Identifying links in an error chain

Aircrew Coordination Training

ACT-01

Mishaps seldom are caused by one factor, but rather by a chain

of events that cumulate in a mishap/incident

By breaking one link, mishap/incident may be avoided

Easy to find AFTER mishap, often hard to detect as they occur

Eleven clues to help identify:

Presence does not mean mishap/incident will occur

Rather, presence indicates risk in operating aircraft is

rising, and crew must maintain proper control through use

of all resources

Error chain clues:

No one flying the plane or monitoring the current state of

progress

No one looking out of the window

Ambiguity exists anytime two or more independent sources

of information do not agree--gauges, people, senses,

throttle position that does not agree with power indications,

and so on

Distraction/preoccupation--the focusing of attention on any

one item to the exclusion of all others

Confused or empty feeling--a sense of bafflement,

uncertainty

(1) Often evidenced by physiological systems

(2) “When the little people start talking to you”

Use of any undocumented procedure--does the crew using

procedures not prescribed in NATOPS/SOPs have a

thorough understanding of the problem

Violating limitations/regulations

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