Accident Human Factors Analysis

ACCIDENT HUMAN FACTORS ANALYSIS (AO-2017-024)
By (Name)
The Name of the Class (Course)
Professor (Tutor)
The Name of the School (University)
The City and State Where it is located
The Date
Table of Contents
Introduction and Background of the Accident………………………….….……………………4
Literature Review……………………………………………………………………………….6
Analysis………………………………………………………………………….……………....7
Active Failures and Latent Condition Failures………………………….….…………………...10
Corrective and Preventive Actions………………………………………………….…………...11
Conclusion…………………………………………………………………….…….…………...12
References…………………………………………………………………….…....……………14
Table of Figures and Tables
Figure 1……………………………………………………………...……………………………4
Figure 2………………………………………………………………...…………………………5
Figure 3…………………………………………………………………...………………………5
Figure 4….......................................................................................................................................8
Figure 5…………………………………………………………………………………….…….9
Accident Human Factors Analysis (AO-2017-024)
Introduction and Background of the Accident
On 21 February 2017, the pilot of a Beechcraft B200 King Air, registered VH-ZCR was operating a charter passenger flight with four passengers on board from Essendon Airport, Victoria to King Island, Tasmania. The aircraft’s take-off was longer than usual and the plane was observed to veer to the left of the runway centerline as the flight progressed. After taking off, the aircraft made a modest climb followed by an extensive left sideslip with slight movement of the wings.


Fig 1: Beechcraft B200 King Air, registered VH-ZCR (ASN, 2017)


Fig 2: Groundspeed and sideslip angle of flight VH-ZCR before the crash (ASN, 2017)
The aircraft began a nose dive and collided with the roof of Bulla Road Precinct Retail Outlet Centre before hitting the ground where it ignited. All persons on board were fatally injured while two people on the ground received minor injuries (ATSB, 2017).


Fig 3: Wreckage of flight VH-ZCR (ASN, 2017)
This report will investigate the human factors associated with the aircraft accident and provide an analysis of what transpired and discuss salient gaps and deficiencies from a human factors perspective using Reason’s Swiss Cheese Model and the HFACS model.
Literature Review
Some of the human causal factors in aircraft accidents include poor organizational climate and processes. The prevailing organizational atmosphere and formal processes in aviation impact the management of human, equipment, and monetary resources which in turn affect the safety of aircraft. Moreover, the lack of management oversight including training, leadership, and professional guidance of flight operators are some of the leading human factors in aircraft accidents (Wilson, 2020). Poor organizational processes also include the failure to correct identified deficiencies in both individuals and equipment before flight.
Poor technological environments including unsuitable design of control and flight equipment as well as interface/display properties or inattention to checklist layouts, automation, and task factors have been linked to aircraft accidents. The mental, physical, and physiological states of the flight operator are other causes of aircraft accidents. Personnel issues related to adhering to crew rest requirement together with other flight readiness mandates also have an impact on aircraft safety (Beaty, 1969). However, the majority of aircraft accidents are related to decision errors that are either skill-based or perceptual and violations both routine and exceptional. The most significant human factors in aircraft accidents are poor judgment on the part of the pilot along with violations of flight procedures and regulations.
Deviating from the checklist or failing to perform a cockpit checklist altogether has been shown to be the primary reason for aircraft accidents even among experienced flight operators. Failing to properly use aircraft checklist before the flights prevents the flight operator from ensuring that the plane is correctly configured for the various flight phases. Pilot inattention has also been blamed for human errors on the flight deck. The flight display contains rudimentary flight data that is useful to pilots in their decision-making process. Inattentiveness by the pilot may lead to poor situation awareness and decision-making thereby resulting in accidents (Green, 1990). Visual and situational awareness is critical in preventing flight errors that are often realized when it is too late.
A critical human factor in aircraft accidents is operating above the maximum take-off weight which tends to affect aircraft performance and handling characteristics. An overloaded aircraft is often improperly balanced and needs more power and fuel to maintain flight. In addition to consuming more fuel, the stability and controllability of the flight is seriously affected by the additional weight. Whenever the certified weight limits are exceeded, the aircraft flight characteristics are adversely impacted and it becomes increasingly difficult for the pilot to maneuver the plane especially during takeoff and landings. Moreover, exceeding the maximum weight often results in longer take off ground rolls and lower climb performances. This problem is compounded if the runway is short and there are impediments along the takeoff flight path that the plane has to clear (NLR, 2007).
Analysis
The Swiss cheese model of human error was developed by James Reason in the early 1990s. It is particularly valuable in accident investigation because it allows the investigator to consider latent failures that contributed to the accident. He theorized that each of the random holes in his cheese model represented human failure and that an accident occurred when all slices had holes through which a...