Aviation - Human Factors Activity 6 ASCI202, Essays (university) of Aeronautical Engineering

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Running head: AVIATION – HUMAN FACTORS Aviation - Human Factors Taylor Jolley Embry-Riddle Aeronautical University March 20, 2018

AVIATION – HUMAN FACTORS

Aviation - Human Factors Summary This case analysis’s goal is to breakdown the human factors that contributed to the crash of United Airlines Flight 173 in 1978. Traveling from Denver to Portland, “when the landing gear was lowered, only two of the landing gear indicator lights lit up,” (Red, n.d.). In order to trouble-shoot the issue the crew remained at around 5,000 feet with the landing gear down. During the next hour, the flight engineer mentioned fuel consumption but “at no time did any of the crew relate the fuel remaining and fuel use rate to the flying time required to reach the airport,” (FAA, n.d.). From 18:06 to 18:11 the plane lost all four engines due to low fuel. The plane then crashed in a wooded suburban area at approximately 18:15, just about 6 miles away from the airport, killing 10 and seriously injuring 23 others. In all, 181 people were on board. It is a miracle more were not killed and that the damage done to the area in which they crashed had not killed anyone else. All in all, this crash is attributed to pilot error and emphasizes the importance of crew resource management (CRM). The lives lost needn’t been if the crew had spoken up about concerns of low fuel, and ensured they did not have tunnel-vision on the landing gear malfunction. This case analysis will be delving into how this crash occurred, as well as how it could have been prevented. Human Factor Problems Human beings, inherently, make mistakes. Throughout history, small mistakes were not typically met with the death of dozens of people. There were not jets that flew at 500 mph, where a small failure could cause the death of every passenger. Today, this growing technology, especially in aviation, has benefitted countless lives. However, with this increase in tech comes increased risk. We have been harshly reminded that flight, while incredible, can easily lead to the

AVIATION – HUMAN FACTORS

changes make a crew more effective and efficient. It increases morale and can potentially save lives. For example, in 1989 Flight 232 lost a primary engine and hydraulic power. Captain Haynes and his crew were able to land the aircraft despite officials thinking there was no way to save anyone onboard. “Haynes credits the use of CRM as being one of the main factors that enabled the crew to guide the stricken DC-10 back to an airport,” (Andino, 2014). Though resulting in the loss of 111 lives, the outcome could have been much worse had CRM not been in play. Had CRM been commonplace on Flight 173, the captain would have paid more attention to the Flight Engineer and the Engineer would have been more assertive about fuel concerns. These actions could have led to saving the lives of those 10 who perished. Disadvantages Modern day CRM is not as effective as it once was. Currently CRM is being “taught as a reactionary tool,” (Marcellin, 2014). In order to remain effective, CRM must bring the focus back to the “big picture” and ensure crews are thinking preemptively instead of reactively. This brings up the primary disadvantage of any program like this. Humans make mistakes and humans become complacent overtime. We can train and practice all we want, there will still be accidents and there will still be lazy, complacent people. There is an argument that constant training and emphasis on the extreme actually creates complacency. The more you see an issue, lets say, the loss of an engine, the less likely you are take the training seriously. Then, when it really does happen real-world, you were not paying enough attention during training to effectively handle the issue. Now, CRM is supposed to fix this issue and it does a pretty good job. What is important to focus on here is a safety culture and a focus on crew cohesiveness and teamwork. We can’t completely rid aviation of human error, but we can learn to combat it more effectively through good programs like CRM.

AVIATION – HUMAN FACTORS

Alternative Action 2 Focus training on overall situational awareness, so that crew’s do not get tunnel vision on a sole issue, neglecting others. Advantages Situational awareness (SA) is a critical part in ensuring success of any mission or operation. While the implementation of CRM accomplishes the goal of maintaining good SA, that is not necessarily it’s primary goal. By focusing on a crew’s ability to maintain a good grasp on their surroundings, you accomplish a similar goal to CRM. For example, had the crew kept the big picture in mind, and the captain had an idea of how much fuel was left vs. how much they needed, they may have been able to make it back to the airport safely. Aviation Knowledge cites Fixation as one of the factors that can tell you if you have lost SA, (Pattendon, 2012). Had the crew realized they had lost SA by focusing too much on the malfunctioning landing gear they could have made it back safely. By ensuring training continues to highlight the importance of maintaining situational awareness, we might avoid future incidents. Disadvantages This kind of training is already taking place in many operations environments including aviation. Like stated as a disadvantage to the first alternative action, complacency is the enemy here. We can train until we are blue in the face but it does not ensure that individuals will actually apply that training real world. In situations like this one, the best we can do is train hard and try to maintain vigilant. Doing nothing is much more dangerous than the chance the training doesn’t work.

AVIATION – HUMAN FACTORS

References Andino, G. (2014, July 21). United Flight 232: Surviving the Unthinkable. Retrieved March 25, 2018, from http://www.nycaviation.com/2014/07/disaster-miracle-united-flight- FAA. (n.d.). Accident Overview. Retrieved March 23, 2018, from http://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=42&LLTypeID= Jedick, R. (2014, July 8). United Airlines 173 – The Need for CRM. Retrieved March 25, 2018, from http://goflightmedicine.com/united-airlines-173/ Landsberg, B. (2016, October 01). Safety Pilot Landmark Accident: Flameout. Retrieved March 25, 2018, from https://www.aopa.org/news-and-media/all-news/2016/october/pilot/landmark-flameout Marcellin, J. (2014, December 01). The Evolution of Airline Crew Resource Management. Retrieved March 25, 2018, from http://www.nycaviation.com/2014/12/evolution-airline- crew-resource-management/ Pattendon, R. (2012, September 4). AviationKnowledge. Retrieved March 25, 2018, from http://aviationknowledge.wikidot.com/aviation:situational-awareness Red, R. (n.d.). United Airlines Flight 173, Portland, OR. Retrieved March 25, 2018, from http:// www.waymarking.com/waymarks/WM10J2_United_Airlines_Flight_173_Portland_OR