ANÁLISE DO ACIDENTE DO P-51D NA INGLATERRA EM 2017 PELOS CONCEITOS DE ERGONOMIA COGNITIVA
ANALYSIS OF THE P-51D ACCIDENT IN ENGLAND IN 2017 USING COGNITIVE ERGONOMICS CONCEPTS
ANÁLISIS DEL ACCIDENTE DEL P-51D EN INGLATERRA EN 2017 POR EL CONCEPTOS DE ERGONOMÍA COGNITIVO
Matheus Prim Markoski dos Santos, Luis Felipe Tarle Magalhães, Victor Ishizuca Teles, Alexandre Fonseca Póvoa da Silva
Resumo
Em 2017, após falhas intermitentes no motor durante sua apresentação no show aéreo de Duxford, Inglaterra, o piloto do P-51 Mustang precisou fazer um pouso forçado em uma fazenda próxima à pista de pouso, ocasionando danos apenas à aeronave e sem vítimas. Acidentes aéreos são costumeiramente analisados sob o ponto de vista da ergonomia cognitiva, buscando elucidar os aspectos que, normalmente, provocam ou contribuem para o erro humano. Entretanto, pode-se destacar que as ações do piloto neste acidente, na maior parte, funcionam como bons exemplos dentro dos conceitos de ergonomia cognitiva. A partir desses conceitos, com base na revisão bibliográfica a respeito de desempenho e erro humano, atenção, observação de operações em cabines de pilotagem e em salas de controle de centrais nucleares, os autores analisaram reportagens, as lições aprendidas e dois vídeos do acidente, disponíveis na internet.
Palavras-chave
Abstract
In 2017, after intermittent engine failures during his performance at the air show in Duxford, England, the pilot of the P-51 Mustang had to make a forced landing on a farm close to the landing strip, causing damage only to the aircraft and without casualties. Air accidents are usually analyzed from the point of view of cognitive ergonomics, seeking to elucidate the aspects that normally cause or contribute to human error. However, it can be highlighted that the pilot's actions in this accident, for the most part, function as good examples within the concepts of cognitive ergonomics. Based on these concepts, based on the literature review regarding performance and human error, attention, observation of operations in cockpits and control rooms of nuclear power plants, the authors analyzed reports, lessons learned and two videos of the accident, available on the internet.
Translation version DOI: https://doi.org/10.4322/rae.v15n2.e202110.en
Keywords
Resumen
En 2017, luego de fallas intermitentes en el motor durante su actuación en la feria. vuelo desde Duxford, Inglaterra, el piloto del P-51 Mustang tuvo que realizar un aterrizaje forzoso en una granja cercana a la pista de aterrizaje, causando daños sólo a la aeronave y sin víctimas. Accidentes aéreo ellos son habitualmente analizado bajo el punto de vista desde ergonomía cognitivo, búsqueda dilucidar tú aspectos qué, normalmente, provocar o contribuir a el error humano. Sin embargo, se puede resaltar que las acciones del piloto en este accidente, en su mayor parte, funcionaron como buenos ejemplos dentro de los conceptos de ergonomía cognitiva. A partir de estos conceptos, con base en revisión bibliográfico el respeto de actuación y error humano, atención, observación operaciones en cabinas y salas de control de centrales nucleares, los autores analizado informes, hacia lecciones aprendió y dos vídeos de accidente, disponible en Internet.
DOI de la versión traducida: https://doi.org/10.4322/rae.v15n2.e202110.es
Palabras clave
Referencias
AAIB (Air Accidents Investigation Branch). (2017, 12 de outubro ). Boletim EW/G2017/07/06.
Air Safety Institute. (2018). P-51 Engine Out, Off-Airport Landing - full analysis [Vídeo]. YouTube.
Airscape. (2019, 4 de janeiro). Valuable lesson. AirScape Magazine.
Bainbridge, L. (1983). Ironies of automation. In Analysis, design and evaluation of man– machine systems (pp. 129-135). Pergamon.
Barker, D. (2018). Air show accidents & incidents 2017. World Airnews.
CC, Creative Commons. (202?). Atribuição-NãoComercial 2.0 Genérica (CC BY-NC 2.0).
Departamento de Defesa dos EUA. (2012). MIL STD-1472G: Design Criteria standard human engineering. EUA: DoD.
Fitts, P. M., & Jones, R. E. (1947). Analysis of errors contributing to 460 "pilot-error" experiences in operating aircraft controls. AAF Air Materiel Command Memo Report TSEAA-694-12, Dayton, Ohio, 2(9).
Gaver, W. W., Smith, R. B., & O'Shea, T. (1991). Effective sounds in complex systems: The ARKola simulation. In Proceedings of the SIGCHI Conference on Human factors in Computing Systems (pp. 85-90).
Hirschman, D. (2018,17 de maio). Inside a P–51 engine-out, off-airport landing. Air Safety Institute, EUA.
High Flight. (2017). Skilful Emergency Landing - P51 Mustang 'Miss Velma' - Flying Legends 2017 [Vídeo]. YouTube.
Hutchins, E. (1995). How a cockpit remembers its speeds. Cognitive Science, 19(3), 265-288.
Kelly, D., & Efthymiou, M. (2019). An analysis of human factors in fifty controlled flight into terrain aviation accidents from 2007 to 2017. Journal of Safety Research, 69, 155-165.
Klein, G. (2008). Naturalistic decision making. Human Factors, 50(3), 456-460.
Latorella, K. A. (1999). Investigating interruptions: Implications for flightdeck performance. NASA.
Leonard, A. (2017, 8 de julho). TF-51D 'Miss Velma' (G-TFSI).
Lower, M., Magott, J., & Skorupski, J. (2018). A system-theoretic accident model and process with human factors analysis and classification system taxonomy. Safety Science, 110, 393-410.
Mumaw, R. J., Roth, E. M., Vicente, K. J., & Burns, C. M. (2000). There is more to monitoring a nuclear power plant than meets the eye. Human Factors, 42(1), 36-55.
Orasanu, J., & Martin, L. (1998). Errors in aviation decision making: A factor in accidents and incidents. In Proceedings of the Workshop on Human Error, Safety, and Systems Development (pp. 100-107).
Rasmussen, J. (1983). Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models. IEEE Transactions on Systems, Man, and Cybernetics, (3), 257-266.
Reason, J. (1990). Human error. Cambridge University Press.
Shappell, S. A., & Wiegmann, D. A. (2000). The human factors analysis and classification system--HFACS.
Smithsonian. (202?). North American P-51D-30-NA Mustang.
Wickens, C. D., & Flach, J. M. (1988). Information processing. In E. L. Wiener & D. C. Nagel (Eds.), Human factors in aviation (pp. 111-155). Academic Press.
Wickens, C. D., Hollands, J. G., Banbury, S., & Parasuraman, R. (2010). Engineering psychology and human performance (3a ed.). Prentice Hall.
Woods, D. D. (1995). The alarm problem and directed attention in dynamic fault management. Ergonomics, 38(11), 2371-2393.
