Case Analysis: Aviation Human Factors

Published: 2021-07-07 15:40:05
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On the 24th of November 2001, a Crossair Flight Lx 3597 on route to Zurich in Switzerland crashed near Bassersdorf. The flight registration HB-IMX was a scheduled flight from the Tegel Airport in Berlin and had 33 persons on board on route to Zurich. The flight departure time was 21.01 CET from Berlin (Aircraft Accident Investigation Bureau, 2001). The flight would later crash into wooded hills at precisely 22.07 CET, which was 4kms away from the scheduled runaway. The impact of the crash led to instantaneous flames and immense damage on the Crossair flight. In the end, bad weather came out as one of the main reasons for this particular accident. However, investigations pointed out a series of pilot errors, which had a direct implication on the eventual crash. The conclusion made was that the crash was a controlled flight into terrain, which was observably erroneous given the pilot’s long-standing experience. In this paper, the assertion made is that the eventual crash may have been a result of lack of communication, complacency, failure to work as a team, and the lack of knowledge. To this end, this paper assesses the primary and secondary factors that may have had a direct implication on the crash.
The eventual crash landing of the Crossair Flight 3597 into the wooded hills of Bassersdorf was fatal and would eventually claim 24 lives out of the 33 on board the plane on a fateful day. The decision to switch the flights landing clearance from the initial ILS runway to the VOR/DME runway 28 and the fact that there was poor visibility were some of the reasons that led to the eventual crash (Aircraft Accident Investigation Bureau, 2001). The pilot and the core pilot made erroneous assumptions about their perceived contact with the runaway, and this led to the crash.
The significance of the Accident
The occurrence of the accident has a significant role in the reformation of safety measures in the airline industry. The Aircraft Accident Investigation Bureau made essential reconsiderations regarding the procedures around the on-flight redirection of landing schedules. The accident also led to the production of the Mayday documentary ‘Cockpit Failure’, which has been an important reference point whenever there is a need to learn airline safety through dramatization. In the end, the procedure of communication between the pilot and the co-pilot flying the Crossair flights also came under scrutiny.
Factor 1: Failure in Communication between the Crew
One of the main human factors that stand out in the dirty dozen lists relates to the issue of communication and the fact that communication failures often lead to fatal accidents. Observably, in the case of the Crossair flight, there were clear instances of failures in the course of communication between the pilot and the co-pilot, which led to poor decisions (Aircraft Accident Investigation Bureau, 2001). For instance, the co-pilot was not sure that the aircraft was in contact with the runway yet he gave the go-ahead to the pilot without explaining his concerns.
Factor 2: The aspect of Complacency on the end of the pilot
The pilot in charge of the Crossair involved in the accident was actually in the rank of an experienced pilot with more than 19500 flight hours. The aspect of complacency then stands out in this case because the pilot may have made certain risky assumptions based on his assumed long- spanning career. The decision to depend on the skewed judgment by the co-pilot betrays a sense of complacency probably due to the pre-notion that this was just another routine landing procedure (Munene, 2016).
Factor 3: The Apparent Lack of Knowledge on the Complexities of the Terrain
In the course of the investigation, it is clear that the Pilot depended on the co-pilot on the information regarding the sudden terrain they had to navigate. The investigation affirms that the pilot had never landed on the runway 28, which means he was dependant on the co-pilot for insights. The co-pilot also turned out to be equally ill-equipped on how to navigate the terrain due to limited information.
Secondary Factors
Factor 1: The level of awareness and Attention by Flight Traffic Control
One of the clear concerns that stand out relates to the lack of traffic control attention and awareness, especially at the Zurich airport (Trifonov-Bogdanov, Vinogradov, & Shestakov, 2013). The failure in communication was partly due to this aspect, which eventually limited the ability to assess the aircraft and report on the off the ladder observations just before the crash.
Factor 2: The Focus on Adherence to Procedure Regardless of the Underlying Danger
The decision to insist on the need for the flight to land on the runaway 28 despite the foreknowledge that the pilot was not familiar with the terrain. The air traffic control had the options of bending the existing regulations with the aim of ensuring the safety of the passengers and the crew, yet they failed to make this consideration (Wiegmann & Shappell, 2011). The outcome of this strict adherence on procedure may have limited the possibility of reducing the eventual fatalities.
Factor 3: Lack of Teamwork
The argument made by the pilot on the reasons for the eventual crash reflect on an aspect of lack of teamwork from both the crew and the air traffic control teams. The process of communication and working collectively would have been critical toward averting the eventual crash.
The recommendations may be necessary in the course of dealing with both primary and secondary human factors. Quality communication approaches stand out as the main ways of avoiding such future fatal accidents. The process of communication, in this case, involves both the crew and the air control officials. The introduction of warning systems that may apply to alert the various parties involved in case of an imminent risk. The other recommendation relates to the need to train the flight crew on some of the emergency measures to take in case of imminent danger and the critical role that teamwork may play during such crises (Wiegmann & Shappell, 2011). The process of training must also address the need for caution even when such crew has long-standing experience. The approach may reduce the concerns associated with complacency.

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