A falha humana como fator desencadeador de ocorrências aeronáuticas

Abstract

This research aims to expose how CRM good practice can positively influence the aeronautical decision-making process and, in effect, air safety. The text presents the models / theories focused on the analysis of human elements and the different types of errors – Shell and Reason models –, as well as CRM approach as one of the main solutions for air safety, from the junction of the so-called “human”, “technical” and “operational” factors, suggesting an interrelation between these factors. Human failures are cited as the main factor in most aeronautical incidents and accidents (80% of them), while 15% to 20% involve equipment failures and maintenance errors. To verify the applicability of the theoretical aspects, the research starts from the study of two cases of accidents, the one that occurred with Varig's RG-254 flight, in September 1989, and with the Qantas 32 flight, in November 2010. The study case study analyzed information from official investigations, publications, audiovisual material about accidents, which, in the first case, detected serious human flaws, in which cognitive and behavioral skills were not used, while in the second case, good CRM practices were applied , which caused the events to have totally different outcomes. Teamwork, communication and assertive decision-making in managing the threats and risks faced in the case of Qantas 32 were explored in the research. From these analyzes, it was possible to formulate a critical assessment of the performance of the management process and its influence on the final result of accidents or incidents.