraft demonstrates that the events in Tenerife constituted a significant basis for the TEM approach. Pilots and controllers in that incident faced all environmental threats at the same time, precisely adverse weather, shortcomings of the airport, ATC, radio congestion, as well as airline operational pressure (Dahlström et al., 2008, p.23). These threats led to procedural and communication errors, which turned into improper ground navigation and consequently, a collide. However, CRM practice shows that training significantly reduces the likelihood of mistakes, including using the TEM approach for analysis and training. Therefore, probably, training for participants in those events would help them avoid a series of fatal mistakes.
However, scientists also need to observe the actions of the flight team in routine conditions to understand the impact of threats. For this purpose, the Line Operational Safety Audit (LOSA) is used, which is a data collection method for reducing human error in complex flight operations. A feature of this method is that it records data directly during the flight, which allows scientists to analyse all the actions, movements and decisions of the pilots. This approach, combined with TEM, help to identify the main errors associated with the human factor and direct efforts to their managing. At the same time, this system uses the principles of a Just culture, which aims to create an environment in which employees are encouraged to provide safety-related information (Civil Air Navigation Services Organisation, 2016, p. 2). Some of the main principles of LOSA’s work are confidentiality and anonymity of data, volunteerism of pilots, and provision of feedback to staff based on the information received (Dahlström et al., 2008. p. 21). Therefore, pilots are not afraid that their routine mistakes will affect their careers and at the same time, receive information to improve their performance.
In addition, a similar approach is used by some lines both privately and by research institutes, which allows obtaining large amounts of information, accurate results and providing universal recommendations for CRM training. Therefore, the development of this approach is another measure that was adopted after the Tenerife accident in 1977 to improve flight safety.
Moreover, Just culture is also only part of the aviation safety system. Many airlines over the years have successfully applied the Safety Management System (SMS), which is an organised approach to ensuring security that includes the necessary procedures, accountability, interactions and policies (“SMS1,” 2014, p.8). The main difference between this system and CRM is that it operates on an ongoing basis and consists of interaction components that monitor and improve the work of aviation personnel. For example, such measures include creating a “security-first” policy, holding weekly meetings to discuss risks, appointing responsible people for different teams to maintain and ensure safety, and creating a Just culture. SMS is often combined with other approaches and measures to provide the maximum education and awareness of staff to avoid threats and impact of human factors. However, at the same time, such a system is all-encompassing and creates the conditions in which safety comes first.
It is also worth noting that the crash in Tenerife pushed scientists to develop new technological tools to facilitate the work of pilots. One of them is remote cockpit management, which is already partially used in aviation (“Remotely Piloted Aircraft System,” 2017). According to McCreary (1998, p.30), this technology helps to create an additional layer of management, and the pilots do not share the responsibilities of the boss and the subordinate but interact on an equal level. This approach can eliminate the problem of the gradient authority that arose in the KML team in 1977, and therefore avoid one of the errors caused by the human factor. A user-centric approach to the control panels design and automation are also the measures for promoting higher safety, since they reduce the likelihood of errors in routine actions due to crew’s stress and fatigue (Perrott, 2014; Harris, 2006). However, such technologies cannot completely replace the human component in the socio-technical system; therefore, CRM training and SMS are necessary to ensure safety in aviation.
Therefore, the collide of KML and Pan Am aircraft were caused by a combination of human factors and weather conditions. A detailed analysis of the communication between the KML crew, Pan Am crew and the airport controllers, as well as the situation in general, demonstrate that the main reasons for accident refer to various groups. The most significant factors were the fatigue and stress of all participants of the interaction, lack of communication, organisational and technical lacks. However, this accident led to the fact that scientists more thoroughly and systematically approached the analysis of air crashes and created a Just culture in which the blame for mistakes is not transferred to one agent or participant of the events. This feature allowed teachers and leaders to develop and apply measures that reduce the occurrence of errors due to the human factor and prevent accidents in aviation. However, the complexity of the aviation system, the interconnectedness of the elements and the unpredictable external conditions still leaves room for errors and, therefore, organisational measures require improvement.
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