Because of a typographical error, a portion of one...


July 25, 1994

Because of a typographical error, a portion of one sentence was omitted from a letter to the editor from Sy Steinberg published yesterday. The sentence should have read: "This naive observation is illusory because the decision makers (those that oversee evaluation and decide what 'systems' are to be procured and fielded for use) mostly make their decisions based upon hardware reliability while omitting consideration of human performance reliability (HPR)simply because its realistic value is evasive."

The Sun regrets the errors.

'Human Failure' Is Really System Failure

The inexcusable but unintended downing of two U.S. Army Black Hawk helicopters by two U.S. fighter jets over northern Iraq last April and the resulting loss of life is a tragedy that escapes description.

The findings of the Pentagon panel assigned to investigate this inexcusable accident are now a matter of record, but these findings were also predictable months ago.


The report indicates that a compounding of tragic "human error," committed mainly by the U.S. Air Force, was primarily due to incompetence and a lack of appropriate training being provided to a number of Air Force organizational elements.

Now the investigation is likely to continue with the search for and punishment of scapegoats. This type of reporting and follow-up behavior is typical, but likewise unfortunate.

I submit that there is a component of this investigation that has not been, nor ever will be, addressed by any committee investigating a similar type blunder. Let me explain.

Persons who are systems-oriented understand that the term "human error" is, many times, a misused, misunderstood, proliferation.

Why? Because humans are an essential component of the system, in that the system will not function reliably without proper human performance and interaction.

Yet the report states that all systems, including the Identification Friend or Foe (IFF) system, functioned properly.

This naive observation is illusory, because the decision makers (those who oversee evaluation and decide that systems are to be procured and fielded for use) mostly make their decisions based upon hardware reliability (HPR), simply because its realistic value is evasive. They reason that with seemingly thorough and proper training, the human component of reliability will approach that of the hardware.

Unfortunately, such reasoning is fallacious, because with complex systems such as is involved in the U.N.'s Operation Provide Comfort, the human component of reliability of the system becomes increasingly critical resulting in a significant increase in the probability of system failure.

The reports are now being sent to the respective commanders of those crews directly involved in the accident and Defense Secretary William J. Perry pledges to take action to both ensure full accountability and that this type of accident is never again repeated.

Mr. Perry has noble endeavors, but his words are emotional rhetoric as are those of Gen. John M. Shalikashvili, chairman of the Joint Chiefs of Staff.

I have no doubt that all operational personnel involved in the tragedy continue to suffer immeasurably and will for the rest of their lives.

I would like to ease their pain somewhat by stating emphatically that numerous others are perhaps more responsible for the tragedy than those who ultimately will be held accountable.

They include: the tacticians who devised the command, control and communications (C3) system; the system reliability statisticians; those responsible for the training plan and the trainers; the doctrine people, the scenario modelers, and computer simulations; and those responsible for operational test and evaluation.

Most of these people don't even realize that they have contributed significantly to the tragedy in a passive sense.

At the expense of being branded a cynic, I feel compelled to state that this type of tragedy will be repeated in the future unless we begin to take stock of our tendency to avoid dealing realistically with the human component combined with our desire to fragment ourselves into bureaucratic specialization groups that don't speak to each other.

Sy Steinberg


The writer is a retired systems/aerospace/human factors engineer.


Let's see if I understand the Baltimore City Council's African-American Coalition and council Vice President Vera P. Hall correctly:

The major qualification of Iris Reeves to be comptroller is that she is a black female and should be in office because "voters elected a black woman" originally.

This logic does not seem quite right to me. What happened to having the best person for the job? The person most qualified to help the city of Baltimore?

If, in fact, Jacqueline McLean won the election to become comptroller because she is a black female, something is wrong with the voters of Baltimore.

I do not care what color or sex the new comptroller is, but to say it has to be a certain color and sex without looking at someone's qualifications is wrong.

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