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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. Unsafe Conditions. The conditions included in the group of unsafe conditions include:
 Organizational failures. This failure results from policies and actions taken by the
organization or management. An organization or a management always has a leader or
manager. The policy of a manager or leader always has a significant influence in the
guidance of safety in an organization.
 Local factor, which includes working environment conditions, lack of equipment or lack
of procedures used. These local factors can be error-producing factors such as low
quality, malfunctioning tools or equipment or violation-producing factors such as local
regulations that may be considered too cautious (over cautious).
 Inadequate defenses, which can prevent the occurrence of human errors or technical
errors. These defenses can be publications (manuals / technical or operational manuals),
discipline culture, work supervision and professionalism.

Unsafe Actions. Unsafe actions are categorized as active failures by aviation operators (not
just pilots, but also technicians, ATC operators, baggage officers and so on). Environmental
factors (unsafe conditions) clearly play an important role against these unsafe actions,
however there are internal factors in the human self itself that can also contribute to this
active failure, among others:

 Memory lapse. The neglect of remembering this can happen when a person's flight does
something unplanned, so that the planned things are missed.
 Action slips. 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). Remember the accident
 Expertise. If a job is done by people who are not qualified, with minimal knowledge and
skills, the consequences can be fatal. That is the importance of placing "the right man on
the right place" in the aviation (business) world.

The above factors are the general classification of so many icons involved in an aviation
accident. We can see, in each group, the human factor is always there.
What Can We Do?

The way out of this human factor problem is the promotion of good human resources.
"Good" means pointed and balanced. On a more practical level, these things must be done by
anyone who wants to be involved in the aviation world:

 Create good management. Starting from the smallest structure (in a flying plane), the
flight always forms a management. In a transport plane for example, there is a Captain
Pilot as a flight leader. Then there was Copilots as his chief aide. There are flight
engineers who are responsible for the in-flight technical system. If there is no good
management, for example a pilot who does not give the engineer confidence so that
interfere with the authority of the engineer, the result can be fatal. Similarly, if an
engineer does not give any advice to the pilot when there are technical problems in flight.
On land, corporate management (institution) also has a significant effect. When there is
openness between field personnel and managers, the crew can fly calmly and with
concentration. Conversely, if a subordinate gets too much pressure (completing a job with
a short dead time), or excessive restrictions (not allowed leave, etc.) then the impact can
be carried away when the subordinate has to fly or do work on the plane. Remember,
there is no small place for a fault in the aviation world! Good management must run a
balanced mechanism of persuasiveness and command.
 Sensitive to your environment. It is generally accepted that a good work environment,
neat and comfortable will make anyone in it work calmly. Any work achievement can be
guaranteed to be good in this kind of work environment. Convenience of work can be
created in various ways, including:

As much as possible to meet the needs of subordinates, of course, by looking at aspects of the
interests of the organization as a whole (financial strength, forward orientation and so on).
Strive to have adequate work equipment both in terms of quantity and quality. Similarly,
rights such as health benefits, expertise to holiday allowances (THR) and salary. The
fulfillment of such rights at least helps them to minimize their problems, especially in
financial terms.

2. Do not make regulations that override the rights of subordinates. Sometimes a leader has
an exaggerated fear of subordinate discipline, so regulations are issued that give too many
restrictions to subordinates that result in subordinates tending to harbor their personal problems.
Allowing such a thing is the same as storing a time bomb that will one day explodee.

 A flexible "defense" form. It is not good to curb subordinates with too binding
regulation, but also not good to let subordinates do their own volition. There must be
strong and tough consequences against each violation. If as a leader you have felt
fulfilled all their rights, you are entitled to demand maximum performance from
them. Similarly, you are entitled to demand that they perform obligations as
subordinates (entering work and home on time and others). This is a form of sensible
2-way relationship within an organization. In terms of work, you must trust the
inspectors you have. They are trained to assess the quality of the mechanics work in
the field.

Good Management = No organizational accident

As long as the unsafe conditions we can remove, then we also have eliminated the
possibility of emergence of unsafe actions. This is because good management can guarantee
the fulfillment of the moral and material needs of each individual in it, so they will have the
motivation to provide the best for the institution where they work.

It is true that what was delivered by Jerome C. Lederer, the first director of the Safety
Bureau of Civil Aeronautics Board USA that "an accident, no matter how minor, is a failure
of the organization.

Responding to the problem of human factor, we are talking and acting towards people
around us. For that, it needs a good management, 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 the aviation world, the problem of human factors is not solely about human
individuals, but rather the system in which the "human" is.

In "Threat and Error Management" there are several levels of "negligent" or "error".

LAPSE

It is an "accidental" type of neglect of "forgetting" something or action. For example; we are


thirsty and intend to go to the fridge to get a drink. A few steps before reaching the
refrigerator, we hear there is a falling object in the kitchen "praaaang" a plate fell. We go
back to the fridge, 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.

Is this kind of "negligent" punishable?


SLIP

Inadvertent "inadvertent" does not take action or negligent in action (omit in action or
ommitted action).

For example; I intend to turn right at an intersection, the sign lights have twinkled me on a
sign I will turn right. A moment later, a beautiful and fantastic woman crossed the street. My
eyes follow the path of the woman who passed me in front of me. Suddenly the traffic lights
turned green and the impatient driver's horns began to bounce. I turned left following this
beautiful little lady. I neglected to turn left although initially intended to turn right.

Another example, I was bathing, water shower was flushing the body and the next sequence
to soap the body. It's a routine human activity that automatically no longer needs to be
memorized because it's routine and simple. For a moment I remembered the task of the boss
that yesterday afternoon has not been completed. 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. This is the one whose name was inadvertently
misbehaved.

Is it true that such a lame person will be punished?

In the science of aviation safety, 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, but
simply forget because the focus of their attention is being distracted by other things.

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.
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, not punish it because we may be wrong not to
teach it well or not provide adequate training.

Why do these three omissions occasionally occur? Because the process of working our brain
in thinking work "serial" instead of "parallel". When the memory process is "destruction"
something else then the whole or part of the thinking process is also disturbed.
VIOLATION

The negligence is grounded by "deliberate" for violating.

This is clearly a form of omission that differs from the previous form of omission (3 above).

Violation of the infringement, anyone infringing should be punished.

But before, we need to look deeper, violations are also levels.

Unintentional Violation:

Just for example, I have "affairs" with a beautiful woman I just met a few months ago. One
day I was arrested by the authorities and declared wrong because he was a "wife" from
another man. I never knew before, I never asked and this woman also never told me that she
is org wife. I am guilty of "breaking". . . .

one day I was convicted of being violated the Act. A Law or Rule that I never knew before.
But because it was "enacted" then legally I remain wrong, either know the contents or not.

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.

this is the lightest example. At midnight I stopped at the red light crossroad of "Coca-Cola"
Cempaka Putih Scout. There were no cars, lonely streets, and I carefully broke through the
red lights because I was afraid of being robbed of red axes if they stopped too long.

I overtaken from the left on the Toll Road or from the shoulder of the road. 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.

In the aerospace industry, there is already an "ethical code" where the terms "green",
"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.
We expect all officers and people to do their work in "green" signs. Various types of
activities are well documented to be used during the work process in order to maintain the
safety and security of aviation. Usually this kind of procedure is summarized in various
manuals.

Then there is a series of procedures that fall into the category of "yellow light" ie abnormal
procedures. The procedure must be done carefully and carefully because the situation is less
normal.

We also suspect people may be breaking the "yellow" sign. If nothing happens, yes the
problem is over. But if there is a problem related to the offense then he knows that he can be
punished.

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. 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.

People also understand that if he violates the "red" sign, there is an accident or not, he can be
directly punished.

There is a lot of motivation, why someone broke a rule or regulation even though he knew it
was a violation.

Usually begins with a specific motivation, 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, like a contagious virus. 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". The perpetrators of the violation with the above
motives must immediately "remove" from his job, in "delete" and directly in "empty" from
"recycle bin".
The conclusion:

This is not an easy part of the "neglect" in the profession as meaningless "negligence" in the
Criminal Code.

Remember, "neglect" is a commonplace as a human limit that begins from accidental acts.

Unfortunately, none of the plane crashes that begin with "motives" want to harm or make
"accidents", will these perpetrators be legal?

Note: there are already internal penalty and flight punishment punishments as set out in Law
No. 1 of Flight 2009 with maximum 15 years imprisonment and / or a fine of 2.5 billion
Rupiah

Meanwhile, the Criminal Code is drafted with rules to punish offenders (and criminals) who
are always preceded by "motives" for committing offenses or crimes. The perpetrator of the
crime can be sentenced to death penalty. Although, we also sometimes want to relieve it with
the term "prisoners" or Penitentiary "(anyway, it is really a jail and not a hall of education)

Meanwhile, 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, rather than
solicit for safety improvement and not for liability or to blame)

I understand correctly, due to human negligence there can be victims died and seriously
injured in plane crash, then whether the pilot (and other personnel) need to be tried by civil
courts?

However, the "Fairness" and "Justice" is not easily disputed to obtain "equilibrum point" for
all, but that is certainly not easy to "satisfy" all parties.

Perhaps a similar situation is faced by the medical profession. If any physician is accused of
malpractice, we should be careful, whether it is malpractice due to haphazard actions or just
such omissions. Besides the situation of patients and doctors is very complex that is rarely
known to the public.
The aviation industry is also supported by a very complex safety system. It is not easy to find
out the "cause" of an accident (even if met, always combined "chain of errors")

Without a factual motive will we try those involved in a plane crash?

In my opinion, only the obvious violations should be punished, not even through the civilian
courts investigated by the police.

In spite of the problem of "fairnes" and "justice", 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.

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), for example Terrorism, Hi-
Jack, Bomb Threat, Kidnap, Suicide,