The Accident of Air India Express Flight 812 - Report Example

The accident of Air India Express Flight 812 University Student Id Course Date Introduction Flight 812 crashed in Mangalore airport as it was trying to take off after overshooting landing zone that was approximately 2000 feet. This is because the investigators had recovered the throttle of the plane in a forward position from the crash site. Investigations indicated that the pilot lost control of the airplane while approaching to land. The plane overshot a runway where it crashed in flames leaving 158 people dead where only eight people survived. The pilot had enough experience to manage safe landing, but he made some errors that caused the accident (Acharya, 2015). Some of the errors included not only overshooting the runway but also he made a fatal split error when he was trying to take off again as the pilot realized he could not control the plane after using brakes to stop the aircraft. Facts surrounding the flight 812 accident The pilot became disoriented when he was landing simply because of touchdown conditions of the aircraft. The air crash can be attributed to pilot error where the pilot failed to adhere to the regulations concerning flying and being on duty without taking a break. The pilot is said to lack enough rest as he had commanded the flight to Dubai Friday night and returned to Mangalore Saturday morning creating high chances that the pilot might have caused the error due to the lengthy journey that might have caused accumulation of stress (Avrenli, 2015). Pilots of Air India are said to experience compressed flying time contrary to the regulations as pilots need enough rest where the maximum time is around 1,000 hours within ten to eleven months. The pilot had contacted traffic controller center informing them that he was facing trouble in the process of descending through the clouds. From that time the controller is said to have lost radio contact and radar with the pilot and the plane. The helicopter support coming from California highway patrol could not respond to the accident due to the bad weather conditions as the weather was rainy and foggy. The accident analysis revealed that the pilot had deployed reverse thrust and made use of maximum manual brakes when he was touching down. There some possibilities that the plane could also be stopped within the run over the area that was paved in the runway avoiding fatal casualties. The accident can then be attributed to the misjudgment of the pilot leading to such fatal accident that led to the loss of man lives. The plan was scheduled to fly to Mangalore from Dubai at 06:30 on 22nd may 2010 where the plane overshot the runway making it catch fire. At the time of the crash, the weather was good as there were no rains where a drizzle just started shortly after the accident posing some challenges to the rescue team. The villagers were the first people to arrive at the scene to rescue the where rescue workers arrived at the scene to help with the rescuing process. Investigations The investigations behind the crash revealed that the aircraft landed around 200 feet beyond the expected point of touching down. The airline officials and staff of the airport were rushed to the crash site o start their investigations concerning the cause of the plane crash. They first started by rescuing the victims where a technical team was also sent to the scene to help with the investigations. Besides, a team of experts was sent to the scene to help to establish the real cause of the crash that involved technical advisers, air safety investigator, specialist in flight operations and aircraft systems specialist. According to the investigators, the pilot was given the clearance to land by suddenly stopped landing. This was because of the fact that the throttle handle of the plane was in the forward position a suggestion that the pilot was trying to abort an attempted landing aiming at taking off again. The report of the inquiry that was given to the civil aviation ministry was suggesting that the pilot slept for more than 90 minutes during the time of flight. The crash of flight 812 was associated with the tricky landing where the pilot was negotiating a safe landing. The accident analysis revealed that the pilot was attempting to reverse thrust where he applied maximum brakes manually at touchdown leading to the crash of the aircraft despite the fact that the overrun area had been paved of the runway (Jenamani & Kumar, 2013). The court also started investigations of the crash where the government appointed the then vice chief of air staff to conduct the investigations. The vice chief was expected to ensure that carry out the investigation to establish reasons that led to the crash where he submitted the findings. The government further made appointments of four experts to assist in the process of carrying out the investigation. The inquiry of the court started by the investigations that involved visiting the site of the crash and made a visit to the crash survivors aiming at gathering information necessary for the investigations. The beginning of the court inquiry started by making a three-day hearing to the public in Mangalore involving the interview of the witness and airport officials. The airport officials informed the court that the aircraft was approaching at a higher attitude than usual and attempted to land beyond landing zone. They also informed the court that the radar of the airport become in operations as from 20th might 2010. The chief fire officer of the airport informed the team doing the investigations that the crash tenders took around four minutes in the process of reaching the aircraft because the road reaching the aircraft crash was undulating and narrow. The cockpit transcript to the conversation of ATC was released that was indicating that the co-pilot was advising the pilot to go around immediately after informing the ATC that there was clearance to land. According to the doctor who was doing the post mortems, the bodies recovered from the crash showed that most of the deaths were caused by burns as the craft caught fire after crashing. The safety officer of Air India flight informed the team that the thrust reverse levers and thrust lever wee in forward position showing that the pilot had made some attempts at going round. The analysis of the CVR showed that there was a pilot who was sleeping in the cockpit as for more than 110 minutes the CVR did not pick any conversation of the pilots where deep breathing and nasal snoring were heard on the recording. The analysis of FDR was indicating that the flight began the final descent at 4,400 feet attitude instead of the usual attitude of 2,000 feet. The aircraft touched down prematurely where the pilot miscalculated the landing leading to the crash. After a long period of inquiry, the court made the conclusion that the primary cause of the accident was because of the error of the pilot as the flight path was incorrect. Reason's Swiss cheese model Reasons model is also known as the Swiss cheese model that is based on the approach that organizations need to employ in the process of ensuring efficient and safe operations. The approach is mainly from the perspective of the pilot aiming at maintaining safety during the flight operations. The system incorporates both mechanical and human aspects in the process of managing safety issues. When using the reasons model holes are used to represent failure or weakness where the holes do not lead to accidents directly due to the defense layers that do exist but once the holes in the model line up an accident can occur. The model has layers that can include unsafe supervision, organizational influences unsafe facts and preconditions. Organizational influences: this layer of the model entails the resources management of the organization and organizational climate. For instance, the crew understanding of the bad weather, maintenance, and equipment. Unsafe supervision: this layer of the model includes inappropriate operations, inadequate supervisions, supervision violation and failing to correct a problem. For instance, failing to of emergency training to the new employees can result in an increase in accident risk. Unsafe action: this layer entails the unsafe action may not cause accident directly ad precautions that can result in an accident. Error and violation: the layer shows that violation and error are part of the actions in the management of safety that are unsafe. Errors can be used to refer to the individuals who are failing to perform in the right way while violation was breaking the set rules. Investigating using reasons model Investigators of an accident make use of the reasons model to investigate the accident using the four layers in the process of trying to determine the cause of the accident. The failure investigators do focus mainly on two categories of failure that can include latent failure and active failure. Active failure Active failure entails unsafe actions that are conducted by a person directly leading to the accident. The investigators at that point are in a position to identify the cause of the accident as the pilot error. In this case, the pilot error can include misunderstanding of the instructions, misconduct in the emergency procedures, ignoring warnings as it was in the case of flight 812 of the air India express. The systems of the aircraft made several warnings to the pilot, but he ignored leading to the crash. The effects that are caused by active failure are likely to show up immediately making active failure dangerous to safety when flying. The primary cause of the accident was caused by the pilot error as he failed to follow the necessary procedures during an emergency. Latent failure: Latent failure is mainly associated with the high-level management. The investigator, most of the time, do ignore the latent failure as it can remain unrealized for a long duration. In the process of investigating the latent failure three level are used to make an assessment. First, they assess whether the management affects the behavior of the pilot. For instance, as it was in the case of the accident of flight 812, the pilot was said to be fatigue because of the tight working schedule as their working hours were compressed. This is an example of latent failure where the management can contribute to the accident through failing to ensure enough rest of the pilot hence creating the potential for the accident to take place (Raj & Balasubramanian, 2015). Therefore, the crash can be indirectly associated with the failure of the manager in ensuring that the pilot does not experience fatigue due to long working hours. Second, the investigator can track the accident precursors that are related to the latent threats. According to the investigation of the accident, the pilot was experienced but probably his miscalculation in the process of landing might have caused the accident. Lastly, investigators can carry out an assessment of the organizational failure to get to know whether the organization can be associated with the accident. For instance, the management failed to ensure that there was enough accident safety in the runway. Corrective actions that might have prevented the accident There is various corrective action that could have avoided the accident from happening. These corrective actions can include ensuring that the pilot had enough time to rest as he was working under stress of long hours in work leading to fatigue. Investigations showed that the pilot might have slept for more than 90 minutes creating some possibilities that sleeping was the cause of the poor landing procedure as he had no time to prepare for the landing. Besides, according to the experts, the runway of the Air India Express posed serious threats as the airport did not have sufficient safety measures on the runway. The international standards of the runway are around 200 meters, but the airport runway was just 50 meters creating high chances of accidents due to the short runway. The Mangalore airport lacks approach radar that could have helped in warning the pilot about the speed, altitude and the glide path hence creating possibilities of preventing the accident. The lack of the approach radar forced the pilot to make use of his judgment and instrument landing system to land. External threats that can threaten the safety of the flight The major external threat to the safety of Flight 812 was landing error. The pilot made miscalculations while landing as he delayed the landing process. The investigations showed that the two pilots might have been sleeping and realized that they were almost landing late. As a result, they ended up crashing the plane. Flight 812 overshot the runway causing many deaths of both the crew and passengers. The pilot failed to discontinue the landing and continued with the landing despite the cautionary calls warning him not to land (Wiegmann, 2003). The pilot decided to land despite the plane being too high to land forcing him to descend at high speed of 4000 feet/minute. Importance of the following and their application on crew errors Communication: it is important in the process of managing the errors that can be caused by the crew where through proper communication the cockpit controller can ensure proper coordination. Procedural: many accidents in the aviation industry have been caused due to the failure of the crew to ensure standard procedures are followed. The procedure is important to the crew as they ensure that they are in a position to avoid possible accidents. Proficiency: English proficiency is essential among the crew in the process of managing emergency situations as the crew can be able to ensure situational awareness. Intentional non-compliance: intentional noncompliance does increase the chances of accidents due to the mismanagement of errors and threats hence it is crucial for the crew to be keen to avoid noncompliance. Operational decision making: decision-making ability among the crew is crucial in the process of selecting the best alternative decision that can help in solving the targeted problem. HFACS model This model is a human error framework that is used in the process of investigating and analyzing the human factors in the aviation sector (Salmon, 2012). The model can be used in describing human errors using various levels that can include the following: Unsafe Acts The unsafe acts are usually categorized into two divisions which are; the errors and the violations. These two categories are further categorized into subcategories whereby the errors are categorized into decision, skill-based and perceptual errors. The violations are categorized into routine violations and the exceptional violations. The term error refers to the unintentional behaviors whereas the term violation is used to refer to the willful disregard regarding rules as well as the regulations. The flight accident can be associated with the unsafe acts of the pilot in the process of landing. Preconditions concerning Unsafe Acts This level entails the prevailing preconditions which are related to the unsafe acts are divided into three major divisions which are operations conditions, environmental factors, and personnel aspects. The divisions can further be divided into sub-divisions whereby the environmental factors are further divided into the physical and technological environment (Kumar & Kumar, 2013). The operator conditions can be categorized into adverse physiological and mental state. The environmental aspects include physical and technological factors and have an impact on the conditions of an individual. The pilot was not ready to land making him make the landing decision at the wrong time. The conditions of operators here refer to the mental limitations which affect the practices of an individual. On the other hand, the personnel factors are the crew resource management which has impact on the practices of individuals. The lack of personnel readiness can be associated with the accident of the flight. Unsafe Supervision The unsafe supervision in aviation can be categorized into four divisions that include inappropriate operation plan, inadequate supervision, failure to correct existing problem and supervisory violation. Under inadequate supervision category, the function of the supervisor entails creating chances for their staff members to perform their tasks safely and also efficient (Shaji & Subbulakshmi, 2013). The plan inappropriate operation usually refers to the certain operations which are accepted in times of emergencies, but they are not accepted during normal conditions for operation. The term supervisory violation is usually used to refer to the various cases when the supervisors willfully violate the both rules and the regulations which exist. In the accident, there is no supervision violation only the pilot violated the rules and regulations when landing. Organizational Influences The organizational influence is categorized into divisions that include the company climate, operational process, and resource management. Resource management is applied when making a decision concerning the allocation and the maintenance of the corporate assets. The term organizational climate is used to refer to the working conditions found in an organization such as the policies and also the culture (Kumar & Kumar, 2013). On the other hand, the term operational process is used to refer to the both of decisions and the rules which constitute the daily activities in an organization such as the oversight and also the procedures. The operational process was violated by the pilot who delayed initiating the landing process causing the accident. References Acharya, A. B. (2015). Role of forensic odontology in disaster victim identification in the Indian context. Journal of Dental Specialities, 3(1), 89-91. Avrenli, K. A. (2015). Effectiveness of adaptive flight planning in the occurrence of total loss of thrust due to bird strike (Doctoral dissertation, University of Illinois at Urbana-Champaign). Jenamani, R. K., & Kumar, A. (2013). Bad weather and aircraft accidents- global vis-a-vis Indian scenario. Current Science(Bangalore), 104(3), 316-325. Kumar Jenamani, R., & Kumar, A. (2013). Bad weather and aircraft accidents–global vis-à-vis Indian scenario. Current Science (00113891), 104(3). Raj, Y. E. A., & Balasubramanian, S. V. (2015). Indian Meteorological Society, Chennai Chapter Newsletter Vol. 16, Issue No. 1, June 2015. Salmon (2012). "Systems-based analysis methods: a comparison of AcciMap, HFACS, and STAMP". Safety Science. Shaji, N. S., & Subbulakshmi, T. C. (2013, December). Black box on earth-flight data recording at ground server stations. In 2013 Fifth International Conference on Advanced Computing (ICoAC) (pp. 400-404). IEEE. Wiegmann, Douglas A (2003). "A Human Error Approach to Aviation Accident Analysis: The Human Factors Analysis and Classification System"  Read More