ABSTRACT
How could this happen? Why did this happen? Was the crew lax? Were they operating in a cavalier manner or were they simply so tired that they failed to think clearly? First of all, no one ever says they are going to have an accident. As a matter of fact, if you were to ask any pilot about the probability of him or her having an accident, what would you expect to hear? More than likely, you would be told they do everything to see that they never have one. In the case just relayed, the captain had an outstanding reputation and he was the one in charge, right? We also know that once you are a captain you believe with all your might that you will never let things like this happen, right? Would it be reasonable to assume that none of the above reasons is why this incident and near tragedy occurred? For that matter, how can anyone explain what happened? The simplest answer of all might be that they were simply performing as humans and humans err. After years and years of trying to prevent humans from making errors, a different approach is beginning to permeate the accident prevention efforts of the airline industry. These efforts include the concept that recognizes that humans will continue to make errors. What is needed is the design and
implementation of procedures and training that recognize that fact. Procedures and training designed to catch the errors before they escalate to a point where they result in a catastrophic conclusion.
