The Human Factor plays a key role in the safety of complex systems, particularly in the aeronautical, nuclear and transportation sectors. The tragic Tenerife accident in 1977, involving two Boeing 747s and claiming 583 lives, is a perfect illustration of how an accumulation of human and organizational errors can lead to catastrophe.
Causes of the Tenerife crash
Several factors contributed to this major accident:
- Bomb attack at Las Palmas airport, forcing many aircraft, including those involved in the crash, to be diverted to Tenerife.
- Saturation of Tenerife airport, initially not designed for such heavy traffic.
- Lack of ground-based traffic surveillance radar, preventing precise visibility of aircraft positions.
- Adverse weather conditions with intermittent fog making visibility almost nil.
- Unusual workload for air traffic controllers, unaccustomed to handling such an influx of aircraft.
- The controllers were distracted by a soccer match on the radio.
- Crew stress, having to cope with long waits, unhappy passengers and operational constraints.
- Time constraints, as the aircraft are expected to operate other flights.
- Crew fatigue, exceeding regulatory and physiological limits after long hours in the cabin.
- The authority of the KLM captain, an experienced pilot and recognized instructor, whose decisions were difficult to challenge.
The importance of the Human Factor
This accident led to a growing awareness of the need to better understand and integrate the Human Factor into safety systems. It is no longer just a question of imagining that humans adapt to tools, but also of adapting tools to humans, by integrating concepts of cognitive ergonomics andUX design.
Following Tenerife, other high-risk sectors, such as military aeronautics, the nuclear industry after Chernobyl, and then the space, automotive, medical and rail industries, gradually adopted this approach to enhance safety.
A safety culture: a necessity
Statistics show that 80% of aviation accidents are due to human error.
Inaeronautics, the most critical phases remain take-off and landing, as well as the periods preceding and following them. However, humans are also capable of identifying and correcting 85% of errors within seconds.
This ambivalence underscores the need to create a working environment that reduces risk while optimizing human performance.
The evolution of human error has followed an inverse trend to the increasing reliability and complexity of technical systems. To mitigate these errors, companies need to integrate the Human Factor into their safety culture.
The Human Factor is also a performance driver
Taking the Human Factor into account not only improves safety, but also enhances company performance by applying Lean principles to the management of Human Factors:
- Reduce human error by simplifying processes.
- Implementation of checklists and best practices.
- Standardization and automation of critical tasks.
- etc.
Implementing a proactive approach: Using "Just Culture" to analyze mistakes and learn from them.
Conclusion
The introduction of Human Factors into aeronautical regulations, notably through PART 145, reflects a more global approach that has spread to various risk sectors. Understanding the human factor means rethinking safety and company organization to reduce errors and improve system resilience. The Tenerife accident remains a key reference point for illustrating this dynamic and the need for a paradigm shift in risk management.
Further information
At Axsens bte , we can help you develop your skills in this area with our Human Factor training course. This training will enable you to :
- Understand the fundamentals of human functioning at work,
- Acquire a safety culture,
- Identify contributors to incidents/accidents to initiate corrective action,
- Become aware of the Human Factor in your business,
- Learn to use simple risk analysis tools.
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