Safety Expert Seeks Answers to 'Human Error' in Plane Crashes : Aviation: Psychologist's career devoted to learning why smart people--pilots, mechanics, controllers--do stupid things.

By CONNIE CASS

Jan. 2, 1994 12 AM PT

ASSOCIATED PRESS

WASHINGTON — People are prone to mistakes--we leave our headlights on when we park the car, we forget to turn off the oven--and the consequences are mostly minor. But for an airline pilot, forgetting to lower the landing gear can be a deadly mistake.

If to err is human, can humans ever be completely safe in the air?

John Lauber thinks so. He sees human error as the last frontier in aviation safety, waiting to be conquered.

Lauber, a psychologist, has devoted his career to learning why smart pilots--and mechanics and air traffic controllers--do stupid things.

As a member of the National Transportation Safety Board since 1985, he leads efforts to use that knowledge to compensate for human weakness, whether by designing better cockpits or adding backup safety systems.

From his office at the safety board, Lauber, 51, likes to watch planes float down toward the runway at Washington National Airport, just across the river. He expects them to land safely.

“The odds of being killed on a U.S. commercial jet are about one in 11 million flights,” Lauber said. But that’s not good enough.

His is a higher goal: eliminating all plane crashes.

Over the years, the jet engine has improved, computers do wonders, but there’s still the human factor. Since worldwide record-keeping began in 1959, almost two-thirds of major airline accidents have been blamed on flight crew error.

“We virtually never have ‘act of God’ accidents, caused by forces somehow beyond reasonable control,” Lauber said. “They are all controllable, manageable things we’re learning how to handle.”

Dec. 29, 1972: An Eastern Air Lines jet plunges into the Florida Everglades, killing 99 people.

The crew was distracted by a burned-out light on the instrument panel. As they tried to change the light bulb, the altitude hold on the auto pilot was accidentally shut off. The plane began to drop, but the pilot and co-pilot didn’t notice until it was too late.

“They were all concerned with this little 59-cent light bulb,” Lauber said. “They forgot to fly the airplane, and they crashed into the swamp.”

At the time, “human factors” study was in its infancy. Lauber was working on pilot training for the U.S. Navy, about to move to NASA’s Ames Research Center near San Francisco.

That crash was still seared in his mind when he arrived at the space administration. “That really triggered what we looked at,” he said.

Lauber led a research team that put airline crews--a pilot, co-pilot and flight engineer--in flight simulators for a series of mock emergencies. The way they worked together--or didn’t--was revealing.

“Some of them really worked as a cohesive team,” Lauber said. “Others were just a shambles, a three-ring circus with nobody knowing what anybody else in the group was doing.”

Researchers created a portrait of a successful flight team: a strong leader, good communication, clear priorities.

And they discovered problems that made some cockpit crews dangerous: lack of discipline, crew members overloaded with duties, co-pilots too intimidated to tell the captain when something goes wrong.

The scientists, carrying NASA’s clout, presented their findings to the airline industry at an international seminar in 1979.

“Up until ’79 there was no concrete scientific evidence that this was a major problem,” said Clay Foushee, a former Ames researcher, now vice president of flight operations for Northwest Airlines.

“The scientific evidence corresponded with people’s gut feeling,” Foushee said. “It was a tremendous ‘Aha!’ in the industry.”

Training methods that grew out of the Ames research--called Crew Resource Management--are now used by almost all airlines worldwide.

And the same training ideas have spread to ships and operating rooms and even into space, Lauber said, “beyond my wildest imagination.”

But human error marches on.

Aug. 16, 1987: A Northwest Airlines jet crashes on takeoff from Detroit. One child survives--the other 154 people aboard die, plus two on the ground.

Hours later, Lauber arrives with a crew of investigators who will look for clues in the charred debris on the runway. It is a bitter duty he shares with four other board members.

“The first impression is always one of just overwhelming destruction,” Lauber said. “The first reaction is horror.”

From wreckage, the investigators piece together the story of each accident--whether a plane crash, train wreck or pipeline explosion.

The safety board then rules on the cause and makes recommendations to federal regulators in hopes of preventing future disasters. The NTSB has no enforcement authority.

In Detroit, the cockpit voice recorder helped tell a classic story of flight crew error: The captain and co-captain forgot to set the plane’s wing flaps because they didn’t follow a required safety checklist before takeoff.

As a result, the safety board called for improved pilot training.

“There was a time, years ago, when the board saw the ‘human factors’ idea as excuses for incompetence and such,” said John Enders, vice chairman of the Flight Safety Foundation. “Without it, you could never tackle the real root of many accidents.”

July 19, 1989: Engine failure renders a United Airlines DC-10 virtually uncontrollable, forcing a crash landing at Sioux City, Iowa. Although 112 people die, 185 miraculously survive--and the crew members become heroes.

The pilot lost control when an explosion in the jet’s tail engine severed the hydraulic system, but the crew worked together to wrestle the plummeting plane toward the nearest airport.

They talked, they disagreed, but working as a team they gained crude control of the jet. The safety board said it was a testament to the crew’s NASA-inspired training.

For Lauber it was proof: “We are making a difference.”