Flight 1420, A Preventable Disaster free essay sample

Flight 1420 was a disaster that taught the aviation community several important lessons. All the Seven Major Elements of Aviation safety can be seen as contributing factors but the greatest factor was human error and the impact of pilot fatigue. With proper preventative measures, the pilots probably would have had the time to arm the MD-82’s spoiler system and the flight would have touched down safely. On June 1st, 1999 American Airlines flight 1420 experienced a tragic accident that claimed many lives and made an impact on aviation worldwide. The event and it subsequent investigation shed light on issues and pressures airline pilots face and resulted in new technologies and new regulation that have made aviation safer for all pilots and passengers. Any aviation accident that results in the death of pilots or passengers is a tragedy but these accidents present lessons to be learned through investigation of the human factors, industry efforts and regulation and other factors of aviation safety. American Airlines Flight 1420 is an excellent example of James Reason’s Swiss Cheese Model of accident causation, whereby causal factors in an accident slowly slip by preventative measures until they compound into a preventable accident. A variety of contributable actions and conditions ultimately lined up to create the opportunity for a major accident to occur. The first action in the chain can be found in the flight plan from Dallas-Ft Worth International Airport to fly to Little Rock National Airport in between two converging storms, called a â€Å"bowling alley† by the flight dispatcher. The aircraft was on its final leg, on a multi-leg flight that started at Chicago O’Hare and the conclusion of a 3-day sequence for the flight crew. The plan to race the storm was not in violation of any company policy or Federal Aviation Regulation but could be deemed risky. The pilots were experienced Captain Richard Buschman and inexperienced First Officer Michael Origel, and both were willing to try and fly between the storms to reach Little Rock. At this point in time, the flight was already two hours delayed and the pilots were already under heavy pressure to make up lost time. (Singer, 2003) This could have hypothetically set the stage for future mistakes and reckless behavior to occur. Later in the event, the pilots would be faced with an extremely heavy workload and it could be assumed the anxiety only compounded on initial worries. As the flight progressed, and the aircraft approached its destination, the flight crew had some confusing interchanges with Little Rock Air Traffic Control (ATC). It became apparent that Little Rock ATC had inferior weather technology compared to the American Airlines McDonald Douglas MD-82 and the controller instructed the flight crew to make their own weather analysis based on the onboard weather radar. (Singer, 2003) Little Rock ATC was equipped with a monochromatic radar that inhibited the controller from noticing the strength and intensity of the approaching storm, enhanced technology could have enabled the controller to alert the aircrew (who may not have been as knowledgeable of weather systems) to the growing intensity of the weather. To compound an already stressful situation ATC also informed the inbound aircraft that surface winds were gusting up to 45 knots, this far exceeded the MD-82’s crosswind limitation of 25 knots. The crosswind limitations for the MD-82 also are specified for dry runways, Flight 1420 was going to be landing in a thunderstorm and crosswind capability on a wet runway is 15 knots. The aircrew decided that since the wind direction was 40 degrees from their vector for the runway and that the aircraft could safely land and the flight continued as planned. As the aircraft neared the airport the aircraft began sending pilot’s windshear warnings via the flight deck computer. The aircrew requested an alternate runway and diverged from the planned approach and requested an alternate landing on runway 4R, opposite of 22L (which was the planned runway). This was a wise decision as landing in a tailwind is one of the most precarious situations a pilot can face, but the added workload of developing a new landing pattern from scratch added one more layer of stress and pressure to the issues that had been mounting since Dallas Ft.Worth. The alternate runway pattern added an additional ten minutes to the pilot’s 2 hour delay. The pilot workload exponentially increased as the aircraft entered in a new pattern and began to have great difficulty establishing a visual fix on the airport. When asked if the aircraft was going to shoot an ILS approach or continue on visual the captain elected to remain on a visual approach. Afterward it can be guessed that Captain Buschman didn’t expect the storm to intensify even further as he neared the field. The aircrew lost sight of the field as the storm worsened and was given approach vectors by ATC. The flight deck voice recorder indicated there was confusion between the pilots and there was a disparity between what one pilot was observing as opposed to the other. (NTSB 2001) As the aircraft finally was lined up final approach the runway visibility dropped to less than 1 mile with a runway visual range of 3000 feet. The crew had a brief disagreement on whether to continue the landing and elected to attempt it. On approach wind were gusting at 45 knots. The aircrew was under immense pressure as the aircraft descended, running through landing checklist, countering the crosswinds and dealing with last-minute configuration changes. The aircrew then made the critical error; they did not arm the spoiler system or the automatic braking system. The spoilers on the MD-82 are designed to disrupt airflow over the wings and eliminate lift so that the weight of the aircraft transfers fully to the wheels. As the aircraft touched down at high speeds, the spoilers never deployed. The aircrafts wheels only supported 10% of the aircraft’s weight as it careened down the runway. (NTSB, 2001) The aircrew noticed that the aircraft was sliding and not losing airspeed, Captain Buschman immediately deployed full brakes. The brakes on the MD-82 would have engaged automatically but were never armed to do so, this isn’t wrong as it is an optional function and the Captain opted to not arm them. However the aircrew also expected the spoilers to deploy and crucial seconds were lost in the pilot’s reaction time. From the cockpit Captain Buschman’s words were â€Å"Were down, were sliding†. The reverse thrust was immediately applied, however too much was used, exceeding the aircrafts recommended pressure ratio. This also is not necessarily wrong as the MD-82 flight manual states that exceeding recommended reverse thrust is acceptable in the event of an emergency. However, the aircraft was still technically flying and the result was a total loss of control as the aircraft began yawing wildly. The aircraft slid of the end runway and slammed into a steel walkway. The walkway was part of  the landing system for runway 22L, most systems like this are designed to be â€Å"frangible†, meaning they will shear off easily after impact. This landing system however was on the slopes of the Arkansas River bed and was firmly rooted underground. Contact with this walkway broke the aircraft into 3 parts and ignited the fuel system; it also killed Captain Buschman instantly. Many passengers revived the crash; emergency services arrived promptly on the scene and began evacuating people from the crash site. Most of the passengers escaped the crash, however 10 were fatally injured. Among 139 passengers, 41 had serious injuries, 64 had minor injuries and 24 escaped unharmed. This qualifies the accident of Flight 1420 as a Fatal, Major Accident. The National Transportation Safety Board (NTSB) investigated the crash; its lead investigator was Gregory Feith. The NTSB set up a command center on site and spent 2 months in the field collecting data. The investigation was conclusive; some of the areas examined were the tire marks from the aircraft skidding which lent evidence that the aircraft was unable to slow down even with full braking pressure applied. Analysis from the flight computer showed the corrective actions the pilot attempted during the skidding; suggesting that the aircraft was still generating lift long after the aircraft had been grounded. Testimony from the passengers and evidence taken from metallurgist confirmed that the aircraft spoilers did not deploy in the entire course of the landing and crash. (Associated Press, 1999) The investigator also did widespread test on airframes similar to the MD-82 to determine if a spoiler malfunction could be found anywhere else in the industry, no compelling evidence was found to indicate the aircraft had a malfunction. The NTSB also tested the runway extensively for unserviceability and ability to transfer water, the runway was found to be serviceable. The classification for the crash was fatal as the pilot and 10 passengers suffered fatal injuries. In 2001, two years after the crash the NTSB finalized their report and listed the following as the probable cause; NTSB (2001) â€Å"The flight crew’s failure to discontinue the approach even when severe thunderstorms and their associated hazards to flight operations has moved into the area and the crew’s failure to ensure the spoilers extended after touchdown. There were numerous legal charges and lawsuits following the crash. In hearings afterward the co-pilot claimed to have called for an abandoned approach but no evidence could be found that supported his claim. (Lunsford 1999) The legal impacts encompassed both a domestic and international passengers. Air Traffic Control technology was an element in the disaster. Little Rock ATC was not equipped with advanced radar equipment that could determine the magnitude of storms. The Dallas Ft.  Worth Flight Dispatcher also did not have access to real time weather such as a Doppler Radar, and was unable to give the flight updated weather information. (NTSB, 2001) If the flight dispatcher or Little Rock ATC had been equipped with a greater weather system they would have been able to alert the crew of the sudden increase in storm intensity. The aircraft weather technology played a role as well. The MD-82 is equipped with windshear detection that functioned as it should, however such technologies did not sound alerts until the aircraft was in the middle of the adverse weather. The MD-82 is also equipped with advanced weather radar technology and the pilots could see the progression of the storm. However subsequent investigations show that the aircrew may not have had the training needed to interpret the radar effectively. (NTSB, 2001) Human Factors, such as stress and fatigue had a major role in Flight 1420’s accident. Industry-wide studies showed evidence that willingly flying into thunderstorms was a common practice. Studies were conducted that observed Dallas Ft. Worth airport during convective weather it was found that 2 out of 3 pilots would continue into a thunderstorm. The term â€Å"get-there-itis†, meaning a symptom of pilot recklessness when behind schedule was coined during the trials and became studied throughout the airline industry. American Airlines has since revamped its human resource policies to address rest and fatigue, the airline also incorporates new training modules designed to train aircrews to challenge each other en flight on action items (such as arming spoilers). During the crash investigation, a test was also conducted to show the aircrew’s likelihood of error related to their Time Since Awakening (TSA). As to be expected it was found that pilots begin to make errors exponential to their fatigue level. Captain Buschman and First Officer Origel had both been awake over thirteen hours, a critical TSA period in which pilots are 40% more likely to make critical errors. (NTSB, 2001) American Airlines changed many of their operating regulations and policies following the accident. One measure is a revised landing checklist to include arming spoilers, also it specifies it is the non-flying pilot’s duty to challenge all the action items on the checklist and it is the specific duty of the flying pilot to arm the spoilers. American Airlines also made changes to its go-around policy and explicitly states now that electing a go-around for diversion is reprise-free. The Flight Safety department of American Airlines also revamped its operational practices to focus more on identifying and tracking big-picture operational trends and revised thunderstorm procedures. A measure was also clarifying landing limits for pilots, especially in convective weather. Pilots of American Airlines also have weather radar familiarization and now carry a weather radar booklet during the flight. (NTSB 2001) The Massachusetts Institutes of Technology’s (MIT) study on the behavior of pilots flying into thunderstorms made large impact industry efforts as well as on safety data analysis. Not only was it observed that 2 out of 3 pilots will fly into a strong thunderstorm but that pilots were more likely to not accept a diversion the closer to the end-goal they got. The NTSB recommended a standard crew duty day be implemented to help pilots avoid the risk high-TSA flight time. (NTSB, 2001) If the trend of pilots flying into dangerous territory had been spotted earlier, airline management could have taken steps to change organizational culture to discourage â€Å"get-there-itis†. American Airline’s Safety Action Program shifted its focus to identifying similar trends and many airlines worldwide adopted related policies. It can be gathered that different methods of gathering safety data could have exposed this trend earlier. The events of flight 1420 forever changed the lives of the passengers, their families and the employees of American Airlines. (Harter, 2001) This incident had a wide-range of impacts on the aviation industry; many airlines became aware of the dangers of pressuring pilots to adhere to deadlines, and the reckless behavior that can result from it. Many airlines realized a training gap existed in pilot’s ability to interpret and make decisions based on weather radar. Also pilots learned that performing task in the cockpit should be the responsibility of all pilots involved, that even experienced and seasoned pilots can make great mistakes under duress. Hopefully the lessons learned have saved other lives somewhere in the world of aviation and hopefully the industry continues learn and improve from this tragedy.