THE HUMAN ERROR
very experienced pilot tried to turn back to the airport he had just taken off from. The turn back was just over the end of the runway at about 150 ft of altitude. The aircraft stalled in the turn and he went straight into the ground at a 90 degree angle. It is impossible to make a 180 degree plus turn with no engine power with only 150 ft of altitude. So what was he thinking as he spoke his last words to the tower? They were: “I’m not going to make i…” Using our model, who made the split-second decision to return to the runway? It had to be the Child with the emotion of fear that wanted to go back where he would be Safe. The Adult realized, too late, that it couldn’t be done and told the tower what it realized. The final report had to say that the pilot was not mentally prepared for the sudden emergency. I am quite sure had the emergency occurred in a Boeing 727 (that he flew for an airline) the Child would have done what it was in the habit of doing in numerous simulator sessions and maintained airspeed as they landed straight ahead in open fields. I believe that the purpose of recurrent simulator training is to train the Child as the Adult, after thousands of hours of flying, knows what to do, but the Child will be the first to react and it will base its decision on emotion, ELDs and habit — not rational thinking. So, who is stronger? The Adult or the Child? The Child has the power to kill or to cure. PTSD, if untreated, will all too often, find a healthy person with a bright future committing suicide as the only answer to the problem. Another example is anorexic people who are starving themselves to death in order for things to somehow be right. You can
rationalize with them that they must eat or they will die, but the Child has greater control. Even with counseling less than 50 percent recover and approximately 20 percent die. However, the Child can cure as
well. I had a friend with terminal liver cancer who was doing very well buying wrecked aircraft and selling recertified parts off of them. Dying, he sold the business and as a last chance he went to the Philippines where a doctor removed the cancer with his bare hands as my friend watched. He returned cancer free and lived another 35 plus years. Who had to believe what I believe were bloody chicken guts and not his cancer? Only the Child does, so it certainly wouldn’t work for me. What can you do to make the best decision possible? The answer is very simple. Take that minute for Safety. Think with the rational Adult mind. Who is making this decision, and is it the right one? The Child has qualities such as ingenuity, creativity and intuition that can save the day, but be sure that the rational mind is making that final decision when all options have been explored. Never let the Child make an emotional decision without looking at the possible rational outcomes. The Child has way more negative emotions to work with than positive and emotions like anger, rage and frustration, to name just a few. Seldom do these have a positive outcome. They say that 70 percent of domestic murders are the result of jealousy, which makes it a very dangerous emotion to allow to control your decision. I hope that this model gives you food for though as it has me when I am able to realize that my Child is taking control of what I am doing
and my Adult mind can stop it before I do something that I’ll later regret. Get in the habit of talking to your Child. It can be persuaded to listen. Take just that moment to know who is making the decision and I promise you will be a Safer and likely happier person for it. It works for me.
* Editors note: Mr. Dupont refers to previous issues of D.O.M. magazine which articles on the specific human factors he is discussing here. If you don’t have copies of these issues and would like to read the articles, you can reference all of our back issues online at
DOMmagazine.com.
Gordon Dupont worked as a special programs coordinator for Transport Canada from March 1993 to August 1999. Prior to working for Transport,
Dupont worked for seven years as a technical investigator for the Canadian Aviation Safety Board (later to become the Canadian Transportation Safety Board). He saw firsthand the tragic results of maintenance and human error. Dupont has been an aircraft maintenance engineer and commercial pilot in Canada, the United States and Australia. He is the past president and founding member of the Pacific Aircraft Maintenance Engineers Association. He is a founding member and a board member of the Maintenance and Ramp Safety Society (MARSS). Dupont, who is often called “The Father of the Dirty Dozen,” has provided human factors training around the world. He retired from Transport Canada in 1999 and is now a private consultant. Visit
www.system-safety.com for more information.
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DOMmagazine.com | apr 2019
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