#054: Human Error
When a fan blade breaks and consequently destroys the engine housing, sending out shrapnel that damages the wing and shatters a cabin window, you’d think that’s it, that flight is going down, and everyone is going to die.
Yet as Southwest Airlines Flight 1380 recently demonstrated, it is very possible to survive such an accident. The pilots handled the incident in a calm and professional manner (seriously, listen to the ATC audio, the pilot sounds like they’re describing a minor problem), dropping the plane to a breathable altitude, and then safely landing the plane at Philadelphia airport with only one passenger ultimately dying.
Afterwards, one of the first questions that comes to mind is “whose fault is this?”. We naturally want to assign blame, find out who screwed up, so we can punish them for their mistake. Yet what happens instead is that a board of inquiry investigates the incident (in this case the NTSB). They were on scene as quickly as possible, to look at the damaged plane. They quickly found the problem (a fan blade broke free, causing havoc), and yet they announced that the investigation is likely going to take 12-15 months. Why take so long if the cause is pretty clear?
Because the cause is never that clear. Sure, the fan blade was an immediate cause of the problem, and it shouldn’t have broken free. But why did it break free, especially since airlines regularly check their engines for fatigues and cracks in the fan blades? And why did the engine housing not contain the fan blade when it broke, since that’s what it’s supposed to do if this happens?
They will also look at what happened after the incident. Did the pilots react correctly? (By all accounts, they did everything right) Did the cabin crew do everything right? How did the emergency measures on the plane work out? Did the emergency crews on the ground handle the incident in the right manner?
One example that will likely elicit a recommendation from the NTSB is the way most passengers handled their oxygen masks. Since while all of them did put on the oxygen mask, many only covered their mouth with it, not their nose, defeating its purpose. This indicates that either more or better instructions are needed for passengers, or maybe even that the oxygen mask design needs to be altered, so passengers will put it on correctly.
As many years of airplane accidents and subsequent investigations have shown, finding a single root cause for any one accident is rarely possible, and even counterproductive. And while the media and the general public often blame accidents on human error, it is rarely that easy. Instead, there are always multiple causes of aircrafts crashing, and so investigators and regulatory agencies have enacted more and more recommendations and guidelines, to improve checklists, to change the environments pilots work in to make similar mistakes less likely, and to improve training, so everyone involved is better equipped to handle such situations (including emergency crews on the ground).
And we can also learn something from this: Whenever someone makes a mistake (regardless of how severe it was), we shouldn’t be too quick to blame them. We humans rarely make mistakes on purpose. Rather, there’s a multitude of reasons why mistakes happen, and if we want to prevent them from happening again, simply blaming someone won’t fix it. Instead, we have to look at the entire picture, and accept that there probably won’t be the one root cause.
Other interesting links from around the web:
- Australia’s Least Likely Tourist Spot: A Test Site for Atom Bombs
- The Surgeon Who Wants to Connect You to the Internet with a Brain Implant
- Contact Is More Than a Movie About Science vs. Religion — Spoiler: It’s also about technology and media.
📖 Weekly Longread 📚
Inside Facebook’s Hellish Two Years—and Mark Zuckerberg’s Struggle to Fix it All (Note that this was published right before the Camebridge Analytica scandal broke)