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Human Factor Errors: Airline flight 1420

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Abstract

This paper looks at human errors that caused American Airline flight 1420, the McDonnell Douglas MD-82, to go down on June 1, 1999 in Little Rock, Arkansas. It will also look at the decisions made a few minutes before landing, including the outcomes and possible reasons as to why those decisions were made. It also illustrates the cause and effect of the situation, and the ways in which human errors contributed to the fall of the plane, taking into account the importance of regulations and safety of transportation, in this case, the aviation industry. At the end, the question whether the accident could have been averted is answered.

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Introduction

American airlines flight 1420, the McDonnell Douglas MD-82, went down in Little Rock, Arkansas on June 1, 1999 due to runway overrun during landing. This accident led to the investigation and filing of the NTSB aircraft accident report in regard to the reason why it went down that day. There were 139 passengers, 4 flight attendants and 2 flight crew members on board. The force of the impact caused post-crash fire and 11 people, including 10 passengers and the captain, succumbed. 105 passengers, flight attendants and the first officer suffered both minor and severe injuries while 24 others were unscathed. The goal of this paper is to name two human factors that contributed to the error chain leading to the crash.

Possible causes and effects

A study done on the possible causes of the accident shows that decision making was affected by the situational stress at the time. Despite the expertise of the two pilots the situation at hand presented no time to go over the decisions they made. It required them to act as they go and it could have contributed to a few wrong calls. With a storm heading their way and approaching fast, the pilot requested for a change of the landing runway from runway 22L to 4R (McCarthy, 2012). As the plane was about to land on runway 4R a thunderstorm hit and wind with a speed exceeding the plane’s limits swept across the runway at the same time. At this time the captain noticed the change in the wind and still decided to land while he should have aborted immediately. In the instance, he may have thought it was the best option to land the plane, but actually such an action would have put the passengers at great risk.

Another study conducted in the Dallas airport on planes that landed in unconducive weather conditions were presented with difficulty. It also indicated recklessness of the pilots on three occasions. A plane ahead of theirs landed in bad weather, at night and while running behind schedule. This is a shocking fact, considering there are lots of lives involved. In the case of flight 1420, the decision made was hasty, and was a result of bad weather conditions. The pilots also did not notice that the ground spoilers hadn't deployed automatically when the plane touched the ground. Once they hit the ground they became very preoccupied with the fact that they hadn't activated them manually. The wet runway made the plane skid even more without brakes, and once it had stopped it broke into pieces and caught fire. This is a result of the bad decision making of the pilot and co-pilot in the said situation (National Transport Safety Board., 2001).

The pilot was an expert captain with more than 10,000 flight hours and had been working for the airline for some time while the first pilot had been working for the airline only a few months but had over 4,000 flight hours. The natural thing to do, according to experts, was to abort the landing once the pilots realized that there was a problem. This is especially when they realized that the wind current had increased rapidly and exceeded the maximum capacity of that of the plane (CNN.com., 1999). In the cause of the chain of errors, the pilots worked more to divert the plane from the oncoming storm and make a safe landing, but in the process had made hasty decisions, which led to the accident.

The FAA, NASA and avionics manufacturers tested equipment that assesses storm and whether it can be incorporated in airplanes. The incorporation of such equipment into airplanes or direct transmission of the finding to the flight crew would make the pilots get first-hand information on the weather situation, and thus they could make informed decisions on how to manoeuvre. It is clear that the propensity to penetrate thunderstorms takes place in the entire industry. However, the safety board believes that the FAA should come up with a working strategy that understands the plight of the aviation industry and guidelines to minimize thunderstorm penetration. It should also verify that these materials are incorporated into air carrier flight manuals and training programs as possible strategies.

Another human factor that may have contributed to the crash, according to the report, is fatigue. The two pilots were awake for 16 hours. A yawn was recorded at 2324:13 from one of the officers (McCarthy, 2012). When questioned about being tired, the first officer stated that he didn't remember being tired or discussing it with the captain. None of the two pilots showed any signs of sleep deprivation as they both went to sleep at about 22:00 and woke up at 07:30. When the captain’s wife was questioned about his behavior in the last three days she said it was normal and routine.

Fatigue is common in this profession as most hours are spent in the air and most destinations warrant long flight hours. In the case of flight 1420, it lasted for 16hours so fatigue is inevitable. It could have dulled their thinking and influenced the decisions made. It is fair to assume that in the absence of fatigue better decisions would have been made, leading to more saved lives and prevention of the accident. Tiredness sets in when one has almost finished a task. The same applies to pilots. The body may have registered that it was tired at the end of the journey owing to the fact that they had completed their flight hours (National Transport Safety Board., 2001).

According to a study done on the alertness and loss of sleep, the body ceases to be alert once sleep patterns are tampered with. The plane went down at 2350:44, which is approximately two hours after both pilots went to bed the night before the accident. This means that their sleeping pattern had been disturbed, causing their bodies not to react promptly to the situation or even not to make accurate decisions. As the plane was coming down, a lot of errors can be noted. These errors can be easily noticed if one's mind is clear. Research shows that the ability to make decisions and to consider options is decreased as fatigue levels increase (McCarthy, 2012). In this accident, the flight crew did not consider delaying or diverting the landing. They concentrated more on the fixed mindset that they should land. As a result of fatigue, they could also not recall properly the tasks they had performed. A clear demonstration is that of the first officer forgetting to activate the ground spoilers.

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The main cause of accidents in transportation industry is fatigue. It has been on the Safety Board' list since its initiation in 1990. Little has been done to this effect as most companies involved in transportation operations, including aviation, still make their employees work for extremely long hours. The companies are more concerned with the input and the number of hours. The board has therefore asked the FAA to set out clear scientifically based hours-of-service regulations and reset schedules within 2 years. It should also put into consideration human sleep, rest requirements and circadian rhythms (Flight Safety Network., 2004)

Conclusion

In conclusion, this paper has established at least two human errors that resulted in a chain of errors leading to the crash of American airline flight 1420, the McDonnell Douglas MD-82 N215AA in Little Rock, Arkansas. The first one is situational stress, which caused the pilots to make decisions that they deemed fit at the time. The situation was dire and it needed immediate solutions, which may have been affected by stress emanating from the situation at hand. Moreover, the pilots had been awake for 16 hours, meaning that they suffered from fatigue. Therefore, it is hard to make a vital decision in the course of a crisis while being tired, as one's sense of alertness is almost gone.

From the above descriptions the two situations caused both pilots to make some wrong decisions. The first officer forgot to deploy the ground spoilers and the captain forgot he had not called for flaps 40. During the crisis, neither of them considered to divert or delay the landing. The best option at the time, according to the flight crew, was to land. In the process of making errors, the pilot used reverse thrusts that were higher than engine ratio for landing. This aggravated the situation even further.

At a closer look, one can tell that everything did not just happen at once. It had been building up from the beginning. The flight crew had enough hours of sleep and woke up on time, but the journey lasted for 16 hours, and weather conditions were harsh. In the presence of a storm and where instant decisions, considering the lives of all people on board, have to be made, the above would not apply. Therefore, there had been a chain of errors that led to the fatal accident. The absence of these human factors would have averted the misfortune.

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