Human Error A Matter Of Life And Death

Captain Tim Lancaster’s ashen face was white as a ghost. His eyes were wide open, as sub zero wind raced past his face at 240km an hour. The top part
03 Jun 2015 08:00
Human Error A Matter Of Life And Death
Prime Minister Voreqe Bainimarama inspects the FMA’s state of the art simulator to offer hands on experience learning for students.

Captain Tim Lancaster’s ashen face was white as a ghost. His eyes were wide open, as sub zero wind raced past his face at 240km an hour.

The top part of his body was numb; the other half of his body was inside the cockpit of the BAC 1-11 aircraft he had been flying a few minutes before.

Flight attendant Nigel Ogden was desperately hanging on to his legs preventing the captain and he from being sucked out of the cabin altogether. Freezing wind raged through the open hole creating frost bite, bruising and exhaustion but Ogden held on.

In the cockpit the sound was deafening with the loss of cabin pressure. The co-pilot Alastair Atchison was desperately trying to regain control of the plane which was now spiraling. The British Aircraft Corporation 1-11 series 5390 plane was in this dilemma because a newly fitted left windscreen had just blown out after taking off.

What was the cause of this 1990 incident?

The maintenance man who fitted the window had used the wrong bolts to secure the window to the fuselage. It was only 1/16th of an inch smaller than the one specified in the maintenance manual but was good enough to cause an incident involving many lives.

Assisted by a minor miracle and courageous endurance the co-pilot Atchison managed to land the plane safely on the unfamiliar Southampton Airport.

Amazingly, Captain Lancaster, after 21 minutes of being exposed to freezing elements, lived to tell the tale and fly again.

Human error a major contributor

Statistics shows that human error is a major contributor to accidents and incidents involving ships and aircraft.

It well known that is impossible to totally eliminate the human factor in accidents. Concerned parties such as the International Maritime Organization (IMO) have introduced a few improvements in form of regulations and others in education and training.

Although  The Japanese 5S system is not an IMO innovation, SERI (Sort) SEITON (Straighten) SAISO (Sweep) SEIKETSU (Standardize) SHITSUKE (Sustain) is one example of avoiding a wrong part being used as in the case of that windshield bolt, an unsuitable bolt would not have been used in that job.

The 5S system prides itself with proper labeling and sorting that only the correct equipment will be available so that even a tired sleepy maintenance man cannot pick the incorrect part.


In ship repair and maintenance there are many pitfalls due to human error and negligence.

Fatigue is a major concern among the in a 24 /7 operation such as operating vessels at sea. To avoid human error caused by fatigue, IMO has introduced the sleep/rest record keeping system.

The system ensures that seafarers get enough rest before and after duty. Records are monitored by administration who can administer serious penalties to vessels which do not comply. The writer can remember being called out to rescue a vessel in which the engine room crew removed a pipe leading to a ballast tank, thus filling half the engine room with sea water.

The cause? Human error

A study of the piping system and risk assessment of the job in hand could have avoided that “near miss”.

At Fiji Maritime Academy (FMA), the curriculum includes training the students to study the systems thoroughly before opening up for maintenance.FMA is fortunate we to have the assistance by a state of the art marine simulator to offer hands-on experience.  FMA teachers also vigorously reinforce the importance of safety in working practices in the industry.



Fiji Sun Instagram
Fiji Plus