Not Black Hawk Down! Helicopter Crash

800px-Anakonda_NTW_9_93_3aDanger is an inherent component of military helicopter missions. Remember the daring mission launched to capture a Somalian warlord on 3rd October 1993 when an American Black Hawk (Super-Six One) was shot down in the city of Mogadishu. Another area of perilous operations is emergency medical missions and oil and gas operations. Two recent reviews highlight the accident statistics in those two types of helicopter operations [1, 2]. Interestingly the former research comes from Germany and the latter from the Gulf of Mexico. Continue reading

Old Facts, New Insights – Lessons from A-320 Part 4

This interesting study by Sarter and Woods revealed that the automation surprises “occur when the crew detects that automation or aircraft behaviour is deviating from their expectations” [2]. In turn, such ‘surprises’ provide the vital opportunity (and learning) to correct unexpected or undesirable aircraft behaviour. Continue reading

Old Facts, New Insights – Lessons from A-320 Part 3

A spate of incidents and accidents during 1990s suggested that pilots flying modern ‘glass cockpit’ aircraft “sometimes fail to detect unanticipated and undesirable automation behaviour in time to recover” [2, 8, 9]. Hence it is important to understand the likelihood of human error for the A-320 pilots monitoring the status and behaviour of the automated cockpit. Continue reading

Old Facts, New Insights – Lessons from A-320 Part 2

The details of the automation surprises faced by the pilots participating in the questionnaire survey is presented hereafter [2]. Continue reading

Old Facts, New Insights – Lessons from A-320

Automation surprises result from an imbalance between ‘autonomy’ and ‘authority’ of advanced automated systems and the gaps in the operator’s mental model of the system and its interactions. The vital factor at play in such cases could be low observability interfaces in novel (“nonroutine elements”) situations with operator caught in a bind while trying to track and anticipate the actions by the system in his hands! Simply put, when he (rather, they, being multi crew environment) is loosing the grip of the unfolding situation and finds himself inadequately prepared for the fast unwinding situation, which was chillingly evident in Air France Flight AF 447 as brought out in the final report [1]:-
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Old Facts, New Insights – Surprises in Glass Cockpit

The final report of crash of Air France Flight AF 447 stated that the precipitating event of the accident was “temporary inconsistency between the measured airspeeds…..that led in particular to autopilot disconnection” which was compounded by “inappropriate control inputs that destabilized the flight path” [1]. This accident has brought the focus of the aviation community back to overdependence on automation at the cost of forgetting basic piloting skills! Continue reading

Who failed in Crash of Flight IX-812? Part 3

Glaring Organisational Failure

For the purpose of brevity, the organisational failures are only listed here. Continue reading

Who failed in Crash of Flight IX-812? Part 2

Various factors defining the success or failure in a multi-crew operations depend on communication, situational awareness, problem solving, decision making, judgement, leadership – followership, stress management, critique and interpersonal skills [2, 3]. In this tragic accident flawed decision making affected good judgement, leading to deliberately compromised situational awareness, aggravated by self-imposed stress and perceived workload with failed teamwork, broken down communication and poor leadership. Continue reading

Who failed in Crash of Flight IX-812?

The report on accident of Air India Express Flight IX-812 highlighted several factors which resulted in the tragic loss of 158 lives [1]. Limiting to the human factors alone, there were both physiological limitations of the crew and failure of crew resource management (CRM), besides organisational shortcomings. Continue reading

Fatigued Pilots! What Happened to Flight IX-812

Air India’s low cost airline, Air India Express, operates a scheduled Quick Turn Around flight IX-811/812 on Mangalore-Dubai-Managlore sector. The onward flight from Mangalore is at 21:35 H (IST) while the return from Dubai is scheduled at 02:45 H (IST, local time 01:15 H), to arrive at Managlore at 06:30 H (IST). On 22 May 2010, while flight IX 812 was landing at Managlore’s tabletop runway, the Boeing 737-800 aircraft overshot the runway resulting in tragic loss of 158 lives, including 6 crew [1]. Continue reading