> Criminalizing Aviation Accidents Only Assures Repeats
> Brazilians Shouldn't Prosecute Humans for Being Human
>
> By JOHN NANCE
>
> Dec. 7, 2006- - On the clear, late afternoon of Sept. 29 , two
> sophisticated jets approached each other along an airway known as UZ6.
> Their combined speed was in excess of a 1,000 miles per hour. Both were
> at 37,000 feet over the Amazon jungle, and neither set of pilots were
> aware of the other.
>
> No alarms went off. No air traffic control warnings were given. And no
> rules were broken because both crews had climbed to their assigned
> altitude.
>
> In a micro-second, the left, upturned "winglet" of the brand-new Embraer
> Legacy 600 business jet sliced into the left wing of the Boeing 737. The
> Embraer's pilots knew only that an explosive force of some sort had
> rocked them, and that they now had a marginally controllable airplane.
>
> For the pilots of the commercial airline flight known as Gol 1907,
> however, the situation was far worse. Their essentially new Boeing 737
> was becoming uncontrollable. As the business jet they'd hit limped
> toward an emergency landing, the 737 impacted the dense forest below.
> All 137 people aboard died.
>
> Within hours of the crippled business jet's safe landing at an airfield
> just north of the collision point, the Brazilian government began
> investigating the accident with a painfully obvious emphasis on finding
> someone to blame, rather than finding an explanation for the tragedy.
>
> The passengers and owner of the damaged Embraer 600 -- held and
> questioned for 36 hours -- were eventually released.
>
> But even as another arm of the Brazilian government began to suspect
> that the crash had been nothing more than a tragic accident and not a
> result of any purposeful or negligent act by either set of pilots, an
> overzealous prosecutor was asking a Brazilian court for authority to
> confiscate the U.S. passports of the two American pilots.
>
> In the weeks afterward, Brazilian authorities confronted the truth --
> that their own air traffic controllers had made a massive human error by
> placing the two jets at the same altitude in opposite directions along
> the same airway.
>
> Yet no effort was made to present that evidence to the court and release
> the crew. Instead, the two American pilots -- both personally devastated
> over the loss of the 737 -- found themselves threatened with prosecution
> for 137 counts of manslaughter.
>
> Beyond the outrage that Brazilian officials have richly earned, Brazil's
> willingness to criminalize an aviation accident also dealt a serious
> blow to aviation safety worldwide. Why? Because most air accidents
> result from unintended human mistakes, and the only way we find out
> about such mistakes, and give ourselves the chance to change our human
> systems in order to prevent further incidents, is by asking surviving
> crew members to speak openly.
>
> But, if telling the truth about your own errors may land you in prison
> and ruin your life, who in their right mind would rush to give a
> prosecutor information that could be used against you? The result is
> that the mere threat of criminal prosecution for mistakes made in the
> cockpit (or the maintenance hangar or the control tower) utterly shuts
> down the flow of vital safety information we need.
>
>
> When a pilot flagrantly disregards rules or procedures or instructions
> and knowingly puts his or her passengers and the public below at risk,
> it's "pilot error."
>
> When a pilot fails because he or she is human -- failures such as
> starting a takeoff on a runway clearly too short to sustain flight (such
> as in Lexington, Ky., earlier this year) -- the problem is "human
> error." The two are markedly different.
>
> Human error problems account for more than 85 percent of all aviation
> accidents. Disasters often result from pilots being imperfect, making
> mistakes despite their best efforts. Blaming humans for being human is
> at once absurd and wholly ineffective in preventing accidents.
>
> The best way to prevent the same human errors from happening in the
> future is to understand everything we can about how the system supported
> the error, and then change that system to safely absorb such errors.
>
> Criminal prosecution of pilots for making human errors only shuts down
> the flow of information we need to get even safer; it does nothing to
> prevent recurrences.
>
> This does not mean that a pilot who purposefully does something unsafe
> (such as drink and fly) should not be held criminally liable. Subjecting
> such fringe-element airmen to prosecution in no way worries the 99-plus
> percent who would never do such things.
>
> But equating human mistake with crime, as some nations have tried to do
> too often over the years, is a trend that must be stopped cold.
>
> As the internationally respected Flight Safety Foundation said just this
> week in a joint resolution issued in response to Brazil's outrageous
> behavior: "...criminal investigations and prosecutions in the wake of
> aviation accidents can interfere with the efficient and effective
> investigation of accidents and prevent the timely and accurate
> determination of probable cause and issuance of recommendations to
> prevent recurrence."
