Aviation Accidents Involving Human Factors

Ryan Everett

AVSC 410G

                                        Final Essay Assignment

In this writing assignment, we will take a look at three different Aviation accidents that have occurred after 1960, some of the causes of these accidents, and what has changed in aviation because of these accidents.

Accident #1:  Tenerife, Canary Islands.   This accident involved 2 different aircraft, in a runway collision.  There were quite a few things that went wrong that caused this accident to happen.  Any number of these, if not all of these things could have been avoided. There was miscommunications on the part of the KLM 747 crew, miscommunications on the part of the ATC working that day and when it was realized that there might be a possible runway incursion happening, neither of the pilot crews or the ATC said anything to clarify the situation.  

Had either of the crews clarified their comments, or had the ATC been clearer with his communication to each crew, this accident would not have happened. Significant blame falls on the head of the KLM pilot, who was a very tenured, high ranking pilot who carried a big attitude with him.  This is labeled as part of the reason why this accident happened, the flight crew for the KLM flight didn’t want to correct this high ranking captain, and their hesitancy to do so cost them their lives. There was definitely a culture problem here with how the crew didn’t act in the best interest of safety, but more in the interest of not wanting to make this pilot mad.  

One of the final items that was cited as causing this accident were the low lying clouds that came in over the airport just before these planes were trying to take off. The visibility was at questionable levels for these planes to take off, and the visibility was low enough that the tower did not have visual contact with either of the taxiing planes.  The pilots no doubt wanted to get airborne as soon as they could and not delay the flight any longer, and this unwillingness to consider staying grounded until the weather cleared was another reason why this accident happened

Accident #2: Air France Flight 447.  A series of errors by pilots and a failure to react effectively to technical problems led to the crash of Air France Flight 447.  The Brazil-to-France flight plunged into the Atlantic Ocean on June 1, 2009, killing all 228 people on board. The accident report details how the pilots failed to respond effectively to problems with the plane's speed sensors or to correct its trajectory when things first started to go wrong.

According to the report, when ice crystals blocked the plane's pitot tubes, which are part of a system used to determine air speed, the autopilot disconnected and the pilots did not know how to react to what was happening.  The crew responded by over-handling the aircraft, which destabilized its flight path and caused further confusing readings.  The Airbus A330 went into a sustained stall, signaled by a warning message and strong buffeting of the aircraft, the report said.  Despite these persistent symptoms, the crew never understood they were in a stall situation and therefore never undertook any recovery maneuvers.  The pilots responded to the situation by pointing the nose upward, rather than downward, to recover.

Some of the recommendations made in this accident report have already been implemented, but it could take years for others fully to come into effect. The use of automatic systems on planes has improved safety overall, when it comes down to it, safety will always be based on the capacity of the pilots and the signals which they are given, which they have to understand and react to.  It's a crash that never should have happened.  The industry will be studying the human factors of the crew on this plane for many years to come.

The Bureau of Investigation and Analysis said its report does not examine the issue of responsibility for the crash, which is the subject of a separate judicial inquiry. The icing-up of the pitot tubes was "a phenomenon that was known but misunderstood by the aviation community at the time of the accident," the report pointed out. Pilots should be trained on how to handle this event and a high-altitude stall with better technical instruction and flight simulator programs, the report said.

The Bureau of Investigation and Analysis said the data indicated that Flight 447 crashed because the aircraft's speed sensors gave invalid readings. The recorders revealed the pilots had failed to discuss repeated stall warnings and "had received no high altitude training" to deal with the situation, the bureau said.  They failed to regain control of the aircraft, and no announcement was made to the passengers, of 32 different nationalities, before it plummeted from the sky.