Increasing Learning from Accidents: A Systems Approach...
Transcript of Increasing Learning from Accidents: A Systems Approach...
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IncreasingLearningfromAccidents:ASystemsApproachIllustratedbytheUPSFlight1354BirminghamAirportAccident
ShemMalmquistNancyLevesonJamesPerryGusLarard
DarrenStraker
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Outline
• WhatHappened• WhydiditHappen?
– NTSBConclusions– CASTConclusions– Comparisons
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WhatHappened?(fromNTSBreport)• OnAugust14,2013,0447CDT,UPSflight1354,anAirbusA300-600,
crashedshortofrunway18duringalocalizernonprecisionapproachtorunway18atBHM.
• Captainandfirstofficerwerefatallyinjuredandplanedestroyedbyimpactandfire.
• Variableinstrumentmeteorologicalcondi\onswithavariableceilingprevailedonapproachcourse.
• FlightcamefromLouisvilleabout0503EDT
• NOTAMineffectindictedrunway06/24,longestrunwayatairportandtheonewithaprecisionapproach,wouldbeclosedfrom0400to0500CDT.– Becausefightscheduledtoarriveat0451,onlyashorterrunwaywitha
nonprecisionapproachwasavailabletocrew.
– ForecastedweatheratBHMindicatedlowceilingsuponarriverequiredanalterna\veairport
– Dispatcherdidnotdiscussthelowceilings,thesingleapproachop\ontotheairport,orthereopeningoflongerrunwayabout0500withcrew.
– Duringflight,informa\onaboutvariableceilingsatairportnotprovidedtoFC
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ATIS
• BirminghamAirportinforma\onPapazeroeightfivethreeZuluobserva\onwind
calmvisibilityonezero.skycondi\onceilingonethousandbroken.seventhousandfivehundredovercast.temperaturetwothree.dewpointtwotwo.al\metertwo
ninerninerseven.localizerrunwayoneeightinuse.landinganddeparOngrunwayoneeight.noOcetoairmenrunwaysixtwo-fourclosed.alldepar\ngaircrabcontacttoweroneoneninerpointninerforclearancetaxiandtakeoff.advisecontrolleronini\alcontactyouhavePapa.
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• Beforedescent,whileondirect-to-KBHMlegofflight,captainbriefedthelocalizerrunway18non-precisionprofileapproach.
• Firstofficerenteredapproachintoairplane’sflightmanagementcomputer(FMS).
• Intendedmethodofdescent(a“profileapproach”)
• glidepathgeneratedbytheFMStoprovidever\calpathguidancefromthefinalapproachfix(FAF)tothedecisional\tude
• Runway18decisional\tudeof1200bmsl
• Airtrafficcontrollerclearedtheflightforthelocalizer18approach.
• CrossedFAF200feethigh
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• About7secondsaberthefirstofficercompletedtheBeforeLandingchecklist,thefirstofficernotedthatthecaptainhadswitchedtheautopilottover\calspeedmode;shortlythereaber,thecaptainincreasedthever\caldescentrateto1500fpm.
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• Firstofficermadetherequired1000-b-above-airport-eleva\oncallout,andthecaptainnotedthatthedecisional\tudewas1200bmslbutmaintainedthe1500fpmdescentrate.
– AlthoughtheapproachviolatedthestabilizedapproachcriteriadefinedintheUPSflightopsmanual,theydidnotperformago-around.
– Astheairplanedescendedtotheminimumdescental\tude,thefirstofficerdidnotmaketherequiredcalloutsregardingapproachingandreachingtheminimumdescental\tude
– TheCaptaindidnotarrestthedescentattheminimumdescental\tude.
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• Theairplanecon\nuedtodescend.
• At1000bmsl(about250babovegroundlevel,anenhancedgroundproximitywarningsystem(EGPWS)“sinkrate”cau\onalertwastriggered.
• Thecaptainbegantoadjustthever\calspeedinaccordancewithUPS’strainedprocedure.
• Hereportedtherunwayinsightabout3.5secondsaberthe“sinkrate”cau\onalert.
• Airplanecon\nuedtodescendatarateofabout1000fpm.
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• Firstofficerconfirmedshealsohadtherunwayinsight.
• About2secondsaberrepor\ngtherunwayinsight,thecaptainfurtherreducedthecommandedver\calspeed,buttheairplanewass\lldescendingrapidlyonatrajectorythatwasabout1nau\calmileshortoftherunway.
• Thecockpitvoicerecorderthenrecordedthesoundoftheairplanecontac\ngtreesfollowedbyanEGPWS“toolowterrain”cau\onalert.
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GiventhisdescripOon:
• Whatcause(s)wouldyouascribetotheaccident?
• Arethereanyaddi\onalques\onsyouwouldwantanswered?
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NTSBConclusions• ProbableCause:
– Flightcrew’scon\nua\onofanunstabilizedapproachandtheirfailuretomonitortheaircrab’sal\tudeduringtheapproach,whichledtoaninadvertentdescentbelowtheminimumapproachal\tudeandsubsequentlyintoterrain.
• ContribuOngtotheaccidentwere:1. Flightcrew’sfailuretoproperlyconfigureandverifytheFMScomputer
fortheprofileapproach2. Captain’sfailuretocommunicatehisinten\onstothefirstofficeronceit
becameapparentthever\calprofilewasnotcaptured.3. Flightcrew’sexpecta\ontheywouldbreakoutofthecloudsat1000b
abovegroundlevelduetoincompleteweatherinforma\on.4. Firstofficer’sfailuretomaketherequiredminimumcallouts5. Captain’sperformancedeficienciesduetofactorsincluding,butnot
limitedtofa\gue,distrac\on,orconfusion,consistentwithperformancedeficienciesexhibitedduringtraining
6. Firstofficer’sfa\gueduetoacutesleeplossresul\ngfromherineffec\veoff-duty\memanagementandcircadianfactors.
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System’sApproach• Looksnotonlyathowpilot’scontributedtoaccidentbutwhythey
believeditwastherightthingtodoatthe\me.• Safetytreatedasacontrolproblem,notafailureproblem
– Whywerecontrolsnoteffec\veinthiscase?– Howcantheybeimprovedforthefuture?
Hazard:ControlledFlightintoTerrain(CFIT)– Usedtobemostcommontypeofaccident– Muchhasbeendonetoreduceoccurrence– Whydidn’tthesecontrolsworkthis\me?
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controlstructure
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
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ControlsforCFIT• Airportphysicalcontrols
– ILS– PAPI
• MSAWandATC• AircrabElectronics
– FMS– EGPWS– Autopilot– Displays
• Capt.Flying,PilotMonitoring• UPSDispatcher• UPSDispatchmanagement• Airbus/Honeywell• Ind.Pilot’sAssocia\on• FAA(FlightStandards,AirportSafetyandStandards,ATO,Cert.)
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ComparisonofFactorsIdenOfied
• NTSB(probablecause,contributorycauses,findings)vs.CAST
• CASTfoundsomecontribu\ngfactorsnotiden\fiedbyNTSB
• CASTiden\fiedallofNTSBfindings
• CASTiden\fiedseveraladdi\onalfindings
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FAAOfficeofAirportSafetyandStandards
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
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Flightcrew-Electronics
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
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• AstheLOCwasprovidinglateralguidancetheaircrabcoulds\lltrackthedisplayedfinalapproachtrackdespitethelackofwaypointsequencing.
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controlstructure
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
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Contextualfactorsexample
HowdidflightendupflyingtheLOC?FromPilotinterac\ons• CrewmissedNOTAMFrompilotinterac\ons• LOCapproachshownearlierinchar\ngsequenceFromATC-Pilotinterac\ons• Controllerofferedit
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DispatchrecommendaOons
• Dispatchersshouldproac\velyprovideinforma\ontoflightcrewsregardingthestatusofapproachesandwhyapar\cularrunwayandapproachislistedinflightplan.
• Ensurethatdispatchersconsiderifacrewmightbefa\guedandhowthatmightimpactthepilot’scogni\veprocessessodispatchercanactproac\velyaccordingly.
• Reviewworkloadfordispatcherstoensuretheycanprovideactualjointauthorityforindividualflights.Currentworkloaddoesnotallowfortheindividualizedanen\ontodetailsthatcanpreventaccidents.
• Providecomputerassistancethatdoesnotencouragerelianceandunques\oningacceptanceofoutputs.
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FAA
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
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FAArecommendaOons
• TheFAAshouldconsiderevalua\ngthecommunica\onsandcoordina\ondeficienciesimplicatedinthislossandwhethertheyaremorewidespreadthantheyarebelievedtobe.Wasthisjustaone-\meeventorarecommunica\onandcoordina\ondeficienciesmorewide-spreadthanbelieved?
• Therolesofdispatchandpilotsandhowtheyinteractneedtobeclarified.
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Systemicfactors
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
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SystemicFactors• SafetyCulture(cargopilots)• Safetyinforma\onsystem• Dynamicsandchangeover\me• Communica\onandCoordina\on
amongcontrollers
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SystemicrecommendaOons
• FAAandcargoaircrabpilotassocia\onsshouldinves\gatewhethertheac\onsofthecargooperatorindustryhasledtomoresuspicionandlesstrustbythepilotsofthosecarriers.
• TheFAAandcargoaircrabpilotassocia\onsshouldins\tuteastudyofwhethercargoaircrabaretreateddifferentlybyairportsandwhetheranydifferencesresultinhigherriskforcargoaircrab.
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SystemicrecommendaOons
• Iden\fyandimplementchangestotheinforma\onsystemtoensurethataccurateweatherinforma\onisavailablewhenneededandtothosewhoneedit.
• TheFAAandotherindustrygroupsshouldstudywhethertheincreaseincargoopera\onshaschangedorincreasedthelevelortypesofhazardssuchthattheyarenolongeradequatelymi\gatedbycurrentproceduresandcontrols.
• Subjectchangesintheprovisionofcri\calinforma\ontoahazardanalysis.
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Summary
• U\lizedGroupChairfactualreports
• Contribu\ngcontrolac\ons(factors)easilyiden\fiablefromcontrolstructure
• Recommenda\onsstemmedfromcontribu\ngcontrolac\ons.