An Evaluation of Accidents Caused by Human factors in Commercial Aviation.



An Evaluation of Accidents Caused by Human factors in Commercial Aviation.


Sandro Jose Chiappe

A Research Project Proposal

Submitted to the Worldwide Campus

In Partial Fulfillment of the Requirements

of Course, ASCI 490, The Aeronautical Science Capstone Course

For the Bachelor of Science in Aeronautics Degree

Embry-Riddle Aeronautical University

July 2018


The purpose of this project is to evaluate specific accidents in Commercial Aviation history. To evaluate various factors that have culminated in such catastrophes, primarily focusing on human error. Although, there are many unprecedented variables such as natural disasters that may result in devastating accidents, they are not as common as human factors (BASI, 1996). The student will review the details of certain accidents that have been attributed to human factors. One of the accidents for instance, will be Aeroperu, flight 603 that crashed on October 1996 (Skybrary, 1996). Although there were a variety of elements that played into this tragic event, it was primarily attributed to human error. One of the other accidents that will be investigated in the duration of this project is the Colgan crash (Collins). The Colgan crash was a result of multiple components, most notably, the failure of following sterile flight deck procedures by both pilots (Collins). Although it is still under investigation, the Cubana de Aviacion crash of May, 2018 is also suspected to be caused by human errors (Whitefield, 2018). Additionally, the student will evaluate the differences between factors and how they came into play in each of these accidents. In addition to human error, other factors may come into play that may increase the chances of devastation. Factors such as, mechanical, weather, instrumental or environmental (Shapell, 2001). The student will delve in each one of these variables and will determine how each of these factors compare to human factors. In addition, the student will investigate what makes human factors the greatest threat in aviation safety and leading cause of accidents (FAA n,d). The main goal is to determine how these accidents could have been prevented and what can be done to prevent future accidents. Comment by Edward Murphy: This should be one paragraph. This is too long.

The student will also share how the FAA has addressed these issues and the preventative measures taken. Laws put into place by the FAA and their precise effectiveness within the industry will be reviewed. This project will cover the improvements that have been made after such actions taken. An example of such action is the relatively new ATP regulation implemented after the Colgan crash. The student will review what caused more restrictive laws and the effect it has had with in the industry (Siebenmark, 2010).

An Evaluation of Accidents Caused by Human Factors in Commercial Aviation

Statement of Project

This project is a partial fulfillment of the requirements of ASCI 490, The Aeronautical Science Capstone Course for the Bachelor of Science in Aeronautics Degree. The main goal of this research project is to understand, review and mitigate future accidents in aviation which could potentially be caused by human factors. To demonstrate the student’s understanding, critical thinking, text and data analyzation, quantitative reasoning, and error mitigation. In completion of this project, it will give the student a better understanding on how to identify and address issues with regards to human error. By analyzing this information, the goal is to improve the student’s situational awareness while on the job and how to appropriately react if an issue is presented.

Introduction Comment by Edward Murphy: Many of your references are not in APA style. Many are not even in the reference list. Make sure any you use are in APA style and in the reference list.

This project primarily focuses on factors that directly correlate to human error. To identify its types, origins, causes and effects within the aviation industry. The purpose of this project is not to judge the actions of those who attributed or lead to fatal accidents. The focus is to reflect and learn from their mistakes and prevent any future incidents. As always, it is a tragedy that such events have taken place however, accidents such as these must always be taken as a learning opportunity.

The majority of accidents have one common denominator and almost always attributed by human factors (FAA). What are human factors? Human factors are variables that are directly linked and are a result of human actions (Shapell, 2001). The reason that makes human factors the greatest threat to aviation safety is because they can cause and be caused by a wide range of things. Human factors can be divided into ten different categories. The reason why human factors are such a threat is because to some degree they are unpredictable, as humans are unpredictable (Shapell, 2001).

Although, human factors have been divided into ten different categories, each individual has had a different walk of life and various life experiences. Depending on the individual and their life experiences, they have the potential to be the cause of one or multiple of these factors. However, the key is to properly self-examine oneself before taking action and the threat of these factors will decrease tremendously. By being self-aware and being aware of the environment one is in and potential threats, human factors have the potential to be obsolete (FAA.,n.d)

Additionally, reviewing accidents primarily caused human error makes it is easier to understand its cause and effects. It makes it easier to understand how a simple mistake or negligence can lead to heightened state of compromised safety (NTSB). A few examples of compromised safety are the Aeroperu, Colgan and Cubana de Aviacion Crashes. Each of these crashes have their own story as to how human error and negligence cost the lives of many.

Critical Thinking

The student will show evidence of knowledge at a synthesis level to define and solve problems within professional and personal environments” (ERAU, 2017, p. 13).

Critical thinking is the ability to solve problems by studying, analyzing data and gathering facts to resolve the issue on hand. Also, it is a disciplined intellectual process, of actively and skillfully conceptualizing, analyzing, comparing and evaluating information gathered to compare, generated either by different means of knowledge. It entails the examination of structures and elements through implicit in all other kinds of reasoning, evolving different viewpoints and modes of thinking (Critical Thinking and Education Reform, 1987).

The student will review and compare texts and literature published by reputable sources such as the NTSB Aircraft Accident Report Loss of Control on Approach, Colgan Air, Inc (NTSB/AAR-10/01, 2010), and the Federal Aviation Administration published book regarding human factors (FAA Human Factors Handbook, 2016).

The student will review certain mishaps in aviation history that led to catastrophes and will learn how to identify them in real life, such as the Aero Peru Flight 603 accident which can be a clear example of the SHELL model, in which it relates the crash to the four main factors of the model. (Directorate of General Transportation Peru, 1996). The student will demonstrate critical thinking by analyzing and comparing the SHELL model from (Hawkins, 1987), against the aviation accidents mentioned below. This model (Hawkins, 1987), is a functional diagram which illustrates conceptual ideas of human factors built into a block model, which helps associate the different components of aviation-related incidents to human factors.

The student will analyze the interference between people and other people, such as crew resource management in the cockpit. Liveware-Liveware (ICAO circular 216-AN31) will demonstrate how leadership, teamwork and cooperation was handled in the cockpit during the time of the emergency as well as how it was handled with air traffic controllers (SkyBrary, 2016). Liveware-Hardware (ICAO circular 216-AN31), will demonstrate the interference from the computer with the pilot and perform a safe operation of the flight (Skybrary 2016). Liveware – Environment (ICAO circular 216-AN31), will demonstrate the relationship between the interface and the external environment and how the aircraft handles the issue that the environment is providing (SkyBrary, 2016). The student will be describing the prevailing standards and scientific approach for accidents reports analysis from the National Transportation Safety Board (DGAC, 1996) and the Colgan Crash accident report (NTSB Loss of aircraft control, 2010). The goal of comparing and contrasting certain accidents with the Shell model is for the investigator to end up with several leads from model and get to the final outcome of the investigation. (ICAO circular 216-AN31). Comment by Edward Murphy: This makes no sense. The interference from the computer with the pilot????????

Quantitative Reasoning

“The student will show evidence of the use of digitally-enabled technology & analysis techniques to interpret data for the purpose of drawing valid conclusions and solving associated problems” (ERAU, 2017, p. 14).

The ability to come up with a conclusion through the study of graphs, data and numerical analyzation is better known as Quantitative Reasoning. It is the ability to compare numerical statistics that were gathered prior to, and after an action taken. To demonstrate this data the student will utilize year 1990 to 2002 providing Federal Aviation Administration frequency of accidents associated with an aircrew of supervisory human error (Shappell, 2006). With this information the student will be able to draw a valuable conclusion by numerically comparing variables or the changes through time, whether they be positive or negative. Comment by Edward Murphy: Says who. Need references here. Comment by Edward Murphy: This is the proper reference. We use the Author, not the title of the document. Comment by Edward Murphy: Howe will you compare. Must use some form of statistical analysis. Also need specifics. The student will gather this data that data this data and compare them statistically using the t-test for changes over time.

The student will demonstrate how human factors compare to other factors and how much more of a threat they are statistically by grouping statistical data from 2009 through 2002 and arrange them in visual graphs. In addition, the student will demonstrate how each of the different human factors compare numerically and determine which of these human factors is the greatest threat, to support the his capstone proposal. The student will show how numbers have changed and corrective measures have taken through a period of eight years, after the FAA and US Congress implemented the new ATP restriction of 1500 hours. (Press Conference, FAA Boosts Aviation Safety with New Pilot Qualification Standards, 2013). This measure have taken action as a result of a catastrophic events, such as the Colgan Accident (Accident Report, Loss of Aircraft Control, 2010). Moreover, the student will present in his capstone proposal quantitive reasoning by analyzing and evaluating the specific areas from the NTSB (n.d.), and the FAA Aviation Statistics (n.d) to determine a change and positive curvature of human factors and safety in the history of aviation. The student will also determine what skills and actions have worked best to reduce accidents and incidents to then apply it in the real world (Shappell, 2006). Comment by Edward Murphy: Makes no sense. Should this bee 2009 through 2012????? Comment by Edward Murphy: Makes no sense Comment by Edward Murphy: This is not the proper reference. Should be a short reference. Also, this is not in the reference list. Comment by Edward Murphy: Garmmar. What measure? This measure have taken. This measure has taken. But makese no sense. Comment by Edward Murphy: How will you statistically analyze/ What specifically will you analyze?????

Information Literacy

“The student will show evidence of meaningful research, including gathering information from primary and secondary sources and incorporating and documenting source material in their writing” (ERAU, 2017, p. 15).

Information Literacy is demonstrated by reviewing material related to the topic through reputable sources. It is understanding how different texts from different sources complement or contradict each other. It is the ability to make a cognitive connection between various texts to then build a highway to a valid conclusion. Such information will be obtained through the Federal Aviation Human Factors Handbook by (FAA, 2010). Comment by Edward Murphy: Who says this. Need the reference. Comment by Edward Murphy: No, you must be specific. What exact information will you gather from the FAA 2010.

In this project the student will demonstrate information literacy by comparing texts regarding to human factors, such as Aviation Human Factors Handbook by (FAA, 2010) and accidents in aviation history. Furthermore the student will also analyze Cognitive Architectures for human factors in aviation (Keving Gluck, N.d) and compare an air force research vs the Federal Aviation Administration. This will allow the student explain in his capstone proposal two different ways of studies and research to reach a main objective. In addition the Student will analyze how the Federal Aviation Administration have changed in their regulations (FAR 2018), towards a more safe sky. Comment by Edward Murphy: Weak, must be more specific. Must show how you will integrate and analyze.


“The student will show evidence of communicating concepts in written, digital, and oral forms to present technical and non-technical information” (ERAU, 2017, p. 16).

Communication is defined as a process by which information is exchanged between individuals through a common system of symbols, signs, or behavior (Merriam-Webster). It is the process of allocating information or share a message directed to a particular individual or a group of people. The student will communicate this project through digital, written, and oral form when necessary to achieve the final outcome of the project. Comment by Edward Murphy: This is not a proper reference. It is also not in the reference list. GO through each reference and make sure it is in your reference list.

On another note, people have different points of views on how the pilot cockpit interaction and systematization, therefore it’s important to add and explain the SHELL model (Hawkins, 1987) and explain the crew resource management in the aviation industry, this will give a precise explanation on how human factors, especially with the Liveware-Liveware (Hawkins, 1987) and explain clearly the person to person interaction and relationship between both pilots and its human factors.

Additionally, the student will utilize resources from the Hunts library, Internet and all previous courses from ERAU, such as aviation safety, Aviation management, Aviation Law, Commercial Aviation, and will reinforce them with reliable and official outcomes such as the Federal Aviation Administration, National Transportation Safety Board, International Civil Aviation Organization and all related official sources, to give a professional outcome.

Scientific Literacy

“The student will show evidence of analyzing scientific evidence as it relates to the physical world and its interrelationship with human values and interests” (ERAU, 2017, p. 18).

Scientific literacy is the ability to interpret scientific evidence in relation to the issue on hand. Scientific literacy is also used to better understand the issue with a scientific perspective. The issue on hand being human factors and their effects in commercial aviation. The student will demonstrate scientific literacy by reviewing the psychological and physical causes of human factors (Human Factors in Aviation, 2010). This information will be focused on how the human body works and copes with stress, fatigue and depression which is something that needs to factored in the equation of a healthy pilot. It is proven that an individual’s physical, emotional, psychological and environmental conditions are main contributors of human factors. The student will provide information by the FAA Civil Aerospace Medical Institute and will that will help identify the causes of human factors to then prevent its effects. In addition, the student will provide solutions that will help reduce human factors and in turn, mitigate future incidences. Comment by Edward Murphy: Says who. Need reference. Comment by Edward Murphy: This makes no sense. Human factors are the psychological and physical causes of aviation incidents and accidents. You have this all backward. Comment by Edward Murphy: Makes no sense. Comment by Edward Murphy: Nothing is ever proven. Who says this???? Comment by Edward Murphy: What information? What reference. Comment by Edward Murphy: What references?

Cultural Literacy

“The student will show evidence of the analysis of historic events, cultural artifacts and philosophical concepts” (ERAU, 2017, p. 19).

Cultural literacy is demonstrated by reviewing events that have happened within the industry. It is reviewing events that have happened historically and reflecting on how it has affected the industry today. Cultural literacy is also demonstrated by reflecting on how environment or situational actions influence human behavior or vice versa. The student will demonstrate cultural literacy by reviewing and reflecting on particular, catastrophic events and how they affected the industry today. This will demonstrate the student ability to analyze and review historical data from the past, such as the American Airlines Flight 965, (Flight Safety Foundation 1998). Due to poor lack of planning and flight crew improper action of reviewing the flight plan and having poor navigational skills, American Airlines Flight 965 Boeing 757 crashed into the mountains of Cali, Colombia. Comment by Edward Murphy: Need reference. Comment by Edward Murphy: Need to make short references for proper use within document. For example, you could just make this (Flight Safety Foundation, 1998). The full title would be within the reference list.

In addition, the student will demonstrate the difference of how the aviation industry approaches technology and flight management system navigation compared to this new aviation age. Because of this error in navigation the student will analyze how important it is to understand and don’t over rely on the automation and navigation the aircraft provides. The student will compare the AA 965 flight with Antonio Chialastri article (Automation in Aviation, n.d), in which states that automation is the use of control systems and information technologies to reduces the need for human work. On the other hand, the student will review how during the Colgan Crash, complacency resulted in a compromised state of safety and how it affected the actions of the pilots. (Accident Report, Loss of Aircraft Control, 2010). The Colgan crash, along with several others causes attributed to human error. The student will review how these events motivated the FAA to push for more restrictive regulations, and how the impact on society and aviation changed after the fatadyical accident as reported by USA Today. (FAA Requires more pilot training after Colgan crash, 2013). The FAA has implemented Regulations as a guideline for human action and behavior. The student will review how new regulations placed by the FAA has affected the culture in commercial aviation as we know it today. In this capstone proposal we will evaluate different points of views in which several people from the industry, agree or disagree that having a higher flight hour requirement, will actually make the pilot better rather than giving a better training program. As Deborah Harsmant from the NTSB states, ”It’s not always about the hours because we see very experienced pilots with tens of thousands of hours making mistakes. In fact, in the Colgan accident, those pilots had more than 1,500 hours, but they still made mistakes’’ (Regional Airline Association, 2018.) Comment by Edward Murphy: This is not in the reference list. This is not a proper reference. Comment by Edward Murphy: This is not a proper reference. Comment by Edward Murphy: Need page number for all direct quotes.

I stopped here. Your reference list is so messed up and not in alphabetical order. Many of your references are missing. Fix above and I will review. Get all these corrections done.

Lifelong Personal Growth

“The student will show evidence of the skills needed to enrich the quality of life through activities which enhance and promote lifetime learning” (ERAU, 2017, p. 20).

Lifelong personal growth is expressed by the culmination of life experiences, training and research and being able to apply them positively in one’s life. In this proposal the student will demonstrate personal life long growth by demonstrating how the material learned can be applied in their personal, day to day life. The student will review the Human Factors Handbook, provided by the federal aviation administration, in which explains the different types of human factors and the different situations and behaviors that a can be addressed to develop into a problem, or it could even worse create a chain of problem that could lead into a terrific accident. (FAA AMT, 2010). Additionally, the student will identify human factors while on the job and how to properly address them, so that safety is not compromised. The student will analyze and compare this information using the Pear Model, which gives a simple explanation of human factor effects on people who do the day to day job. (FAA AMT, 2010). The student will also analyze the physical conditions that affects human factors. The student will analyze the Tenerife disaster, when a Pan Am and KLM Boeing 747 collide against each other in the runway, demonstrating that there had to be a change in the way people looked aviation. Stating that it is not anymore only just about the equipment, but also there should be a special emphasis on the human who is actually controlling the equipment. (AOPA GA Human Factors, n.d). In this capstone proposal, the student will also provide information on why is aviation more prone to have more human factors deficiencies in todays industry, compared to the 1970, or the 1980. The student will compare an interview from a pilot who has flown in the 1970, 1980 and in this century and will demonstrate why in this days we are more prone to errors due to the higher emphasis on automation and technological advancements. (USA Today, 2015).

Aviation/Aerospace/Aeronautical Science

“The student will show evidence of advanced concepts of aviation, aerospace, and aeronautics to solve problems commonly found in their respective industries” (ERAU, 2017, p. 22).

Science can be utilized to gain a better understanding of the underlying problems within commercial Aviation. The main topic of this project is human factors, its causes and its effects. Human factors everything to do with humans, how they think and how they act. To better understand the root causes of human factors the student will delve in each of the ten categories of human factors. In this proposal the student will implement different aeromedical factors, such as confusion, fatigue, stress and spatial disorientation that could lead into a human factor accident, this information will be provided by the Pilot Handbook of Aeronautical knowledge. (PHAK,2012). The student will demonstrate life events or life experiences that can alter an individuals state of mind, this will be presented as personal life experience situations. Additionally, the student will review what can be done to identify these factors in others and in oneself and how to appropriately address them.

Aviation Legislation and Law

The student will show evidence of the basic concepts in national and international legislation and law as they pertain to the aviation, aerospace and aeronautics industries” (ERAU, 2017, p. 23).

Aviation legislation and law are a very important and vital aspect of commercial aviation. Laws, legislation and regulations provide a comprehensive guideline and standardizes practices with in the industry. The student will review laws and regulations set by the FAA that have been put in place to address human factors. Soon after the Colgan crash the FAA implemented stricter regulations in order for pilots to obtain an ATP (Urdis). In addition, the FAA has put laws in place that address factors such as work load, minimum rest requirements or fatigue to keep the employee and employer in check. The FAA has implemented several rules depending of the type of flying performed, such as part 121, 135, 91 and 61. (FAR AIM,2018). The FAA has also implemented strategies to keep any person who works in aviation accountable. Regardless if it is a pilot, flight attendant or mechanic, there are safety check put in place that meant to mitigate human factor based incidences (FaaSafety). As a result the Federal Aviation Administration works hand to hand with the National Transportation Safety Board to mitigate and solve any outcomes regarding aviation. There are several program assisting pilots and aviation personnel, in allowing a margin of error, if the person reports it to the FAA. This is called the Aviation Safety Reporting System, (Nasa) program. In the case that there has been a violation or any issue regarding aviation, the person has the chance to report it and use it as a “get out of jail” card. (AOPA, 2012). In this proposal the student will explain how accepting the errors and learning from them, will help the aviation community to grow and be safer each day.

Aviation Safety

“The student will show evidence of basic concepts in aviation safety as they pertain to the aviation, aerospace, aeronautics industry”(ERAU, 2017 p. 24).

Aviation law and legislation are very closely correlated to aviation safety. The FAA continuously revises laws to address aviation safety and concerns. The most effective way of avoiding a compromised state of safety is by adhering to these regulations. A great way of doing so is by keeping your peers accountable for the work they do and ask that they keep you accountable in the same way. However, when it comes to safety on the job it is important to accept personal responsibly for every action take. The student will demonstrate the Human Factor and Classification System, demonstrating human factor errors in an aviation accident (Wiegman & Shapell, 2001). It is important to constantly pause and evaluate oneself or being aware of oneself and the environment on is in. In this proposal we will explain and analyze the IMSAFE checklist, a precise checklist where the person does their own personal assessment of how safe they are, and how good they feel before starting a shift (PHAK, 2013). This checklist is something that all instructors teach their students since day one. The student will analyze the checklist and compare it to the Air France Flight 447, in which the most probable cause of the accident was human error by pilot stress. (AFP,2014). While on the job, the FAA advices to always expect to find something wrong, to always double check the work down and to never fill out paperwork to a job not completed (FaaSafety). It is important to understand the real meaning of every accident because its what will take a step to prevent something worse in the future, so this job is very important in regarding to, solve or get to the final truth and then help and support the aviation community.

Aviation Management and Operations

“The student will show evidence of sound, ethical management principles within standard aviation, aerospace, and aeronautics operations” (ERAU, 2017, p. 25).

Aviation management and operations is the result of various parties coming together to improve the safety within the commercial aviation industry. Many times these parties have an obligation to themselves, to each other and to the public. An example that can be shared is how the NTSB investigates particular events to find the root of the cause of the accident or incident. As a result of the investigation in combination with the desire to prevent the same mistake, the FAA sets the standard for laws and legislation with in the industry. This laws and regulations could be shown in the Federal Aviation Website, and also by observing Advisory Circulars that are usually send when there an urgent fix. (FAA Circulars, 2018). Additionally, once a solution is formulated, the affected parties by the legislation are responsible for properly carrying it out. Communication is also an very vital piece of aviation management and operation. In order to avoid miss understandings, clear and concise language is used to convey expectations ensure that every one involved understands what is being communicated (FAA). As Culture Factors (2010) states, management and leadership contribute in a significant role for the importance of safety within the workplace, by implementing policies that go hand in hand as well as an open culture in regards to solving issues that matter. Therefore the student will demonstrate in this proposal how leadership should surround management and safety operations.

References Comment by Edward Murphy: These are not in APA style. The second line must have a full indent. We use title casing on title. That means we only capitalize the first word, proper names, and after a colon. You fix the one’s I did not fix. This must also be in alphabetical order.

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