clearly; as situational awareness decreases, the risk of human error increases, with potentially deadly consequences.
Green recently addressed the Wright Brothers Chapter of the SAFE Association, a professional society of engineers and scientists concerned with safety and human performance.
He described how human error in mid-air collisions has driven changes to commercial and military aviation regulations.
The topic was timely, as the National Transportation Safety Board recently ruled human error as a factor in the October 2004 crash of American Connection Flight 5966 in Missouri, which killed 13 people and severely injured two others.
The board cited pilot fatigue and failure to follow cockpit procedures but also pointed to the airplane’s lack of a low-altitude warning system. Five months after the crash, regulators made that system mandatory.
"Many of the rules we apply in air traffic control, sadly, are written in the blood of other people’s failures," Green said.
A 1960s study cited human factors as the leading cause of aviation accidents. But not until 1981 did a major air carrier, United Airlines, put a human factors management program in place.
"Subsequently, crew resource management training, or CRM, was implemented to focus on aircrew dynamics, communications and leadership," he said.
CRM became mandatory for Air Force aircrews and controllers after an F-16 and a C-130 collided over Pope Air Force Base, N.C., in 1994.
The C-130 landed without incident, but the F-16 pilot ejected, and his aircraft crashed into a staging area where 24 Army paratroopers were killed.
Investigators blamed a chain of errors by civilian and military air-traffic controllers.