Human Factors in Aviation Safety - JetBlue Airways Flight 292 - Essay Example

Running Head: Human Factors in Aviation Safety Human Factors in Aviation Safety: JetBlue Airways Flight 292 (School) Human Factors in Aviation Safety: JetBlue Airways Flight 292 On September 21, 2005, a JetBlue Airbus A-320-200 aircraft was diverted to Los Angeles where it landed at Los Angeles International Airport (LAX). The flight was on its way to John F. Kennedy airport in New York from Burbank, California, when it was discovered that the wheels beneath the nose could not be retracted and were turned sideways. The pilot circled Long Beach airport to rid the plane of excess fuel before landing at LAX. The landing was made safely and none of the approximately 146 passengers and crew on board was injured. The incident was investigated by the Federal Aviation Agency (FAA) and the National Transportation Safety Board (NTSB). At the time, it received high-profile attention from the media, which covered the incident on live television (JetBlue plane, 2005; JetBlue passengers, 2005; JetBlue Airways, 2006). The purpose of this paper is to explore the human factor as it relates to this mishap. What is the Human Factor in Airline Safety The pilot and crew are the first to become the focus of any airline mishap. Other human factors involve maintenance, traffic control and aircraft design. As noted by Wikipedia, "the ability of the flight crew to maintain situational awareness is a critical human factor in air safety" (Air Safety, 2006). A broad definition of situational awareness in flight is observing everything that happens in the immediate area and determining its importance in a complex environment. Initiation of a pilot checklist in 1937 and the relatively new concept of situational awareness have contributed to aircraft safety. Even so, pilot error is considered the most common factor of aviation crashes. Although it is often a factor in midair collisions, additional causes might be due to adverse weather conditions. Crew resource management (CRM) training is another recent effort to reduce pilot error. Terrorism has been added to the human factor list following 9/11/1001, which involved four different commercial aircraft (Air Safety, 2006). In the case of the 2005 JetBlue mishap, pilot error was never an issue. In fact, Robert Boser, editor of Aviation Safety.com, commended the pilot, Captain Scott Burke, who managed to stop the plane in the middle of the 12,000-foot runway at LAX without having the nose break off. The only damage to the plane was in the front wheel area and no one was injured. Because of sparks and smoke, Burke asked if there was any fire visible, but did not receive an answer from the tower. He therefore used air stairs to disembark the passengers for safety reasons (Boser, 2005). This was his response to an emergency in progress, but was there some way he could have known the problem existed before takeoff What Were the Contributing Factors What were the human factors involved in this incident and how well was the emergency handled In addition, why did it happen at all In the case of pilot error, possible factors that could be involved are alcohol use, nicotine addiction withdrawal, error in copying air traffic control clearances, or mental illness. In the JetBlue incident, the pilot and crew were exonerated of any blame and in fact were lauded. Other factors include oversights in aircraft maintenance, mistakes in air traffic control, or weaknesses in aircraft or equipment design. One question in the relatively short history of JetBlue Airlines is whether such a problem has occurred before. And if it has, what was the cause and what human factors were involved JetBlue has only been in business for six years and offers low fares and extra incentives such as live television, leather seats and wireless Internet, which are not available on other popular low-cost airlines such as Southwest. Because of the passengers' ability to watch CNN on the airline's DirectTV hook up, however, with televisions at every seat, they were able to follow the emergency as it occurred, not knowing of course what the outcome would be, especially since the video system was turned off before landing (JetBlue Airways, 2005). This is a human factor not previously in existence in aircraft safety, and the repercussions of this technology had a notable effect on the people in the plane as well as promoting excessive media coverage that might not have occurred without the live-coverage aspect of the situation. It was not a contributing factor to the incident but it certainly brought it to public attention. CNN covered the incident , and MSNBC published an online article describing it with a photograph captioned "Flames stream from the broken nose gear of a JetBlue Airbus A320 as it makes an emergency landing at Los Angeles International Airport Wednesday" (MSNBC, 2005). It should be noted that Captain Burke had asked the tower if there were any flames and did not receive an answer. He therefore made the right choice when he used emergency measures to remove the passengers. The quotes from passengers regarding their experience indicated that it definitely had a traumatic effect, one that would not easily be forgotten. Emergency measures were followed on the plane, with passengers asked to assume a crash position, with their heads between their knees" (MSNBC, 2005). In retrospect, however, Wikipedia stated that former airline pilots and safety experts believed that, despite the drama, there was actually little real danger to the passengers or crew of the A320, which like all modern airliners is massively over-engineered for safety, and, in fact, could be landed without any nose gear at all (JetBlue Airways, 2006). The A-320 is JetBlue's major carrier with the recent acquisition of several smaller Embraer 190 aircraft, and a similar incident, with a sideways landing gear but no live coverage, occurred on an America West Airlines A320 flight in 1999 (JetBlue passengers, 2005). The National Transportation Safety Board found that the cause was a "failure of the external 'O' rings in the nose landing gear steering module" (MSNBC, 2005; Boser, 2005). The French had issued, prior to this incident, a service bulletin reporting the problem, but America West chose not to follow up on it, resulting in the emergency landing (Boser, 2005). Had this been the only such incident until the recent mishap, JetBlue might have considered the problem resolved, but it did not happen just once. On November 1, 2002, "An Airbus A320, being operated by JetBlue, landed at the John F. Kennedy International (JFK) Airport, New York, New York, with its nose landing gear (NLG) turned 90 degrees" (Boser: Analysis and Findings, 2005). According to Boser, this airplane had come out of maintenance where the NLG dynamic seal was replaced approximately three days prior to the incident. It was what he called a "design-induced maintenance error." The report of this maintenance action did not say there was any connection between the repair and the fault. If this had been the first time it happened, the maintenance action might have been an issue. But it was not the first, and Boser further noted that Messier-Dowty, manufacturer of the NLG shock absorber, reported two other similar incidents, one involving a Canada 3000 A320 and the other in Ireland. No injuries were reported. Following the November 1st incident, a United Airlines A320 experienced the same problem on November 21, 2002, but it did not become evident until the plane had landed and sparks could be seen coming from the nose gear. Again, no one was injured. Additional incidents brought about by Boser's so-called design-induced maintenance errors, were as noted below: Feb. 2, 1995. VASP B737. Emergency return to Sao Paulo, overran runway followed by collapse of nose and right main landing gear. No. 3 leading edge flap actuator fractured due to corrosion. Some 1981 Boeing service bulletins not complied with, including one calling for replacement of the aluminum leading edge actuator with a steel one. No injuries. Aircraft hulk used as fire trainer. Nov. 6, 1997. Royal Air Force BAe146 (one of three aircraft used to transport the Royal Family). Emergency landing at London Stansted Airport. Loss of oil from all four engines of aircraft. Magnetic chip-detector plugs (MCDPs) had been installed without oil seals ('O' rings). Supervisor with no engine maintenance training performed the work himself, asked a technician to sign the job card as doing the work, and then signed as the person who supervised the work. No injuries. More Maintenance Mayhem 2002 Could the Incident Have Been Prevented The landing gear problem was discovered almost immediately after the A320 departed Bob Hope Airport in Burbank and was airborne, and the Airbus was required to circle the Long Beach Airport before being cleared to land at LAX. According to Federal Aviation Administration spokesperson Donn Walker, "it stayed in flight for three hours to burn off fuel" (JetBlue passengers, pars. 7-8). Although some news media reported that pilots were dumping fuel over the ocean, the Airbus A320 does not have the equipment to do this and excess fuel had to be burned off in flight. This was done to lighten the plane and reduce potential stress on the landing gear. (JetBlue Airways, 2006). Since the plane was in the air when the problem presented itself, in this particular case the problem could not have been prevented. According to the FAA and NTSB, the event was not even considered an accident because "malfunctioning landing gear occurs several times a year around the world" (Significant Safety Events, 2005). The significance, as noted by Airsafe.com, was because of the extraordinary media attention. It is quite possible that safety inspection did not recognize the recurring problem of defective equipment in the landing gear, perhaps because insufficient research had been done on past incidents. Perhaps it was because there was no way to determine the problem until the plane was in the air. It would seem that one small part in the nose landing gear could have been redesigned at some point between 1999 and 2005 so that such mishaps would no longer occur. Preventative Measures and Recommendations In Narinder Taneja's 2002 study of human factors in aircraft accidents, the holistic approach to investigation was encouraged. The paper presented a chart on human error, linking aircraft with subheadings of mechanical and engineering design to aircrew with subheadings of selection and training (Human Factors). In an electronic age, connections can be made to every aspect of investigation regarding air safety, and a human factors framework and database could present an overall view leading to a specific area of concern. In the case of JetBlue's Airbus A320, the FAA and the Department of Transportation, an airworthiness directive (AD) was issued, effective November 30, 2005, inspecting and correcting, if necessary, braking and steering control units as well as a check of the NLG strut inflation pressure to determine if adjustment was necessary. Also required was a revision to the aircraft flight manual (Airworthiness Directive, 2005). Perhaps this should be carried one step further and the whole unit should be redesigned and replaced in the selected Airbus models A318-100, A319-100, A320-200, A321-100 and A321-200. Boser (2006) stated that the A320 incident was only one of at least 67 "nose wheel failures" on the models above. The AD, in this case, referred only to the most recent JetBlue A320 incident, but research indicates the problem has existed for quite some time. A 2004 article by SARMA's Bernard LeFevre mentioned the Airbus A320 nose wheel steering control unit but made no mention of any problems with it. This equipment, LeFevre stated, is used to "steer the aircraft before take off and after landing on the runway and replaces a mechanical system. The 'wire' control is more accurate and offers weight saving." (par. 20). The A320 is controlled with "fly-by-wire" technology with hard limits. In other words, the computer makes the decisions in a number of different areas, and the pilot cannot override the controls. The A320's closest competitor, the Boeing 777, does have an override. However, in both cases, problems can occur. For instance, in one case involving the A320, the pilot flew too low and the computer automatically landed the plane, running into the trees. In another case, with the Boeing, the pilot went into override but forgot one of the steps, and the plane ran into a mountain. (How does the fly-by-wire, n.d.). The fly-by-wire system warns the pilot of malfunctions in equipment after the fact, but it cannot prevent them. This is where the pilot must make decisions, regardless of whether override is an option or not. In the case of the 2005 JetBlue incident, the right decisions were made once the malfunction was discovered. Future plans: Electronic Flight Bags (EFB) Airbus has decided to trial EFBs in 2006 with the possibility of using them on all of its fly-by-wire aircraft (Electronic, 2006). What is an electronic flight bag and does it have the potential to predict malfunctions before they happen There are two types. One is a small portable computer that takes the place of the flight bags filled with hard copies of instructions that pilots must take with them on flights. This type of EFB can be wireless, LAN-enabled, or used with USB memory sticks, allowing the pilot to download updated information as necessary before takeoff. The second type of EFB is fixed in the cockpit and can access critical systems before, during, and after takeoff. The question is: Could it access and report malfunctions in equipment, such as the nose landing gear steering module The Airbus's fly-by-wire technology allowed the pilot to discover the NLG problem almost immediately after takeoff, but not while the plane was still on the ground. Would an EFB be capable of programming that would predict the problem before takeoff The EFB is still in its experimental stage, and prediction of possible malfunctions would be a useful application in the interests of safety. Regardless of the assurances of safety experts that the plane could have been landed without any nose gear, it doesn't mean that there was no danger. The plane could have caught fire, the brakes could have failed, and the nose could have touched down too soon, causing injuries to the passengers and crew. Safety issues resolved The FAA directive regarding the NLG and steering control that required feedback by November 30, 2005, was introduced in June 2005 (Airworthiness Directive). The JetBlue incident occurred on September 21, 2005. Since the AD had been issued before this incident occurred, why was the defect not taken care of, or was it repaired and considered safe If so, what went wrong Perhaps one answer lies in the fact a similar directive was issued in July 2004 and Airbus designed an integrating ring and seal that was in the process of being tested for qualification purposes (Boser, 2005). Was the design still in the process of being tested as of September 21, 2005. If so, it either did not work or it was not being tested in the Flight 292 Airbus. Conclusions JetBlue has experienced phenomenal success since its inception in 1999. If the 2005 landing incident had resulted in fatalities, especially given the live coverage for the event, it would have had a devastating effect on a company whose safety record until that time had been impeccable. Because it is so new, it doesn't have a realistic statistical record of safety. Although the A320 Airbus has been involved in mishaps, no fatalities have been recorded. It should be noted that the live news coverage added to the traumatic effect of the incident. The in-flight video was turned off before landing, but was that helpful or harmful Either way, the thought of live coverage is frightening for passengers who are facing death. This is one area that requires further study. Obviously, JetBlue meant well, offering their passengers extra benefits at a low price. But this benefit could backfire very quickly in the event of a crash leading to fatalities. In the case of United Airlines Flight 93, one of the four hijacked planes involved in the 9/11/2001 tragedy, several passengers had mobile phones and were in contact with family and officials while the event was in process. There were no survivors following the crash in Pennsylvania (United Airlines, 2006). In this case, it was determined that the actions of the passengers forced the hijackers to divert the flight away from Washington, D.C. to Pennsylvania. Terrorism is a new concept in airline safety, but it is a subject that requires follow-up, especially since the EFT in-flight technology could possibly prevent the hijack before it occurs. Technology offers capabilities in aircraft safety that have yet to be determined. In the meantime, Roger Hughes, manager of human factors with JetBlue Airways, believes that education in human factors for maintainers as well as for pilots will reduce aircraft accidents/incidents/injuries. According to Hughes, the Maintenance Error Decision Aid (MEDA), developed by Boeing, is an approach he believes will force identification of all factors and bring about a team effort at resolving issues (Change Agent, 2006). The MEDA event database, Hughes said, is "one source of measurement in tracking trend data" (Change Agent, 2006, final par.) The conclusion reached in this paper is that the leading factor in the JetBlue Flight 292 incident is the defective NSG, which involves several human factors: the designer of the equipment, the maintenance crew, and the pilot who must make immediate decisions in the case of a mishap. It is obvious that efforts have been made to correct the problem, but no recent data is available to support its resolution. References Air Safety: Human Factors. (page last modified April 20, 2006). Wikipedia, the free encyclopedia. Retrieved April 22, 2006, from: http://en.wikipedia.org/wiki/Air_safety Airworthiness Directive. November 16, 2005. Federal Aviation Administration. Retrieved April 22, 2006, from: http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/0/dab3d387241954d5862570c2005d49bc!OpenDocument&ExpandSection=-4 Boser, Robert J., ed. (September 21, 2005). JetBlue Emergency Landing: LAX 050921. Updated September 26, 2005. Aviation Safety.com. Retrieved April 18, 2006, from http://www.airlinesafety.com/editorials/JetBlueLAX.htm Change Agent: Interview Roger Hughes, JetBlue Airways. March 1, 2006, Aviation Today. Retrieved April 24, 2006, from: http://www.aviationtoday.com/cgi/am/show_mag.cgipub=am&mon=0306&file=changeagent.htm Electronic flight bags: to integrate or not to integrate. (2005). Flight International, December 20, 2005, pp. 10-11. Retrieved April 23, 2006, from: http://www.sita.aero/News_Centre/Publications/Solutions_at_SITA_Q1_2006/Features/Electronic_flight_bags_to_integrate_or_not_to_integrate.htm How does the fly-by-wire in Boeing 777 differ from the Airbus system (n.d.) Air Travel [online), FAQ 9. pars. 6-7. Retrieved April 23, 2006, from: http://www.geocities.com/khlim777_my/asB777vsA340issues.htm#How JetBlue Airways Flight 292. Page last modified April 6, 2006, Wikipedia, the free encyclopedia. Retrieved April 19, 2006, from: http://en.wikipedia.org/wiki/JetBlue_Airways_Flight_292 JetBlue plane lands safely at LAX. (2005). USA Today. 9/21/2005. Retrieved April 18, 2006, from: http://www.usatoday.com/travel/news/2005-09-21-airliner-emergency_x.htm JetBlue passengers watch live coverage of plane's equipment problems. (2005). USA Today. Retrieved April 18, 2006, from: http://www.usatoday.com/travel/news/2005-09-22-jeblue-fliers_x.htm Lefevre, Bernard. (2004). New technology lowers cost per aircraft passenger. SKF Evolution. October 18, 2004. Retrieved April 23, 2006, from: http://evolution.skf.com/zino.aspxarticleID=620 More Maintenance Mayhem. (August 18. 2002). Air Safety Week. Retrieved April 21, 2006, from: http://www.findarticles.com/p/articles/mi_m0UBT/is_32_16/ai_90503146 MSNBC. (September 22, 2005). Emergency landing televised on JetBlue flight. Retrieved April 21, 2006, from: http://www.msnbc.msn.com/id/9430871/ Significant Safety Events Since 2000 for JetBlue Airlines. 2005. Retrieved April 19, 2006, from: http://www.airsafe.com/events/airlines/jetblue.htm Taneja, Narinder. 2002, Human Factors in Aircraft Accidents: A Holistic Approach to Intervention Strategies. Proceedings of the 46th Annual Meeting of the Human Factors and Ergonomics Society. Retrieved April 21, 2006, from: http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/humfac02/tanejahf02.pdf United Airlines Flight 93. 2006, Wikipedia, the free encyclopedia. Retrieved April 24, 2006, from: http://en.wikipedia.org/wiki/United_Airlines_Flight_93 Read More