Where is the Evidence?

[Antun Rehak <antun.rehak@dina.hr>]

It is good question "what caused the pilot error" because it is not so
easy to understand what is in human resources system problem and what is
human part of the problem. There are two articles good for anyone who
want have more explanation about problem caused by people and what is
problem caused by system:

	" Human and Organisational Error as a Basis for Process
Reengineering: With Applications to Systems Integration Planning and
Marketing", Jose M. Nieves and Andrew p. Sage, Life Fellow, IEEE, vol.
28. No. 6 November 1998.
	" Managing Human Error in Aviation", Robert L. Helmreich,
Scientific American, may, 1997

Let see what is in the second article:
" The research showed clearly that more than 70 percent of airline
accidents involved some degree of human error. More surprising was that
most of these errors stemmed from failures in communication, teamwork
and decision making rather that from technical shortcomings.

The airline industry was shocked to realise that well-trained and
technically proficient crews could crash airworthy craft because of
failures of human interaction and communication- areas in which neither
training nor formal evaluation was required by the Federal Aviation
Administration (FAA) or any other country's aviation regulatory agency.

The realisation led to the development of programs - collectively known
as crew resource management, or CRM for short - that target the team and
leadership aspects  of piloting an aircraft".
The system problem is no such kind of programs. 

For me it is not necessary to have evidence for Deming's 98:2 or Juran's
85:15 percent. It is important that I will not make mistake if I will
try to solve the problem first of all with improving the system.
Tony
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