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HUMAN ERROR

Human error. Those two words are the words we often hear in the aviation world. This
phrase is also a phrase that is quite frightening for human flight, because human error is often
accused of causing a number of plane crashes that often result in the loss of life of one or even
many people at once. But do we know, what is human error?

When an accident is declared due to human error, our thoughts will be directed to the crew:
the pilot or the other crew at the time. While people who think slightly more broadly will include
elements such as: meteorological tasks, air traffic controller (air traffic controller) and others.
Basically, the two thoughts are just as narrow, counter-productive and just as wrong as the
human error actor himself. So, how?

Safety in Aviation Technology
In modern technology, especially aviation technology, safety issues become very crucial and
vital. There are at least two reasons for this:

aviation- "conquering" the air and exercising in it-not the natural human nature destined to live
and thrive on the land.

technology to fly-like any other technology-is purely man-made, which has many weaknesses
and limitations, like the man himself.

Two basic reasons that make people should be more concerned about safety issues, both in the
work on land (pre flight and post flight check or maintenance of aircraft) and when flying itself.
The philosophy of "the sky is vast but there is no room for error" is a flight axiom that persists
during the flight. The more advanced and advanced a technology, the more important it is for the
concerns of fly and work safety issues, and it can be done only with a good understanding of
human error.

Very wise if we do not go too far to call human error. It may be more appropriate to call the
human factor involved in almost every aviation accident. The fact is. Only 80% of them are
human error. There's a difference, right? This human factor is undoubtedly undoubtedly due to
the fact that aviation technology and its supporting devices (aircraft, ground power unit, radio,
runway and so on) are human creations. The entire manual and operating instructions of the
aircraft and its supporting devices are also man-made. Inspection activities, maintenance and
preparation of aircraft and supporting devices were also conducted by humans. When the plane
flew, it was also human.

Basic Elements of Human Factor The human factor is divided into two major groups that are always involved in every accident: 1. Usually occurs in very routine work and is too familiar to a crew (a start procedure that is "out of the head" or doing other routine things). Also included in this category is excessive confidence (over confident).  Inadequate defenses. These defenses can be publications (manuals / technical or operational manuals). baggage officers and so on).  Action slips. malfunctioning tools or equipment or violation-producing factors such as local regulations that may be considered too cautious (over cautious). with minimal knowledge and skills. among others:  Memory lapse. the consequences can be fatal. Remember the accident  Expertise. which includes working environment conditions. An organization or a management always has a leader or manager. The above factors are the general classification of so many icons involved in an aviation accident. The conditions included in the group of unsafe conditions include:  Organizational failures. work supervision and professionalism. .  Local factor. discipline culture. ATC operators. The policy of a manager or leader always has a significant influence in the guidance of safety in an organization. We can see. the human factor is always there. lack of equipment or lack of procedures used. If a job is done by people who are not qualified. The neglect of remembering this can happen when a person's flight does something unplanned. Unsafe Actions. Environmental factors (unsafe conditions) clearly play an important role against these unsafe actions. These local factors can be error-producing factors such as low quality. That is the importance of placing "the right man on the right place" in the aviation (business) world. Unsafe actions are categorized as active failures by aviation operators (not just pilots. so that the planned things are missed. which can prevent the occurrence of human errors or technical errors. This failure results from policies and actions taken by the organization or management. however there are internal factors in the human self itself that can also contribute to this active failure. in each group. Unsafe Conditions. but also technicians.

When there is openness between field personnel and managers. In a transport plane for example. On land. It is generally accepted that a good work environment. but also not good to let subordinates do their own volition. "Good" means pointed and balanced. by looking at aspects of the interests of the organization as a whole (financial strength. corporate management (institution) also has a significant effect. 2. neat and comfortable will make anyone in it work calmly. forward orientation and so on). including: As much as possible to meet the needs of subordinates. Sometimes a leader has an exaggerated fear of subordinate discipline. the result can be fatal. What Can We Do? The way out of this human factor problem is the promotion of good human resources. Any work achievement can be guaranteed to be good in this kind of work environment. Similarly. so regulations are issued that give too many restrictions to subordinates that result in subordinates tending to harbor their personal problems. There are flight engineers who are responsible for the in-flight technical system. for example a pilot who does not give the engineer confidence so that interfere with the authority of the engineer. especially in financial terms. rights such as health benefits. Strive to have adequate work equipment both in terms of quantity and quality. the crew can fly calmly and with concentration. The fulfillment of such rights at least helps them to minimize their problems. or excessive restrictions (not allowed leave. if an engineer does not give any advice to the pilot when there are technical problems in flight. Convenience of work can be created in various ways. expertise to holiday allowances (THR) and salary. the flight always forms a management. It is not good to curb subordinates with too binding regulation. there is no small place for a fault in the aviation world! Good management must run a balanced mechanism of persuasiveness and command. There must be .  A flexible "defense" form. Similarly. etc. of course. If there is no good management. Starting from the smallest structure (in a flying plane).) then the impact can be carried away when the subordinate has to fly or do work on the plane. Remember. Allowing such a thing is the same as storing a time bomb that will one day explodee. these things must be done by anyone who wants to be involved in the aviation world:  Create good management. On a more practical level. if a subordinate gets too much pressure (completing a job with a short dead time). there is a Captain Pilot as a flight leader. Conversely.  Sensitive to your environment. Do not make regulations that override the rights of subordinates. Then there was Copilots as his chief aide.

We go back to the fridge. In "Threat and Error Management" there are several levels of "negligent" or "error". A few steps before reaching the refrigerator. you are entitled to demand that they perform obligations as subordinates (entering work and home on time and others). They are trained to assess the quality of the mechanics work in the field. we are talking and acting towards people around us. open the door and look at the contents of the fridge and we "forgot" want to take what ya? It's an accidental type of forgetting when it was intended to take a drink. strong and tough consequences against each violation. If as a leader you have felt fulfilled all their rights. Is this kind of "negligent" punishable? . you are entitled to demand maximum performance from them. LAPSE It is an "accidental" type of neglect of "forgetting" something or action. you must trust the inspectors you have. is a failure of the organization. the problem of human factors is not solely about human individuals. Good Management = No organizational accident As long as the unsafe conditions we can remove. neat and directed to be able to "humanize human" so that the goal we want to achieve the success of aviation mission-and aerospace mission broader-we can make it safely. In terms of work. Similarly. no matter how minor. This is a form of sensible 2-way relationship within an organization. Responding to the problem of human factor. For that. Lederer. the first director of the Safety Bureau of Civil Aeronautics Board USA that "an accident. we are thirsty and intend to go to the fridge to get a drink. but rather the system in which the "human" is. This is because good management can guarantee the fulfillment of the moral and material needs of each individual in it. In the aviation world. then we also have eliminated the possibility of emergence of unsafe actions. For example. it needs a good management. It is true that what was delivered by Jerome C. so they will have the motivation to provide the best for the institution where they work. we hear there is a falling object in the kitchen "praaaang" a plate fell.

MISTAKES This is an "accidental" misconduct " If anyone is asked 2 times 2 equals 6 or 2 plus 2 it says equals 6 then most likely the cause is that during the lesson he did not really notice it in the classroom. Is it true that such a lame person will be punished? In the science of aviation safety. Suddenly the traffic lights turned green and the impatient driver's horns began to bounce. What needs to be done? If anybody lacks understanding of the job then the solution is to put it back in the classroom or repeat the training. What is a good answer for the boss later in the office so the boss is not angry? I took shampoo and started to soap the body with shampoo. A less common but can happen.SLIP Inadvertent "inadvertent" does not take action or negligent in action (omit in action or ommitted action). Another example. I turned left following this beautiful little lady. It's a routine human activity that automatically no longer needs to be memorized because it's routine and simple. water shower was flushing the body and the next sequence to soap the body. I intend to turn right at an intersection. a beautiful and fantastic woman crossed the street. not punish it because we may be wrong not to teach it well or not provide adequate training. but simply forget because the focus of their attention is being distracted by other things. the two "negligence" above should be followed up by being "reminded" rather than punished for the fact that they are not stupid or untrained actors. My eyes follow the path of the woman who passed me in front of me. I neglected to turn left although initially intended to turn right. I was bathing. This is the one whose name was inadvertently misbehaved. For a moment I remembered the task of the boss that yesterday afternoon has not been completed. When the memory process is "destruction" something else then the whole or part of the thinking process is also disturbed. the sign lights have twinkled me on a sign I will turn right. . Why do these three omissions occasionally occur? Because the process of working our brain in thinking work "serial" instead of "parallel". A moment later. For example.

one day I was convicted of being violated the Act. Both examples illustrate that his actions were "deliberate" but his violations were "inadvertently" Intentional Violation The violation that he knows that he violated and done consciously.VIOLATION The negligence is grounded by "deliberate" for violating. "yellow" and "red" "Green" lights are all very clear terms and procedures aimed solely at maintaining safety (and security) factors and I think this applies equally to all "sensitive" types of work on the safety factor. One day I was arrested by the authorities and declared wrong because he was a "wife" from another man. Unintentional Violation: Just for example. I never asked and this woman also never told me that she is org wife. . I am guilty of "breaking". we need to look deeper. anyone infringing should be punished. But because it was "enacted" then legally I remain wrong. . and I carefully broke through the red lights because I was afraid of being robbed of red axes if they stopped too long. I know violated but I had to do because a string of double trucks was left Violation is heavy: very easy to find the example itself. this is the lightest example. A Law or Rule that I never knew before. violations are also levels. I have "affairs" with a beautiful woman I just met a few months ago. But before. This is clearly a form of omission that differs from the previous form of omission (3 above). lonely streets. There were no cars. Violation of the infringement. I never knew before. there is already an "ethical code" where the terms "green". either know the contents or not. At midnight I stopped at the red light crossroad of "Coca-Cola" Cempaka Putih Scout. In the aerospace industry. . I overtaken from the left on the Toll Road or from the shoulder of the road. .

Then there is a series of procedures that fall into the category of "yellow light" ie abnormal procedures. yes the problem is over. The perpetrators of the violation with the above motives must immediately "remove" from his job. If nothing happens. why someone broke a rule or regulation even though he knew it was a violation. This is indirectly a group of procedures containing "bans" in which people are expected to commit no offense at all because the situation is very dangerous. . Then there is a series of "emergency" or "danger" procedures that require high degree of precision without being mistaken for people to be stuck in a chain of emergency. Usually this kind of procedure is summarized in various manuals. among others:  I am a hero!  I will show you that I can do better than other  I like something unusual  I hate everything around me  I know better than you Violation of this type is very fatal if ignored. Usually begins with a specific motivation. People also understand that if he violates the "red" sign. We also suspect people may be breaking the "yellow" sign. there is an accident or not. The procedure must be done carefully and carefully because the situation is less normal. But if there is a problem related to the offense then he knows that he can be punished. Various types of activities are well documented to be used during the work process in order to maintain the safety and security of aviation. in "delete" and directly in "empty" from "recycle bin". he can be directly punished. like a contagious virus. There is a lot of motivation. If one offender is silenced it will be transmitted into "culture" followed by others. In the aerospace industry (especially aviation safety sector) the solution for such violators is only one "destroyed" In fact I was the first person to "kill him".We expect all officers and people to do their work in "green" signs.

it is really a jail and not a hall of education) Meanwhile. but that is certainly not easy to "satisfy" all parties. "neglect" is a commonplace as a human limit that begins from accidental acts. the investigation of plane crashes is regulated by ICAO Annex 13 Aircraft Accident Investigation from various International Conventions aimed at understanding the root causes of accidents in order to make repairs not to repeat similar events. Besides the situation of patients and doctors is very complex that is rarely known to the public. Unfortunately. none of the plane crashes that begin with "motives" want to harm or make "accidents". If any physician is accused of malpractice.5 billion Rupiah Meanwhile. the "Fairness" and "Justice" is not easily disputed to obtain "equilibrum point" for all. . Remember. Perhaps a similar situation is faced by the medical profession. we should be careful. Although. rather than solicit for safety improvement and not for liability or to blame) I understand correctly. whether it is malpractice due to haphazard actions or just such omissions. then whether the pilot (and other personnel) need to be tried by civil courts? However. The perpetrator of the crime can be sentenced to death penalty. we also sometimes want to relieve it with the term "prisoners" or Penitentiary "(anyway.The conclusion: This is not an easy part of the "neglect" in the profession as meaningless "negligence" in the Criminal Code. will these perpetrators be legal? Note: there are already internal penalty and flight punishment punishments as set out in Law No. due to human negligence there can be victims died and seriously injured in plane crash. 1 of Flight 2009 with maximum 15 years imprisonment and / or a fine of 2. the Criminal Code is drafted with rules to punish offenders (and criminals) who are always preceded by "motives" for committing offenses or crimes.

In spite of the problem of "fairnes" and "justice". for example Terrorism. always combined "chain of errors") Without a factual motive will we try those involved in a plane crash? In my opinion. I am also worried about the "aviation safety system" in Indonesia getting worse if the perpetrators of the accused are prosecuted and the international world is getting "angry" because the Republic is not subject to conventions and ICAO Annex which has been ratified many member states of the United Nations. . Kidnap.The aviation industry is also supported by a very complex safety system. On the other hand I also want to convey that the perpetrator of the accident on the basis of "intentional violation error" or "professional negligance" to be punished so hard and banned operate an aircraft (but not imprisonment) Perpetrators of aircraft accident investigation should only law enforcement and didadili in civil court if indicated criminal offenses (with criminal motives). Bomb Threat. not even through the civilian courts investigated by the police. Suicide. Hi- Jack. only the obvious violations should be punished. It is not easy to find out the "cause" of an accident (even if met.