Airlines grapple to root out human error

Recurring cycle of mishaps points to deeper flaws, safety critics say

by Miya Tanaka

The airline industry and the transport ministry are trying to overhaul safety standards following a series of blunders involving commercial aircraft, but finding a quick solution will not be easy.

At least 13 of about 20 major problems revealed this year resulted from human error on the part of pilots, cabin attendants and mechanics, raising fears of a major crash, like that of the Japan Airlines jumbo jet in the mountains of Gunma Prefecture in 1985 that killed 520 people — the worst single-aircraft disaster in history. The crash was blamed on faulty repair work after the jet’s tail scraped a runway on an earlier flight.

“Flight crews have become nervous, fearful of repeating any blunder, but such a tense atmosphere is unhealthy because that could trigger other mistakes,” said Ken Mamba, a 43-year-old JAL captain.

Fortunately, none of the recent problems has caused severe injury or death. But safety problems are serious, particularly at JAL, where mistakes have been continuing despite a safety revamp the airline undertook in response to a March 17 improvement directive from the government.

On Jan. 22, a JAL pilot had to abort a takeoff roll at New Chitose Airport in Hokkaido because he had not been cleared by air traffic controllers to depart.

On March 16, JAL flight attendants forgot to demonstrate the emergency evacuation procedures to passengers before takeoff.

Other airlines have blundered as well. On June 5, for example, an All Nippon Airways plane was found to be flying 1,600 meters higher than instructed by controllers. The mistake was attributed to a number of factors — a malfunctioning altimeter, an erroneous assumption by the captain, and maintenance staff who failed to give him proper guidance.

Even air traffic controllers are not immune. In April, two planes were instructed to land on a closed runway at Tokyo’s Haneda airport when all 18 controllers on duty forgot it was closed.

Airplane experts and those in the trenches, however, say JAL and ANA have experienced similar spates of human error, which seems to show that neither the government nor the airline industry are taking safety seriously.

“The same kinds of trouble are repeated because the root of the problem has not been eliminated,” said Tomoki Kuwano, a former JAL captain who now directs the Human Error Laboratory at the Japan Institute of Human Factors.

The factors being studied in the airline industry are wide-ranging and include training, aircraft design and corporate management systems.

Research in this field has been drawing increasing attention since the ’70s, because studies show that human-caused problems, instead of mechanical ones, are responsible for many airline accidents, Kuwano said.

Flight crews were primarily responsible for 62 percent of the world’s commercial jet accidents involving fuselage loss between 1959 and 2003, according to a statistical summary published by Boeing Commercial Airplanes.

But Kuwano believes that humans’ share of the problems is larger than that because the remaining causes cited, including faults involving the airplane itself, may have been caused by mechanics or designers.

The 64-year-old former captain, however, said human error should not be reduced to pointing out the failures of individuals.

“In Japanese society, people often tend to sum up certain problems as resulting from an individual’s personal deficiencies, including a lack of safety awareness,” he said. “But in many cases, mistakes occur despite individuals doing their best, and other factors lie behind the trouble.”

A JAL union official, for example, suggested that flight attendants not take the sole blame for failing to explain emergency evacuation procedures, saying the carrier did not respond promptly to their complaints that a revision of the procedures in February had made them misleading.

JAL later scrapped the revision and went back to the original. “A similar case may not happen again, but that does not mean other problems will not happen, as long as the company maintains its attitude of not listening to what workers say,” the labor official said.

Kuwano said Japanese companies are generally reluctant to give serious consideration to solving problems related to human factors because this would significantly affect management policies, including streamlining and cost-cutting programs.

In June, the Land, Infrastructure and Transport Ministry set up a panel in the Civil Aviation Bureau to discuss measures related to human error and the government’s monitoring of airlines.

It will compile a report by the end of August.

But some analysts and airline workers doubt the panel can be independent enough to delve into governmental affairs, including deregulation, that have been criticized as undermining safety.

Taking a different approach, a Tokyo-based engineering and research organization has called on the government to encourage aviation workers to voluntarily submit reports on safety issues they have to promote information-sharing within the industry.

The group, the Association of Air Transport Engineering and Research, maintains a database on safety information. Although the group receives some 60 reports a year from domestic airlines, an official said they are just the tip of the iceberg.

“Understanding small risk factors would lead to a deeper analysis of Japan’s aviation system,” said Shozo Hirose, general manager of the association’s engineering department.

The government should establish a legal framework to protect aviation whistle-blowers from administrative penalties when they disclose blunders under certain conditions, he said, referring to systems already in place in the United States and South Korea.

In the face of public criticism, airlines have started taking additional steps.

ANA has launched a “communication project” at its flight operation division. The goal is to train flight crews to work as a team and improve communications and decision-making. But Shinichi Inoue, senior vice president of flight operations, admitted the training proved ineffective when one of its planes was found flying at the wrong altitude.

JAL held 220 emergency safety meetings in April and May to promote interaction between management and employees, admitting the carrier “lacked awareness of safety.”

But as Japanese airlines struggle to recover passengers’ trust, workers and unions remain pessimistic.

JAL should have a deeper sense of crisis about its safety problems, a JAL employee and former mechanic said, recalling the atmosphere at the carrier was much more acute following the ’85 crash.

Masahiro Takeshima, vice secretary general of the Japan Federation of Aviation Workers’ Unions, said: “The company seems to have forgotten what it learned from that accident, and I am afraid that airline companies will soon forget about what they have learned from the recent safety warnings.”