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Human Factors & Performance in Aviation

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by

Dan Whitaker

on 23 May 2015

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Transcript of Human Factors & Performance in Aviation

Group Project - TNT Airways 352
Human Factors & Performance in Aviation
Poor visibility at Stansted.
Entered into holding pattern for 30 minutes, then diverted to Eastmidlands (EMA).
1 mile from EMA landing threshold, the autopilot was momentarily disengaged then re-engaged.
Caused a deviation from the intended flight path.
Sequence of Events
Contributing Factors
Human Factors
Conclusion
Latent Failures
Active Failures
SHELL Model Analysis
Crew tiredness
CATIIIA approach recent experience
Weather forecast
Ineffective training of the co-pilot
Co-pilot had limited English
ATC inappropriate radio transmission
Pilot inadvertently disengaged the autopilot
Co-pilot failed to call a "Go-Around"
Both pilots assumed control.
Liveware
Liveware
Software
Hardware
Environment
Bad decision to divert flight so late
Cockpit design; Autopilot switch
Authority gradient among crew

Captain was still fresh
His first category IIIA approach as PIC
Promoted only four month prior to incident

Fatigued crew
Confusion over message to divert from ATC

Resultant Changes
Both pilots have equal responsibilities for the aircraft
No ‘expecting’
More assertive co-pilots
Workload distributions/Task allocations

Understand own aircraft’s instruments
For new captains, undergo simulated instrument approaches as pilot-in-command

Have the flight instrument comparator give aural warnings
Place autopilot disengage button away from radio transmitter button

References
AAIB report
SITUATIONAL AWARENESS

The co-pilot made the incorrect SOP call
The captain lost S/A in the latter stages of approach
Pilot and co-pilot had both assumed control

TASK AND WORKLOAD MANAGEMENT

Co-pilot had difficulty finding approach charts
tower controller confusion
Captain responds to ATC while attempting the approach
Whilst responding to ATC, he inadvertently disengaged the auto-pilot

JUDGMENT AND DECISION MAKING

Improper procedures, the failure to follow SOP
Incorrect flight control inputs, resulting in an undesirable aircraft state
GO round initiated, however to late and hit ground.
Tore right landing gear off.
Diverted to Birmingham (BHX), and managed to land with extensive damage to the right engine.
"It is recommended that the Kingdom of Belgium Civil Aviation Authority require TNT Airlines in Belgium to carry out a review of their standard operating procedures to ensure that it is clear to all pilots when go-around action is required."
Civil Aviation Authority Recommendation
Additional Recommendations
Additional Recommendations
Additional Recommendations
This event shows how a combination of event compounded with human factors can result in accidents occurring.
COMMUNICATION/TEAMWORK

The go round called late by co-pilot, after the initial impact
Both pilot said they had control of the aircraft after the initial impact, where the right landing gear was lost
ATC transmitted a TNT company message to the aircraft during the very late stages of the approach
Full transcript