Boeing 737 Human Factor in Aviation PDF

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Summary

Human Factor in Aviation Essay.
Introduction
Body
Crew of the Aircraft
Crash Event
Impact on Aircraft’s Body
Boeing 737 History
Investigation
Causes of the Crash
Aftermath
Findings
Recommendations
Conclusion
R...

Description

Boeing 737 Crash in Russian Flight U9 363 Course: Human Factor in Aviation Name: Date:

Table of Contents Introduction...........................................................................................................................................3 Body......................................................................................................................................................3 Crew of the Aircraf...........................................................................................................................3 Crash Event........................................................................................................................................4 Impact on Aircraf’s Body...................................................................................................................4 Boeing 737 History............................................................................................................................5 Investigation......................................................................................................................................6 Causes of the Crash...........................................................................................................................7 Afermath..........................................................................................................................................9 Findings.............................................................................................................................................9 Recommendations...........................................................................................................................10 Conclusion...........................................................................................................................................11 References...........................................................................................................................................12

Introduction On 17 November 2013, at 19:24 local time, a tragic event took place creating chaos and despair in the lives of many individuals. A Boeing 737 domestic plane operated by Tatarstan Airlines, crashed in the city of Kazan killing all individuals on board. Flight 363 took off from Domodedovo International Airport (DME) of Mexico and was headed towards Kazan International Airport (KZN), Russia. In the crash all 44 passengers, along with six flight crew members lost their lives. According to the reports, the airplane aborted two landing attempts and crashed during the third attempt. The problem didn’t lie with the flight but with the faulty landing. The aircraft went around two times before its fuel tank caught on the fire on the third landing attempt. Irek Minnikhanov, the son of Tarstan President Rustam Minnikhanov, was among the victims of the crash. According to the Interstate Aviation Committee’s (IAC) official investigation report, the crash was caused due to pilot error, which arose from the pilot’s lack of skills to recover from a nose-up attitude. The pilot’s deficiencies were a result of airline’s safety management and regulatory oversight. This report analyses where the problem causing the crash lays. The report explores if the crash was due to a human error or technical problem that is whether it was in the aircraft’s systems or engines or with the crew member’s skills and training. It also determines whether the weather conditions or poor quality fuel were also contributing factors in this tragedy.

Body Crew of the Aircraft

The captain of the aircraft was a 47 year old individual named Rustem Gabdrakhmanovich Salikhov. Since 1992 he had worked under Tatarstan Airlines. His total flying hours were 2,755 which included 2,509 hours of Boeing 737. The first officer of the plane was also 47 year old individual, named Viktor Nikiforovich Gutsul. He had been with Tatarstan Ariline since 2008 and had 2,093 total flying hours, of which 1,943 were on Boeing 737.

Crash Event Boeing 737 VQ-BBN under the Tatarstan Airlines was scheduled to fly from Moscow to Kazan on 17th November, 2013. At 18:20 local time, the flight took off from Domodedovo Airport (DME) of Moscow for Kazan. The weather was suitable for landing at the Kazan international airport. During the flight, the crew discovered that their navigation system’s map was displaced. The flight crew configured the aircraft for landing hurriedly. This action was unstabalized and as they turned toward the runaway, it was determined that they were too high to land successfully. So the pilot initiated the go-around. During the go-around which was caused due to the unstabalization of the plane while approaching the runaway, the flight crew members failed to identify the autopilot disconnection, which resulted in the aircraft getting into nose up attitude. As the pilot was undertrained and lacked upset recovery skills he lost the spatial orientation and let the plane pitch nose down steeply until it crashed on impacting with the ground. The plane collided with the ground between the main taxiway and the runaway. After the first impact with the ground, a second explosion took place, after approximately 40 seconds. All fifty individuals on board, i.e. 44 passengers and six crew members died on the impact. There were no survivors and no ground individuals were hurt.

Impact on Aircraft’s Body The airframe of the aircraft was broken down into a number of fragmented parts. The aircraft was destroyed and it caught fire after impacting with the ground. The main aircraft fragments or the biggest aircraft parts founded at the accident site were: 

Forward Fuselage

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The Cockpit

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Centre wing section

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Right wing

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Left wing

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Horizontal stabilizer

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Vertical Stabilizer

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Left side Fuselage

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Left engine fragments

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Right engine fragments

Boeing 737 History The Boeing airplane that crashed in Kazan, was made in 1990 and was bought by the Tatarstan Airlines in December 2008. The aircraft had been in service since 23 years and it had been undergoing regular or routine maintenances. It wasn’t the first time in the crash of 2013 that the aircraft experienced problems. A year before when the plane was on its way to Moscow, it had to make an emergency landing at the same terminal as within twenty minutes of take-off due to depressurization, alarm sensors were triggered. No one was injured in this incident. This isn’t the only accident in Russia involving Boeing 737. UTair’s 400 jet model caught fire soon after landing at Vnukovo airport of Moscow. Fortunately none of the passengers on

board were injured. On another occasion on December 2012, Red Wings Airlines’ TU-204 jet hard-landed at the Vnukovo Airport of Moscow, crashing into the nearby highway and breaking into several parts. Only the plane crew was on board, and this landing killed five people while injuring four other.

Investigation A proper investigation was undertaken to probe into the root causes of the crash. An investigation Committee was set up to probe into the crash, which was being headed by Vladmir Markin. The main causes identified by the head of committee were pilot error, weather conditions or technical malfunction. Russia’s federal aviation authority experts also joined the official investigation process. Interstate Aviation Committee (MAK) was officially investigating the causes of the crash, with Rosaviatsia officially reviewing the flight operations of Tatarstan Airlines. It was reported by Rosaviatsia Russia’s Civil Aviation Authority on 18th November, that Boeing 737, flight 363 of Tatarstan Airlines collided with the ground between main taxiway and runaway. One of the main reason or cause of crash was the ineptness of the pilot. The pilot tried to land the plane several times. It was during the landing that one of the fuel tanks detonated. MAK reported on November 19th, 2013, that it was revealed in the investigation that the standard approach profile was not followed by the plane crew. On Nov 22nd, 2013 it was announced by the Great Britain's AAIB that they had joined the investigation as well and had dispatched their investigators to Kazan. After recovering basic information from the flight data recorder, IAC released the following preliminary details on 19th November, 2013. The flight crew members were not able to follow the standard landing procedure that is defined by the regulating board. Using the TOGA

(Take off/ Go around) mode, the crew started to go-around during which one of the autopilots was switched off and the flight had to be operated manually. The airplane collided with the land or ground at quite a high speed of approximately 450 km/h and they had a very negative pitch angle. There was no mention in the preliminary report that would indicate the cause of crash being failure of systems, engines or units of aircraft. The interstate Aviation Committee (MAK) on 24th December, 2015 released their final report stating probable causes of crash in Russia. The main causes included under-trained crew members by Russian Civil Aviation Authority and Tatarstan Civil Aviation Authority that led to the assignment of unqualified crew members to the flight. During the go-around procedure, the crew members were unable to recover from a nose-up attitude due to lacking in proper skills and experience. Due to being over worked and stressed, the crew members did not comprehend the warning messages associated with the auto-pilot disconnection. Other probable causes included non-functional safety management system of the airline and systematic weakness in classifying and monitoring the levels of risk by the crew members.

Causes of the Crash One of the pilot’s qualification requirement is to demonstrate skills and knowledge concerning human resources, which included principles of error controls and human factors threats. These qualifications are necessary and applicable for all types of pilots. Flight crew members are not permitted to perform their duties or functions unless they have proper training to gain skills and knowledge related to human factors and hazards in flight. They should have such knowledge as to how to prevent such conditions and human errors and their correction.

However, there was no pilot’s training programs on human factors and methods of controlling hazardous situations and errors in Tatarstan Airlines. Resultantly the training level of the plane pilots did not match with the required qualifications and they should not have been allowed to carry out their functions. Flight safety is also largely dependent on pilot instructors. It was determined that Tatarstan Airline’s pilot instructors weren’t face with high requirements of qualifications, along with no requirement to gain a professional pilot education. Aviation authorities at all levels lacked in the control of the quality level of training provided to the crew members. The captain didn’t have any primary flight training and the crew members were under qualified. The unqualified flight crew members were allowed to upgrade to Boeing 737 while being unprepared. At the airline there was inadequate level of organisation of flight operations, which resulted in failure to identify and correct deficiencies in working with the crew interaction, pilot technique and navigation equipment. The crew missed to recognize the fact that the autopilot was off, when the go-around approach was executed. It also caused the aircraft to pitch up to a complex spatial position. The lacking flying skills of pilot in a complex spatial position led to the formation of a large negative overload. It also caused the loss of spatial orientation and transferred the aircraft into a steep dive until the crash with the ground. There were systemic shortcomings in the identification of risks and hazards along with nonfunction safety management system in the Tatarstan Airlines. The Tatarstan Airlines did not had any documented or functional process for the identification for potential and existing safety hazards. There wasn’t any process for assessing the risks associated with safety hazards either.

Tatarstan Airlines didn’t have any corrective action plan to achieve targeted safety performance indicators either.

Aftermath It was recommended by the Russia’s Federal Air Transport Agency in early December 2013, that Tatarstan Airline’s certificate should be revoked due to their inadequate training operations and their oversight in the training of the crew members. So on 31st December, 2013, the revocation was announced and the company’s unit comprising the aircraft was transferred to AK Bars Aero. It was decided that some sort of compensation should be paid to the families of the victims. So after deliberations and great consideration, it was decided by the authorities and Tatarstan Airline’s insurance company to pay US$ 93,700 to the families of each victim as a compensation token for their loss. Further to remember and grieve the victims of the crash, 17th November is set as an official day of mourning.

Findings For the whole flight route, the Boeing 737 aircraft was sufficiently fuelled with certified fuel. The take-off weights and the landing weights were within the specified standards limitations. There was no airframe failure or the failure of the engine or systems. Before the accident impact there was no in-flight destruction or explosion. The weather conditions were appropriate for safety landing. The problem laid with the pilot or flight crew. Initial pilot training was not undergone by the pilot at a certified training organization. There was oversight of the aviation authorities at every level on the quality of training provided to the flight crew members. The Tatarstan Airlines did not have any proper risk management program and had an ineffective and inoperative safety management system.

The members of the plane crew were over worked and stressed, thus they were not able to handle a situation of emergency as effectively as it could have been. Their inability to perceive the warning signals that were indicating the disconnection of the auto-pilot during the go-around procedure, caused a great tragedy. The crew members should have been properly screened by the airline and their training should have met up with the required qualifications.

Recommendations Tatarstan Airlines need to introduce and implement a functioning and proper Safety Management System that: 

Contains a process that identifies existing and potential hazards associated with safety.

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Contains a process that carry out proper assessment risks associated with safety hazards present.

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Makes sure that safety performance is maintained through corrective actions.

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Ensures continuous monitoring of the processes.

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Ensures regular analysis safety indicators.

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Ensures constant improvement of safety management system’s performance indicators.

It is recommended that Boeing should introduce changes in their nose-up recovery procedure, so that it eliminates the chance of any misinterpretation by the pilots. The Tatarstan Airline should review its hiring and training procedures more diligently. The airline’s documents or guidelines outlining the training process should be revised. Additional training should be provided to the crew members as to how to handle a situation of emergency or any threats if they emerge.

There should be proper and rigorous screening procedure in the selection of crew members, so that no underqualified or ill trained individual should be selected. There should be quality check of the training organizations and the qualification of the teaching staff at the organization by the proper authorities on a regular basis. Regular joint conferences for flight personnel should be conducted so that they can share their experiences on a bigger platform. This will allow the employees or crew staff to become aware of possible situations that can arise during a flight and the proper cautions that can be taken to dissipate them.

Conclusion The crash of Tatarstan Airline’s Boeing 737 was caused due to inoperable system management system (SMS), deficiencies in determining and controlling existing and potential safety hazards, airline’s oversight over flight crew member’s training and unqualified flight crew members. The accident was caused due to the no initial flight training of the pilot, unqualified crew members, oversight of the airline in the quality of the training, the ineptness of the crew to act properly at the moment of emergency and inadequate risk control mechanisms. The preliminary report released by the Interstate Aviation Committee listed the probable causes of the crash. Among the causes listed, there was no mention of the failure of the aircraft, failure of the systems or engines of the plane. So it’s quite apparent that the problem didn’t lie with the plane or its engine and systems but with the crew members of the plane. The ineptness of the crew members can be traced back to the training authorities and the Tatarstan Airlines. It was partly Airline’s fault in not conducting proper training and screening of the crew members before embarking them on a flight. The crew members were not

qualified enough to handle an emergency situation. Their action during the emergency procedure resulted in the crash. The pilots and other crew members should have been properly trained in the scenario of a safety hazard taking place. They should have been properly equipped with the adequate skills, knowledge and training as how to conduct themselves during such situations and how to dissipate them. The ineptness of the flight crew members and the oversight of the Tatarstan Airline or the Aviation Authority at every level, not only resulted in the loss of 50 lives but also in the reputation of the aircraft manufacturer and the airline. No amount of compensation provided by the Tatarstan Airline’s insurance company could mount to the value of the lives of the victims of the Boeing 737 crash.

References 

Interstate Aviation Committee. (n.d.). Final Report, Boeing 737-500 (53 A) VQ-BBN. Retrieved from https://skybrary.aero/bookshelf/books/3640.pdf

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Ranter, H. (n.d.). ASN Aircraft accident Boeing 737-53A VQ-BBN Kazan Airport (KZN). Retrieved from https://aviation-safety.net/database/record.php?id=20131117-0

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Crash: Tatarstan B735 at Kazan on Nov 17th 2013, crashed on go-around. (n.d.). Retrieved from https://avherald.com/h?article=46b9ecbc

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Boeing airliner crashes in Russia, 50 killed. (2013, November 17). Retrieved from https://www.reuters.com/article/us-russia-crash/boeing-airliner-crashes-in-russia-50killed-idUSBRE9AG0A820131117

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50 dead as passenger jet crashes in central Russia (PHOTOS,VIDEO). (2013, November 17). Retrieved from https://www.rt.com/news/passenger-plane-crashkazan-866/

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Updated: Tatarstan Airlines' Boeing 737 Crashes in Russia. (2013, November 18). Retrieved from https://www.airlinereporter.com/2013/11/tatarstan-airlines-boeing737-crashes-in-russia/...