When things go wrong in aviation the consequences are usually severe and because of this the industry has long been at the forefront of safety research and development. Not only have aircraft become increasingly reliable, but advancements in the understanding of human performance have also contributed to better safety performance. Over the years, a range of human factors skills have been identified that are now considered prerequisite for safe and efficient task performance in aviation. In this article we take a look at two aviation case studies and identity key lessons that can inform good practice in other workplace contexts such as oil refineries, chemical factories and gas terminals where the consequences of things going wrong are also very high.
Tenerife Airport disaster – teamwork and communication
Two Boeing 747s, operating KLM Flight 4805 and Pan Am Flight 1736 collided on the runway resulting in 583 fatalities. This accident is the deadliest in aviation history. Whilst there were a range of contributory factors such as poor weather conditions, some key aspects were a misunderstanding of communication regarding clearance to take off and an overruling by the captain of a flight deck engineer expressing concern about the interpretation of the communication.
Key lessons for good practice on high hazard sites include development of a workplace culture of openness and engagement, meaning it’s OK to challenge upwards and indeed it is expected that people speak up if they’ve got any concerns about safety. Another useful lesson from this example is to always check safety critical communications and avoid ambiguous phrases and terminology.
Kegworth plane crash – situation awareness and decision making
47 people were killed and 74 injured when Boeing 737-400 Flight 92 from Heathrow to Belfast suffered engine trouble and crashed on the M1 motorway embankment near Kegworth, Leicestershire. The pilots misinterpreted the origin of smoke in the ventilation system and shut down the wrong engine. Their situation awareness hadn’t taken into account changes to the ventilation system on the 400 compared to earlier versions of the 737.
Key lessons for good practice on high hazard sites include keeping up-to-date with any changes in the plant, systems and processes on site. This is particularly important during maintenance work where the plant may not respond in the usual manner due to alternations required to allow maintenance work to be completed. Another example of learning from this case study is to ensure all available sources of information are considered. The pilots announced they were shutting down the engine on the right side but some cabin crew and passengers has seen the failure was actually on the left. They didn’t speak up, believing they couldn’t contribute to the pilot’s understanding of the situation.
These are just some of the lessons from the aviation industry and are part of an approach to human factors called CRM – Crew Resource Management. This is a set of principles and practices that improve human performance and task performance on the flight deck and among the wider aircraft crew. It’s easy to see how this approach can map across to the context of a COMAH site control room and the wider organisational community.