Human Error on the Flight Deck - Case Study Example

HFACS framework embodies four levels of human failure (unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences) that lead to an accident (Harris, 2011). Errors correspond to human activities that fall short of producing intended outcomes (Wiegmann and Shappell, 2012). In this accident, the captain made a skill-based error by failing to prioritize his attention; he told the investigators that the use of the auto brake system diverted his concentration from thrust reversers. Violation refers to willful discounts for safety rules and regulations (O'Connor & Cohn, 2010). The violation committed in this case is a failure by the pilots to adequately familiarize themselves with the auto brake system; they were using it for the first time. They both resulted in delayed responses.

Preconditions for unsafe acts refer to incidents resulting in unsafe acts (Wiegmann and Shappell, 2012). In this case, the pilots lacked effective communication/coordination. This can be seen when the first officer took away the captain’s hand from the thrust reverser levers rather than directing him to engage thrust reversers. Under unsafe supervision, the pilots were not allowed sufficient brief time as they departed without the latest updated weather information and dispatch documents and only evaluated and analyzed the procedures for the auto brake system while en route.

Southwest Airlines failed to provide precise landing calculations to its pilots; all of the landing calculations were completed by the On Board Performance Computer (OPC) which wrongly completed the calculations. Hence, organizational influence level error.

In summary, e accident was caused by divided attention, insufficient preparation, lack of communication/coordination, and unclear landing calculations.  The auto brake system distracted the pilot’s attention and unfamiliarity with such a system, together with inappropriate communication, hampered the response time. Inaccurate results provided by the OPC also contributed to the accident.