THE HUMAN ERROR
THE HUMAN ERROR I
’ve made all too many human errors in my 53 years in aviation, all while managing to survive and not kill anyone (that I know of). My name is Gordon Dupont and many know me as the
father of the “Dirty Dozen.” The “Dirty Dozen” are the contributing factors to you making a human error. They are certainly not the kind of siblings anyone would
want to have, but they will be part of the articles for which the D.O.M. team has very kindly provided space in this magazine. Sadly, I have seen way too many human errors as an accident investigator for the Transportation Safety Board of Canada. Statistics show that more than 80 percent of all aviation accidents are due to human error — but it wasn’t always that way. Human error has increased as an accident cause steadily
over the years. Why? We humans are not getting stupider or less caring, but we are getting much better at building more reliable aircraft and even “Murphy-proofing” them to help prevent human error. They often do this by replacing the human with “error proof” computers. That way nothing can go wrong, go wrong, go wrong.
Air France flight 447 over the Atlantic proved that things can still go wrong when the pitot tubes froze over for only 37 seconds, and in the three minutes it took to fall from 30,000 feet, the humans in the cockpit made a costly human error when they were unable to figure out what they were doing wrong. I would like to discuss what we can do to avoid the error we never intend to make in the articles to follow. My next article for the November/December issue of D.O.M. magazine will be titled “To Error is Human But Not With Aircraft.” If you have any thoughts or ideas on the subjects of human factors or safety that you would like me to write about, please communicate them to us. You can e-mail Joe at
jescobar@DOMmagazine.com and he will forward them to me, or you can email me directly at dupontg@
system-safety.com. I have a pet project that I feel strongly about and hope
that you will assist me with. The following article says it all and I hope that you will agree.
By Gordon Dupont, System Safety Services
Why Safety Deserves a Capital “S” H
ave you ever noticed that the names of people, cities, countries, months, days and important places all start with a capital letter? Titles, car types and
most abbreviations for words are honored with a capital letter. In short, we tend to use capitals to denote important words.
So why not a big, for all to see, capital “S” for Safety? The
only logical answer I can find is that it is not traditional to do so. If that is the case, then it’s time we updated the tradition. Why shouldn’t Safety have a capital S? It has never been so important as now with so many lives depending on it. I’ve given it a capital for years except when Microsoft Word drops it back down to a small s when my back is turned. I can remember not that many years ago, when Safety was for wimps or mama’s boys as they were called back then, because real men just used their common sense to survive
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won’t allow you to take a child home from the hospital without a Safety approved car seat.
and didn’t need silly Safety rules to dictate what they could or couldn’t do. Sure, some of those without common sense were killed, but it was survival of the fittest and good for the gene pool. Then, organizations like the Canadian Centre for Occupational Health and Safety (CCOHS) and the Occupational Safety and Health Administration (OSHA) began to make Safety rules. Please note that these Safety organizations were given capital letters, but not Safety unless part of the title. The FAA, CAA, ICAO, TC, etc. also got into the Safety
business and with regulations and rules untold thousands of lives have been saved, but no one thought to recognize Safety for the importance in saving lives that it deserves. Safety is an important factor in a person’s life. Today, they
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