Loss of Control on the Ground - An Analysis by SERA Software
Keywords:
Human Error, SERA, Classification System, Flight 3054.Abstract
Due to increasingly reliable aircraft technology, equipment and material failures have become rare. Today, aircraft accident causes are primarily attributed to the human link in the system. The ability to investigate, classify and detect the human factors that cause incidents and accidents is thus vital to prevent their recurrence and for designing the logic to help prevent their propagation. The goal of this work is to analyze an accident which took place in Brazil, which included at least one human factor as a probable cause, and with the respective investigation already concluded by the authority. For this purpose the SERA software is used as a tool to investigate, analyze, classify and to prevent recurrences.
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Perda de Controle no Solo - Uma Análise pelo Programa SERA
RESUMO: Com o constante aumento da confiabilidade da tecnologia aeronáutica, as falhas que ocorrem devido a equipamentos ou materiais são cada vez mais raras e as principais causas de acidentes são atribuíveis, hoje em dia, ao ser humano. Assim, a habilidade para investigar, classificar e detectar os fatores humanos, que se encontram na origem de acidentes e incidentes, passa a ter importância central no esforço de se evitar recorrências ou ainda no estabelecimento de defesas, de modo a impedir que os "erros humanos" se repitam ou se propaguem. O objetivo deste trabalho foi analisar um acidente ocorrido no Brasil, onde houvesse pelo menos um fator humano como uma das hipóteses prováveis para o acidente, e, cuja investigação já tivesse sido concluída pelo órgão investigador. Foi escolhido o programa SERA (Systematic Error and Risk Analysis), uma ferramenta que é utilizada para investigação, análise e classificação de erros humanos em acidentes aeronáuticos e, portanto, tornando possível a prevenção das recorrências destes erros.
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PALAVRAS-CHAVE:
Erro humano, SERA, Sistema de Classificação, Voo 3054.
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