Accidents: Deviations from plan

Synopsis: A combination of random factors contributes to disaster happening - or being averted.


We tend to believe that forces beyond us control disasters. They happen following Murphy’s Law that everything that can go wrong, does. And, the people affected survive only by luck or chance.

Unexpected events

Disasters grow out of unexpected events interrupting or interfering with routine proceedings. They precipitate deviations from planned behaviour that invoke risks.

For example, the now-famous American Airways airliner 15(4)9 took off on a routine flight from La Guardia Airport, with about 156 people on board.

The flight path, however, crossed that of migratory birds. The plane collided with a flock of geese, within minutes of take off. Bird-hits are said to cost the American aviation industry up to 600 million USD annually.


Water rescue

The event caused both engines of the plane cut out, preventing its return to land. Using the icy waters as the only accessible runway, the captain ditched the plane into the Hudson River.

The most impact passengers suffered were being thrown against the seat ahead. The plane also stayed intact and level in the water, so they could clamber out onto the wings and floating door.

But experts say even five minutes’ exposure in those freezing temperatures would still have caused severe hypothermia if not fatalities.

Responders speeded up the rescue process, even driving an inflatable boat onto the plane’s wing. Paramedics found one passenger had broken legs and others with less serious injuries. Everybody, including an infant, survived the ordeal.

Random factors

The bird-hit damage raised the potential of disaster. But the skill and presence of mind of the aircrew and first responders on the ground made it a miraculous escape instead.

Not one isolated event, but a combination of random error factors contributes to disaster happening - or being averted. These include:

• Situational factors like atmospheric conditions
• Individual factors like perception, cognition and physiological responses of people
• Specific personal factors like vision, age, experience, perceptual style and perceptual-motor relationships
• Psychological qualities of the people involved

The Hudson miracle wasn’t all due to providence. While situational factors were the driving forces for disaster, the human factors - individual, personal and psychological - of key people withstood their power.

Processing state

The pilot, an airways safety consultant, former fighter pilot and commercial pilot for nearly three decades, also had extensive glider experience. He glided the plane onto water so it didn’t break up on impact. Since 9/11, ground rescue workers have trained long and hard at disaster management in different scenarios. Their combined competencies ensured that all aboard the ill-fated liner disembarked safely.

Every industry invests in safety, putting precautionary barriers especially in hazardous job situations. But the mere presence of procedures doesn’t guarantee safety. Each procedure also has inherent weaknesses or ‘blind spots’ whereby it only works under certain conditions, or up to a point.

Bridging the gap between the plan and reality needs creative thinking. It also depends upon individual ‘processing state’ – functioning at full alert to expect the unexpected, or multitasking on autopilot with attention divided.

Cont’d 2…The human factors