| Reliability, safety, and a burned out light bulb |
Lack of “situational awareness”
leads to accidents.
contributed by John P. MacLean, Orem, Utah
If the dome light in our car burns out, most of us don't trade the
vehicle in. We don't think of it as a reliability problem because
we are still on the road.
However, a small thing like a failing light bulb has been known
to have tragic consequences.
Several years ago, a United Airlines flight was preparing to land
in Portland, Oregon. United's Chief Pilot was at the controls—the
man perceived as the best trained, most conscientious, most expert
pilot in their employ. The plane carried the normal complement of
co-pilot and flight engineer. The engineer was not nearly as experienced
as the pilot and was likely a little intimidated by his captain.
As they began their approach, they threw the switch that would lower
the landing gear or wheels. A light that was supposed to come on
to tell them that the gear was locked in place didn't light up.
They then did what pilots call a fly-round while they tried to figure
out if the wheels had failed to come down, or if it was just a burned-
out bulb. Several times the flight engineer made a timid remark
to the busy captain; something to the effect of, "Uh . . .
Captain, . . . we don't have too much fuel left." Each time
the captain brushed him off, saying that he had things under control.
In a short while the pilots were amazed when their engines quit.
That's not a good thing several thousand feet up in the air. They
landed in a forest. Some survived as there was no fire. No fuel
to burn.
The captain should have listened. Maybe the engineer should have
yelled, "Captain, we have 3 minutes of fuel left! Get this
#%@& thing on the ground."
What caused the accident? Equipment failure? The burned-out light
bulb? It's hard to tell after you land in a forest. You could
also point to a process failure. There was a process in place for
monitoring fuel levels, but monitoring is of no avail if humans
do not take cognizance of the information.
The immediate cause was the captain's lack of "situational
awareness". Most lost-time injuries and deaths are like that.
A hazardous condition or a system failure is not usually enough
on its own to cause an accident. In looking for the cause of a workplace
injury or death we can almost always point to several interrelated
factors.
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