AIA Flight 808 Accident

Posted: January 5th, 2023

AIA Flight 808 Accident

Student’s Name

Institutional Affiliation

AIA Flight 808 Accident

Task 1

1. Circumstances of the Accident

On 18 August, 1993, and American International Airways (AIA) aircraft type Douglas DC-8-61with the registration number N814CK hit level landscape 1,400 feet of the approach end of the runway while touching down at Guantanamo Bay, Cuba with the goal of proceeding to the U.S. Naval Air Station in the area. The vessel appeared from the south and was navigating a right turn for the runway with a heightening angle of bank to align with the runway. The nose sloped up and the wings swung towards wings level at about 250–300 feet beyond the ground level. The wing on the right side seemed to stop, and the aircraft budged to 90-degree angle of the bank and the nose pitched downwards. The likely cause of the incident is attributed chiefly to the impaired decision-making, flying capacity, and judgement of the captain and the cabin crew because of fatigue following an extended working hours. The three occupants of the aircraft sustained serious injuries. The pilot chose to land on Runway 10 as he approached the airport. Lawton (1994) informs that an approach to this specific stretch requires traffic to be regulated to avoid the relatively busy Cuban airspace, which starts 1.3 kilometers west of the runway. As the pilot moved through the traffic pattern, the one in charge of plane struggled to locate a beam of light that highlighted the western horizon of the naval base (Lawton, 1994). The crew was not aware that the strobe light was non-functional. While moving from base leg to the final lap, the pilot banked the aircraft more than 50⁰ to stay clear from overshooting the targeted runway. The plane stopped and crashed 428 meters on the western side of the approach end of the runway where it ought to have stopped (Lawton, 1994). The crew onboard had worked for 18 hours consecutive at the time the incident occurred according to a report by the U.S. National Transportation Safety Board (NTSB).

1. Events and Error Sequence that Led to the Incident

The cabin crew day commenced in Dallas at 2300 hours U.S. local time on 17 August 1993. The crew departed Dallas at 2400, landed at St. Louis, Missouri, then continued to Detroit in Michigan, where they landed on 0325 on 8 August. After changing aircrafts and waiting for the cargo to be loaded onto the craft, the team left Detroit at 0620, and touched down in Atlanta at approximately 0750. The cabin members, who were supposed to be clear of their duties until 2300 that same night, then left the station (Lawton, 1994). However, an AIA aircraft in another place was put off because of mechanical complications, and the team that was supposed to be off-duty was recalled to cover for the cancelled flight. Operating as an AIA Flight 808 under an agreement by the U.S. Department of Defense, the crew departed Atlanta at about 1010 and progressed to the Naval Air Station in Norfolk where they landed at about 1138 and waited there for around two hours whereas goods were packed onto the airplane (Lawton, 1994). During this time, ten cabin members examined their flight schedule as well as analyzed whether the weather is conducive for the next trip to the NAS stationed in Guantanamo Bay, because none of the cabin crew members had ever steered a DC-8 to the place before. The team also examined the arrival and landing plans for the destination (Admiral-Cloudberg, 2020). The plane left Norfolk at 1414 on and moved straight to Guantanamo Bay, but before reaching the coastal area of Cuba, the team was required to cancel their instrument flight rules flight schedule and proceed with the visual flight rules to stay away from the Cuban airspace (Lawton, 1994). The plane was in contact with radar of the Guantanamo controllers by 1633 who informed the captain to clear off the Cuban coast. Entering the right runway was a major concern and had to hover over the landing area before settling on the suitable spot. Witnesses said that it was evident the aircraft had problems landing, and when the vessel struck the level terrain, the impact caused fire that had to be extinguished by the firefighting team at the Guantanamo Bay Naval Station. The rescue team responded within one minute of the incident, and played significant functions in putting off the fire that had started to spread around the aircraft debris and an approximate 29 acres of vegetative cover surrounding an area of the incident (Lawton, 1994). The value of the damaged vessel was estimated at $55 million (Lawton, 1994).  

Task 2

1. Identifying, Classifying and Evaluating the Human Factors using SHEL Model and other Tools

The most likely causes for the incident were the impaired decision-making, judgement, and flying capacities of the captain and cabin crew because of the impacts of fatigue, and the pilot’s failure to appropriately analyze the conditions for touching down and maintaining observant awareness of the aircraft while penetrating through the final approach, his failures to avert the loss of airspeed and avoid a stop while taking a steep bank turnaround (NAP, 2011). The accident is also attributed to the pilot’s failure to take immediate action to pick up from a stall, according to the report by the NTSB.

The SHEL model provides a suitable avenue for understanding how human factors contributed to the incident. It is a conceptual framework of human factors that makes clear the scope of human factors in aviation and to know the connection between human components in the sector and environment. Elwyn Edwards first developed the framework that Frank Hawkins built upon later on. The first aspect in the model that may help to understand how human factor contributed to the incident is software, which refers to the intangible and non-physical features of the aviation structure that regulate how systems function and how information within the system is structured. A possible software that contributed to the incident is the lack of proper guidance from the team in the ground. The controllers kept providing contradicting information with the, which did not provide much guidance to the captain (n of cockpit resource management was poor, chiefly due to the fatigue developed from nonstop working (National Transportation Safety Board, 1993). One of the officers instructed the captain to keep going round until they find the perfect time and spot to land the aircraft. Therefore, the conflicting information led the pilot to bring down the plane but not safely. The other component of the SHEL model (hardware) provides key information as to why the accident may have happened (National Transportation Safety Board, 1993). Witnesses reveal how the captain had problems steering the aircraft, which show that he encountered some technical hiccups that further made it difficult to regulate the plane safely. One of the pilots for a Lockheed C-130 that was parked on the airport’s ramp observed DC-8 approaching and his account reveals that the captain must have experienced some problems controlling particular features that resulted in the untimely and fatal landing. The Navy pilot said that he was surprised to see DC-8’s captain overshooting at 200-300 meters, and when the nose pitched up and the wings leveled and appeared to be stalling, he knew tragedy was looming (Lawton, 1994). The third aspect that may help to understand how human factor contributed to the accident is by looking at the environmental factors surrounding the entire incident. An evident environmental factor that delayed the landing, and contributed significantly towards the accident is lack of familiarity with the region, and inability to recognize the strobe lights because they were non-functional (National Transportation Safety Board, 1993). Captured information in the cockpit voice recorder reveal how the captain informs the other cabin members that he was experiencing hurdles being familiar with the runway environment as the aircraft approached the airport, and the wing flaps dropped by 50 degrees (Lawton, 1994). The pilot appeared to be much preoccupied with identifying the light strobes to avoid entering the Cuban airspace. The pilot, therefore, had to rely on the guidance from the control unit at Guantanamo Bay, and constantly received information on the appropriate runway to use (National Transportation Safety Board, 1993). Lack of familiarity with the region, therefore, played a key role in causing the accident. The final aspect of the SHEL model that may help to know how human factors contributed to the incident is liveware, which entails the influence of various people involved in the whole process. The first person to begin with is the one who assigned the aircraft to the team yet the members of staff were supposed to be relaxing following their prior trip. It is apparent that those who made the decision made a blunder that was the origin of the entire ordeal (Admiral-Cloudberg, 2020). The other human factor is lack of effective coordination between the captain and the non-physical supporting systems within and outside the aircraft. It is likely that a pilot would encounter confusions such as improper indexing, confusion of maps and charts, misinterpretations of signs and symbols, and experience inappropriate feelings when faced with a threatening situation such as the one the cabin crew experienced on that fatal day.

Another suitable model for understanding how human factors contributed to the error is workload analysis developed by Rasmuseen and Petersen. The model implies that it is possible to experience human error when a worker performs more than he or she should or can do. Often unbearable workload may result in fatigue or lack of interest in what one does (Anonymous, n.a.). The AIA flight 808 case study reveals that one major factor that might have contributed to the fatal incident is too much workload on the crew that sustained serious injuries when the plane unsuccessfully landed on Guantanamo Bay. A suitable way to prevent human error according to the workload analysis model is to ensure that workers only do the amount of work that they can complete without experiencing fatigue.

1. How Investigation Findings help to understand Human Factors better

The investigations revealed that several factors contributed to the 1993 incident but the primary one is human factors. A background and qualification review of the cabin crew reveals that all the three people in the aircraft had vast experience in their areas of operation. The 54-year-old pilot, for example, had a United States airline transport pilot certificate. The pilot has worked for several aviation firms, and an interview with his workmates shows he knew how to relate with other workers, and was always disciplined (Lawton, 1994). The 35-year-old flight engineer was equally qualified and competent in his work. He had a commercial pilot certificate, and his peers described him as contentious and competent (Lawton, 1994). Thus, one would not relate the accident to lack of competence on the side of the crew members, but to other human factors. Therefore, the investigation helps to understand the role of human factors, especially human errors, contribute to the emergence of more accidents. Therefore, it is imperative to ensure that everyone involved in the processes of an aircraft play their duties well without making blunders that could end up causing devastating effects. For example, the management should assign duties wisely, and the flight crew should provide relevant information when they feel they are not competent enough to embark on a journey.  

Task 3

1. Comparing Official Investigations with Personal Findings

The official findings attribute the accident to the challenges of accessing the runway and human factors. The findings of the incident shows that the AIA’s scheduling of the cabin crew played major roles in contributing to their substandard outcome and fatigue. The revelations showed that duty and flight time restrictions applied through different directives to benefit the firm’s economic interests were ways of ensuring highest productivity through improper utilization of the crew without consideration to human factors that are essential to take into account, such as recreation and rest (Lawton, 1994). The findings ruled that keeping the workers going for almost 24 hours through a series of hardships is traumatizing. Moreover, investigations show that the coordination lacked in vital phases of the flight, and the application of cockpit resource management was poor, chiefly due to the fatigue developed from nonstop working (National Transportation Safety Board, 1993). Assessment showed that despite the decaying speed that the other two crew members had complained about, the pilot disregarded the calls and opted to find an alternative to the issue (n of cockpit resource management was poor, chiefly due to the fatigue developed from nonstop working (National Transportation Safety Board, 1993). The findings of the official investigations concur with my views regarding the incident. I think that the human errors were as a result of prolonged working hours, which made the crew members less productive and in a haste to complete the trip.  

1. Lessons to the Aviation Sector

The incident that happened in broad daylight and what could be termed as visual meteorological conditions pass vital lessons to the aviation sector that may help to prevent similar incidences in future. Operators in the sector learn the significance of creating more effective policies that allow pilots and other crew members enough time to rest before embarking on other trip. The incident teaches the importance of engaging various stakeholders in finding suitable plans for ensuring that fatigue does not contribute towards fatal accidents such as the one witnessed in Cuba.

1. Policy Formulation

A suitable policy in this case would be to devise a framework that outlines the need to allow adequate rest when employees return from considerable amount of time. The U.S. government, through the Federal Aviation Administration (FAA) and the U.S. (Federal Aviation Administration, 2011). Transportation secretariat continues to develop regulations that would ensure that the pilots of commercial airplanes have adequate time to rest before they resume duty. Coordinated activity between the two agencies resulted in the formation of the Pilot Fatigue Rule Comparison that was formulated in 2011 (Federal Aviation Administration, 2011). The regulation stipulates that the permitted length of flight period depends on what time the pilot begins his activities and the number of flight divisions he is expected to make, which should range between 9 to 14 hours. In addition, the FAA places a 10-hour minimum resting duration prior to the time of flight, which is an additional two hours over the past regulations (Federal Aviation Administration, 2011). The rule also requires that a pilot must have the chance for eight hours of undisturbed sleep within the stipulated 10-hour rest time provided for by law.

The new policy will provide additional features on the already existing framework to cut the time it would take to come up with an effective plan. The new policy will address possible cumulative fatigues by putting weekly and 28-day regulations on the amount of yearly restrictions on real flight duration. The policy will also require that pilots have about thirty succeeding hours free from work on a weekly schedule, and a twenty five percent growth over the past policies. Moreover, the new regulation will require firms to take joint obligation when finding out whether a pilot has the necessary qualifications to serve, encompassing whether they are likely to suffer the effects of fatigue emanating from pre-duty operations such as long journey. The new regulation will require pilots to affirmatively inform about their fitness to serve at the start of each flight unit. The policy will be in such a way that is a pilot informs that he or she is easily fatigued after duty, especially tiredness emerging from pre-activities such as commuting, he or she will not get the chance to serve in demanding positions. Moreover, the new policy will put emphasis on following a Fatigue Risk Management Plan, which requires an airline to come up with an appropriate plan on how to address the issue of fatigue among its workforce, especially pilots (Federal Aviation Administration, 2011). Such improvements will help to reduce the accidents that emerge due to human blunders.  

Conclusion

Human factors are among the key factors that cause accidents in the aviation sector, and those in charge must take appropriate measures to avoid experiencing similar incidences in future. The study describes how pilot fatigue led the Douglas DC-8-61 to crash while trying to land at Guantanamo Bay, Cuba. The crew serves beyond the required timeframe making the pilot less effective during the assignment before the accident. The incident calls on relevant stakeholders to take proper mitigation measures, including reviewing the current policy on pilot rest so that these workers have enough time to relax and resume duty when the have enough energy and vigor to embark on the trip. Operators in the aviation sector can draw other important lessons from the incident that they can apply in their current operations and ensure that both passengers and crew members are safe and secure.

References

Admiral-Cloudberg. (2020). At the edge of endurance: The crash of American International

            Airways flight 808. Retrieved from https://admiralcloudberg.medium.com/at-the-edge-of-

            Endurance-the-crash-of-american-international-airways-flight-808-62ade22f26d3

Anonymous. (n.a.). Human error analysis techniques. Retrieved from https://dvikan.no/ntnu-

            studentserver/reports/49E7ABF2CE7783CB3A529BA5B547E97A.pdf

Federal Aviation Administration. (2011). Fact sheet – Pilot fatigue rule comparison. Retrieved

            from

https://www.faa.gov/news/fact_sheets/news_story.cfm?newsKey=12445#:~:text=The%2

            0rule%20sets%20a%2010,duty%20and%20flight%20time%20limits.

Lawton, R. (1994). Steep turn by captain during approach results in stall and crash of DC-8

            freighter. Flight Safety Foundation Accident Prevention, 51(10), 1-8.

National Transportation Safety Board. (1993). Aircraft accident report. Washington, D.C.:

            National Transportation Safety Board.

NAP. (2011). The effects of commuting on pilot fatigue. Retrieved from

https://www.nap.edu/read/13201/chapter/5