| Document ID (ISN) | 109528 |
| CIS number |
09-718 |
| ISSN - Serial title |
0003-6870 - Applied Ergonomics |
| Year |
2009 |
| Convention or series no. |
|
| Author(s) |
Rodrigues de Carvalho P.V., Gomes J.O., Huber G.J., Vidal M.C. |
| Title |
Normal people working in normal organizations with normal equipment: System safety and cognition in a mid-air collision |
| Bibliographic information |
May 2009, Vol.40, No.3, p.325-340. Illus. 40 ref. |
| Abstract |
A fundamental challenge in improving the safety of complex systems is to understand how accidents emerge in normal working situations, with equipment functioning normally in normally structured organizations. This article presents an analysis of a true case of a mid-air collision between a commercial carrier and an executive jet, in a clear afternoon sky in which 154 people lost their lives. The focus was on how and why several safety barriers of a well structured air traffic system failed, leading to the occurrence of this tragedy, without any catastrophic component failure, and in a situation where everything was functioning normally. |
| Descriptors (primary) |
analysis of accident causes; air traffic control; air transport; Brazil |
| Descriptors (secondary) |
safety engineering; human failure; human factors; cognitive performance |
| Document type |
D - Periodical articles |
| Country / State or Province | Brazil |
| Subject(s) |
Transport and communications
|
| Broad subject area(s) |
Physiology, ergonomics
|
| Browse category(ies) |
Air transportation
Accident research
|
