Erros humanos em situações de urgência: análise cognitiva do comportamento dos pilotos na catástrofe do voo Air France 447

Abstract

On June 1st 2009, the Airbus 330 of Air France that left from Rio de Janeiro to Paris, falls into the Atlantic Ocean killing 228 people on board. One of the causes of the accident mentioned by official agencies were the mistakes made by the pilots, which combined with technical failures led to the loss of control of the plane. Human error was again appointed as the last link in the chain of events leading to the accident and, therefore, as its immediate cause. In this paper it is proposed an alternative explanation, which is not limited to the identification of mistakes made by the crew but proposes an explanation of mistakes. In a cognitive analysis of accidents based on the concept of action and situated cognition, the error is not the point of arrival of the diagnosis of the causes of an accident, but it is its starting point. Like this, resumed the official results of the accident, the specific reference to the expected behavior of pilots in relation to evolving unforeseen and breach of aviation rules during the four minutes leading up to the fall of the aircraft in the ocean. This critical analysis makes room for a more comprehensive explanation of the pilots behavior, based on another frame of reference -the cognitive analysis of accidents -not yet incorporated in the official models of analysis of human factors in safety, and allows to speculate on other actions for prevention.

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