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Human Error in Aviation (Critical Essays on Human Factors in Aviation)
Human Error in Aviation (Critical Essays on Human Factors in Aviation)
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On January 31, 2000 Alaska Airlines Flight 261 was in route from Puerto Vallarta, Mexico to Seattle, Washington with a stop planned for San Francisco, California. Things went catastrophically wrong, even with the subtle hints of disaster that could be seen lurking in the shadows from takeoff. All 83 passengers and 5 crewmembers aboard the MD-83 (N963AS) ultimately paid the price for simple oversights. This paper will try to shed light into the underlying circumstances that led up to the uncontrollable crash. This will include the flight crew overlooking obvious signs of trouble from liftoff, to the preventative maintenance that was performed, and finally delve into the heart of the investigational findings of Alaska Airlines Flight 261. Climbing into the afternoon sky above Puerto Vallarta, Mexico, on Jan. 31, 2000, 5 flight crew members and 83 passengers settled in for the nearly four hour flight to San Francisco. As the jet passed 7,500 feet, Capt. Ted Thompson turned on the autopilot as he had done many times before being a seasoned commercial airline pilot with 10,400 hours of flight time under his belt, alongside 1st Officer William Tansky whom was no stranger to aviation himself logging more than 8,047 hours to his credit. After 13 minutes of smooth flying, nearing the cruising altitude of 31,000 feet, the auto-pilot disengaged indicating to the flight crew that the stabilizer trim system was apparently not working properly and the aircraft was going to have to be flown manually (by hand) for the rest of the flight. After interviewing several veteran airline pilots, it was in agreement that the crew probably thought it was nothing serious, and had no reason to alert passengers and cause them needless worry. The stabi...
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...e lawsuits brought by surviving family members were settled out of court before going to trial. The construction of a memorial sundial was placed at Port Hueneme to cast a shadow on a memorial plaque at 4:22 p.m. every January 31st as a reminder of the people who lost their lives due to the oversight of others.
Works Cited
Wallace, J. (2000, Dec 9). A hierarchy of human error may have doomed Alaska Flight
261. Seattle Post-Intelligencer Para. 11
Wikipedia Encyclopedia. (2000, January 31). Alaska Airlines Flight 261 Web site.
Retrieved June 26, 2007, from http://en.wikipedia.org/wiki/Alaska_Airlines_Flight_261 Seattle Post Intelligencer. (2001, January 30) Flight 261 Web site. Retrieved June 26,
2007, from http://seattlepi.nwsource.com/flight261/
Aviation Weekly. (2005, October 9) Alaska Airlines, FAA Scrutinize MD-80 Jackscrew issues. Frances Fiorino
Two tragic incidents, the Challenger Space Shuttle crash of 1986, and the Three Mile Island near meltdown of 1979, have greatly devastated our nation. Both these disasters involved failures of communication among ordinary professional people, working in largely bureaucratic companies. Two memos called the “Smoking Gun Memos,” authored by R. M. Boisjoly, of Morton Thiokol, and D. F. Hallman, of Babcook and Wilcox, will always be associated these two incidents. Unfortunately, neither of these memos were successful in preventing the accidents of the Challenger and the Three Mile Island near meltdown.
The 25th of September proved to be a tragic day in the legacy of Big Island Air. The final report from the NTSB included that the likely cause of the accident was the pilot’s poor decision to fly into known instrument meteorological conditions of the cloud covered terrain. The final report also concluded that the pilot’s failure to navigate properly and a direct disregard for standard operation procedures were all contributing factors. The pilot’s blatant disregard for flying into instrument meteorological conditions while operating under VFR rules and failing to ever obtain a weather brief all played a major role in this tragic disaster.
...e ultimately saved that flight. Before getting back into the plane, he could have taken a moment to walk around and look at how the snow was affecting the wings. He would have seen that snow was collecting on the surface and could have made a decision to have the plane de-iced and had a coat of anti-ice on. They could have been more patient with the plow truck. Gave the plow truck more time to clear the runway then get off. Then he would have never had to turn off the engine bleeds to obtain a shorter take off distance. The pilot could have made a decision to hold off on the departure till the weather got better. With the ceiling at 900 feet and visibility at 1 ¼ doesn’t offer much room for error. I feel as if the pilots had made a decision to change at least one of these things, the plane would have never crashed. It is a good learning experience for other pilots.
The investigation was also one of the largest international law enforcement endeavors of its time (Birkland, 2004). This tragedy, like most devastating events, changed the course of history and is a directly affected aviation safety as we know it today. The forensic findings during the investigation also helped change aviation safety policy and procedures. The result was improvement in training for airport security personnel, examination of quality control issues and heightened aviation security regulations (Birkland,
The Colgan Air Flight 3407 was a very interesting case to look at. On February 12, 2009, at 10:17 pm, flight 3407 crashed at a house in New York after the pilots experience a stall. Flight 3407 was scheduled to fly from Newark, New Jersey to Buffalo, New York. The NTSB reported the cockpit voice recorder (CVR) revealed some discrepancies both pilots were experience. The first officer did not have any experience with icing condition but icing was one of the reasons the plane went into a stall. On the other hand, the captain had some experience flying in icing condition. The captain was experiencing fatigue, which indeed, made him unfit to recover from a stall. With that in mind, the Human Factor Analysis Classification System (HFACS) will give insight of some errors both pilots made.
Throughout the years there have been limitless legal cases presented to the court systems. All cases are not the same. Some cases vary from decisions that are made by a single judge, while other cases decisions are made by a jury. As cases are presented, they typically start off as disputes, misunderstandings, or failure to comply, among other things. It is possible to settle some cases outside of the courts, but that does require understanding and cooperation by all parties involved.
Air Crash Investigations: Cockpit Failure (S10E01). (2014, March 5). Retrieved May 19, 2014, from Youtube: http://www.youtube.com/watch?v=s1FG8gOKMoo
On February 24, 1989, United Airlines flight 811 was en route to Sydney, Australia from Honolulu, Hawaii. They later experienced decompression due to the cargo door failure in front aft during flight. Flight 811 made successful emergency landing at Honolulu with nine passengers missing out of 337 passenger aboard. The cargo door that was ejected on Flight 811 damaged engines 3 and 4, which led to crew to turn back to Honolulu.
The explosion aboard the Service Module caused many vital systems to fail and required a quick and decisive response by the crew. Any mistake could have potentially been fatal. All personnel involved were able to handle the situation quickly and effectively in order to ensure what was deemed by Lovell a“successful failure”. (Lovell,1969, para. 3) The flight crew had run hundreds of simulations to prepare for problematic situations and system failures, but they had never run a simulation like what had happened aboard Odyssey.
It was the afternoon of July 25, 2000. One hundred passengers, most of them German, boarded the Concorde Air France Flight 4590. This was a trip of a lifetime for many people, as Concorde was restricted to the wealthy class of people. The excitement in people was cut short by the unfortunate delay in flight, because of maintenance in one of its engines. The passengers boarded the plane a couple of hours after the scheduled time. Finally, it was cleared for taxi on runway 26-Right. The pilots lined the aircraft parallel to the runway. A tragic accident, however, was about to befall.
As the aviation industry developed rapidly over the years it was difficult for air traffic control (ATC) to keep up with the increased demands, and maintain an acceptable level of safety. Needed improvements to the ATC network had been identified by several government appointed committees, which included such things as: radar surveillance equipment, transponders, increased navigational facilities, more control towers and increased ATC staffing. However, due to continued budget cutbacks by Congress it wasn’t until the harsh reality of several deadly midair collisions that lead way to actual appropriations being made to update the airway and ATC system.
Simmon, David A. (1998). Boeing 757 CFIT Accident at Cali, Columbia, Becomes Focus of Lessons Learned. Flight Safety Digest.
part of the Doctrine Hedley Byrne and Co. Ltd V Heller and. Partners Ltd (1964), Rondel V Worsley (1969).
When I stepped into the large neatly organized white polished plane, I never though something would go wrong. I woke up and found myself on an extremely hot bright sunny desert island filled with shiny soft bright green palm trees containing rough bright yellow hard felt juicy apples. The simple strong plane I was in earlier shattered into little pieces of broken glass and metal when crashing onto the wet slimy coffee colored sand and burning with red orange colored flames. After my realization to this heart throbbing incident I began to run pressing my eight inch footsteps into the wet squishy slimy light brown sand looking in every direction with my wide open eyes filled with confusion in search of other survivors. After finding four other survivors we began moving our small petite weak legs fifty inches from the painful incident. Reaching our destination which was a tiny space filled with dark shade blocking the extreme heat coming from the bright blue sky, I felt my eyelids slowly moving down my light colored hazel eyes and found myself in a dream. I was awakened the next day from a grumbling noise coming from my empty stomach.
Emergencies are a rare and unforeseen occurrence, but serve as a primary example of how pilots perceive situations differently. Every pilot is thoroughly trained to handle many emergency situations and have simulated them countless times. Although, as an emergency arises at FL300, the situation becomes a reality and the pilot has to effectively execute intelligent and knowledgeable decisions to counter the emergency at hand. When pilots become preoccupied with other tasks, or are interrupted, there is not a good “memory trigger” to help them remember to go back to the previous task (Veillette, 2007). Referencing checklists, troubleshooting switches, and communicating with the co-pilot are a few items that are promptly exhausted in attempt to isolate the situation. If the emergency continues, the pilot has to effectively communicate to air traffic control declaring the emergency and receive first priority over all other arriving or departing aircraft. An emergency adequately measures the ability of the pilot to make correct decisions based on the initial perception of the problem and the actions utilized to ensure safe