{"id":810,"date":"2012-08-05T21:48:11","date_gmt":"2012-08-05T18:48:11","guid":{"rendered":"http:\/\/www.hvtd.org\/?p=810"},"modified":"2012-08-05T21:48:11","modified_gmt":"2012-08-05T18:48:11","slug":"2003-diyarbakir-kazasi","status":"publish","type":"post","link":"https:\/\/www.hvtd.org\/?p=810","title":{"rendered":"2003 Diyarbak\u0131r Kazas\u0131"},"content":{"rendered":"

\"\"<\/a>8 Ocak 2003 g\u00fcn\u00fc Diyarbak\u0131r’da d\u00fc\u015ferek 75 ki\u015finin \u00f6l\u00fcm\u00fcne neden olan THY u\u00e7a\u011f\u0131 kazas\u0131, pilotu veya THY’yi temize \u00e7\u0131karmaya veya tersine karalamaya \u00e7al\u0131\u015fan, b\u00fct\u00fcn su\u00e7u sise veya ILS cihaz\u0131 bulunmay\u0131\u015f\u0131na, ya da u\u00e7akta cep telefonu kullan\u0131m\u0131na ba\u011flayan yorum ve yaz\u0131lar\u0131n yaratt\u0131\u011f\u0131 bilgi kirlenmesinin d\u0131\u015f\u0131nda de\u011ferlendirilmelidir. Havac\u0131l\u0131k T\u0131bb\u0131 Derne\u011fi, kazalarda insan fakt\u00f6r\u00fcn\u00fcn teknik konulardan \u00e7ok daha \u00f6nemli oldu\u011funa ve bu y\u00f6nde yeterli \u00e7al\u0131\u015fma yap\u0131lmad\u0131\u011f\u0131na inanmaktad\u0131r.<\/p>\n

Kat\u0131 ger\u00e7ek: <\/strong>Havac\u0131l\u0131kta “u\u00e7ak kendili\u011finden d\u00fc\u015fmez, onu bir d\u00fc\u015f\u00fcren vard\u0131r ve bu da genellikle pilottur.<\/em>” Sis, ILS cihaz\u0131 olmay\u0131\u015f\u0131 gibi unsurlar bu kazan\u0131n tali nedenleridir; her u\u00e7u\u015fta benzeri olumsuz durumlarla kar\u015f\u0131la\u015f\u0131labilir ama iyi e\u011fitilmi\u015f bir pilot bu durumda kazadan ba\u015fka yapabilecek bir \u015feyler bulur (meydan turu ile zaman kazanmak, ini\u015fin iptali, vs.) Kazada teknik nedenlere a\u011f\u0131rl\u0131k verilmesine kar\u015f\u0131n, havac\u0131l\u0131k t\u0131bb\u0131 a\u00e7\u0131s\u0131ndan yakla\u015f\u0131ld\u0131\u011f\u0131nda \u015fu olas\u0131l\u0131klar kazay\u0131 a\u00e7\u0131klamakta daha \u00f6nemli gibi g\u00f6r\u00fcnmektedir:<\/p>\n

a.<\/strong> Bu kazan\u0131n olu\u015fumunun sis i\u00e7inde ba\u015flamas\u0131 ve Ula\u015ft\u0131rma Bakan\u0131 taraf\u0131ndan, “pilotun pozisyonu hakk\u0131nda tam olarak bilgi sahibi olmad\u0131\u011f\u0131<\/em> ” yorumu yap\u0131lm\u0131\u015f olu\u015fu, kazan\u0131n havac\u0131l\u0131k terminolojisinde durum muhakemesi kayb\u0131 (loss of situational awareness-LSA) denilen bir problemle ilgili olabilece\u011fi kanaati uyand\u0131rm\u0131\u015ft\u0131r. Pilot sis i\u00e7inde g\u00f6r\u00fc\u015f referans\u0131 olmadan u\u00e7makta, belki de sis aras\u0131ndan yeri g\u00f6rebilece\u011fi bir bo\u015fluk aramakta iken gere\u011finden fazla al\u00e7alm\u0131\u015f, ini\u015f tak\u0131m\u0131 lambalar\u0131n\u0131n sisteki yans\u0131mas\u0131 g\u00f6r\u00fc\u015f\u00fc daha da bozmu\u015f, hatta yalanc\u0131 bir t\u0131rman\u0131\u015f hissi vermi\u015f de olabilir. Bu s\u00fcre\u00e7te kule ve u\u00e7u\u015f ekibi ile ileti\u015fimini s\u00fcrd\u00fcrmeye \u00e7al\u0131\u015fan, \u00e7ok k\u0131sa bir zaman diliminde karar vermek zorunda kalan pilot durum muhakemesini yitirmi\u015f, u\u00e7a\u011fa yanl\u0131\u015f kumanda vermi\u015f olabilir… (Olay kaide d\u00f6n\u00fc\u015f\u00fcn\u00fcn hemen \u00e7\u0131k\u0131\u015f\u0131nda olsayd\u0131 koriolis ill\u00fczyon<\/em> da d\u00fc\u015f\u00fcn\u00fclebilirdi.)<\/p>\n

b.<\/strong> Olaya d\u0131\u015far\u0131dan bakan, konuya yabanc\u0131 bir g\u00f6z bile, pilotun bu ko\u015fullarda ini\u015fi iptal etmesi gerekti\u011fini d\u00fc\u015f\u00fcnebilir. Pilot neden \u015fans\u0131n\u0131 fazla zorlam\u0131\u015f ve riske girmi\u015ftir? Burada u\u00e7u\u015f psikolojisi unsurlar\u0131 d\u00fc\u015f\u00fcn\u00fclmelidir. \u00d6rne\u011fin al\u0131\u015fkanl\u0131k tuza\u011f\u0131: Ayn\u0131 meydana daha \u00f6nce (g\u00f6rerek) defalarca inebilmi\u015f bir pilot i\u00e7in, bazen kurallar\u0131 biraz zorlayarak veya risk alarak zor bir ini\u015fi ba\u015far\u0131yla tamamlamak kendisine ve \u00e7evresindekilere kar\u015f\u0131 bilin\u00e7d\u0131\u015f\u0131 mekanizmalarla bir ho\u015fnutluk duygusu verebilir. Bu tatminin \u00f6tesinde, pilot bu i\u015fi ger\u00e7ekten ba\u015farabilece\u011fine de inan\u0131r.<\/p>\n

c.<\/strong> Belki kazadan 5 dakika \u00f6nce yolculara bir anket uygulansayd\u0131, b\u00f6ylesine sisli bir havada pilotun ko\u015fullar\u0131 biraz zorlayarak ini\u015fi denemesi y\u00f6n\u00fcnde istek belirtecek ki\u015filer belki de %70-80’lerde olacakt\u0131. Tersine, pilotun ini\u015fi iptal edip \u0130stanbul’a d\u00f6nme karar\u0131 ald\u0131\u011f\u0131 yolculara iletilseydi, gene %70-80 gibi bir memnuniyetsizlik tepkisi gelecekti. \u00c7\u00fcnk\u00fc \u00e7o\u011fu insan\u0131n i\u00e7inde “kendisine bir \u015fey olmayaca\u011f\u0131, hatta \u00f6lmeyece\u011fi” gibi bir incinmezlik d\u00fc\u015f\u00fcncesi<\/strong> (invulnerability) vard\u0131r. Ayr\u0131ca iyi bir pilotun b\u00f6yle zor zamanlarda ustal\u0131\u011f\u0131n\u0131 g\u00f6stererek zoru yenece\u011fine dair bir inan\u00e7 vard\u0131r.<\/p>\n

d.<\/strong> Burada “eve d\u00f6n\u00fc\u015f sendromu<\/strong>” olarak bilinen bir gizli etkenden de s\u00f6z edilebilir. Yolcu ve m\u00fcrettebat\u0131n 5 dakika sonra “hay\u0131rl\u0131s\u0131yla” bitecek bir u\u00e7u\u015f sonras\u0131 i\u00e7in planlad\u0131klar\u0131 bir\u00e7ok i\u015f olabilir (\u00e7ocu\u011funun ya\u015f g\u00fcn\u00fc, e\u015finin hastal\u0131\u011f\u0131, \u00f6zlemler, ticari i\u015fler, vs.). \u0130ni\u015fin iptali y\u00fcz\u00fcnden geri d\u00f6nmek, programlar\u0131n alt\u00fcst olmas\u0131, yeniden yolculuk s\u0131k\u0131nt\u0131lar\u0131na girmek vs. bir hayal k\u0131r\u0131kl\u0131\u011f\u0131 yarat\u0131r. Pilot bu manevi bask\u0131y\u0131 daima s\u0131rt\u0131nda hisseden ki\u015fidir ve onu risk almaya zorlayan g\u00f6r\u00fcnmez nedenlerinden birisi de bu olabilir. \u00d6zg\u00fcveni y\u00fcksek ve kararl\u0131 bir pilot bunlara kar\u015f\u0131 koyabilmelidir.<\/p>\n

U\u00e7aklar sofistike elektronik-mekanik sistemleriyle m\u00fckemmellik s\u0131n\u0131r\u0131na ula\u015fm\u0131\u015ft\u0131r. Ama sistemin en zay\u0131f halkas\u0131 insand\u0131r. B\u00fct\u00fcn ara\u015ft\u0131rmalar ve kaynaklar t\u00fcm kazalar\u0131n % 70-80’inin insan fakt\u00f6r\u00fcne ba\u011fl\u0131 oldu\u011funu g\u00f6stermektedir. Bu oran\u0131n yar\u0131s\u0131 (% 52) ise karar verme hatalar\u0131 ile ilgilidir.<\/p>\n

Havac\u0131l\u0131kta hatal\u0131 karar vermenin alt unsurlar\u0131: <\/strong><\/p>\n

* fizyolojik duyu yan\u0131lg\u0131lar\u0131 (ill\u00fczyonlar) nedeniyle pozisyon alg\u0131s\u0131n\u0131n bozulmas\u0131 (disoryantasyon, vertigo),<\/p>\n

* durum muhakemesi kayb\u0131 (LSA)<\/p>\n

* psikolojik bozukluklar (a\u015f\u0131r\u0131 g\u00fcven, riske girme, ma\u00e7o tutumlar, kurallara uymama, yanl\u0131\u015f al\u0131\u015fkanl\u0131klar, inisiyatif eksikli\u011fi, vs.)<\/p>\n

* ileti\u015fim sorunlar\u0131 (CRM),<\/p>\n

* dikkatsizlik, fiksasyon, idari ve lider hatalar\u0131\u2026<\/p>\n

\u015e\u00fcphesiz hi\u00e7bir pilot kendi ya\u015fam\u0131na da mal olan bir yanl\u0131\u015f karar\u0131 bilerek-isteyerek vermez. \u0130\u00e7kulak denge organ\u0131n\u0131n (vestib\u00fcl) veya g\u00f6z\u00fcn baz\u0131 u\u00e7u\u015f hareketleri y\u00fcz\u00fcnden yanl\u0131\u015f mesajlar \u00fcretmesi (ill\u00fczyonlar), pilotlar\u0131n zaman zaman kar\u015f\u0131la\u015ft\u0131klar\u0131 ve \u00f6nlemlerini bildikleri konulard\u0131r; ama bu hissi ya\u015farken onu yok saymak da \u00e7ok zordur. \u00c7aresi e\u011fitimdir.<\/p>\n

Ula\u015ft\u0131rma ve Sa\u011fl\u0131k Bakanl\u0131klar\u0131, THY, TALPA ve \u00dcniversite T\u0131p Fak\u00fcltelerinin Sorumluluklar\u0131 ve Beklentiler: <\/strong><\/p>\n

U\u00e7u\u015f kazalar\u0131n\u0131 s\u0131f\u0131rlamak belki \u00fctopyad\u0131r ama bilimsel yakla\u015f\u0131mlar ve e\u011fitim ile bu hedefe yakla\u015f\u0131labilir. Havac\u0131l\u0131k t\u0131bb\u0131 bak\u0131\u015f a\u00e7\u0131s\u0131yla sivil havac\u0131l\u0131kta \u00e7e\u015fitli oranlarda sorumluluklar\u0131 olan ki\u015filerin, daha \u00e7ok bilim, daha \u00e7ok e\u011fitim, daha \u00e7ok kontrol ilkesini g\u00f6z ard\u0131 etmemeleri gerekti\u011fine inan\u0131yoruz.<\/p>\n

Do\u00e7. Dr. Muzaffer \u00c7eting\u00fc\u00e7 <\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

8 Ocak 2003 g\u00fcn\u00fc Diyarbak\u0131r’da d\u00fc\u015ferek 75 ki\u015finin \u00f6l\u00fcm\u00fcne neden olan THY u\u00e7a\u011f\u0131 kazas\u0131, pilotu veya THY’yi temize \u00e7\u0131karmaya veya tersine karalamaya \u00e7al\u0131\u015fan, b\u00fct\u00fcn su\u00e7u sise veya ILS cihaz\u0131 bulunmay\u0131\u015f\u0131na, ya da u\u00e7akta cep telefonu kullan\u0131m\u0131na ba\u011flayan yorum ve yaz\u0131lar\u0131n yaratt\u0131\u011f\u0131 bilgi kirlenmesinin d\u0131\u015f\u0131nda de\u011ferlendirilmelidir. Havac\u0131l\u0131k T\u0131bb\u0131 Derne\u011fi, kazalarda insan fakt\u00f6r\u00fcn\u00fcn teknik konulardan \u00e7ok daha \u00f6nemli oldu\u011funa ve bu y\u00f6nde […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[9],"tags":[],"class_list":["post-810","post","type-post","status-publish","format-standard","hentry","category-turkucakkazalari"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts\/810","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=810"}],"version-history":[{"count":1,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts\/810\/revisions"}],"predecessor-version":[{"id":812,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=\/wp\/v2\/posts\/810\/revisions\/812"}],"wp:attachment":[{"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=810"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=810"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.hvtd.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=810"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}