Human Factors In Aviation

AERO2653

Individual Assignment Report: Human Factors

and The accident involving aircraft VH-ZCR.

SUBMITTED: Capt. Quan Luong

Student name: Duong Hoang Trong
Student ID: s3872865
Student email: [email protected]
Wordcount: 2077 words
Table of Contents
I. Human Factors....................................................................................................................................3
II. Human Factors in Safety-critical industries, especially in Aviation......................................................3
III. The accident....................................................................................................................................4
A. Findings and identification of human issues....................................................................................4
a. Issues related to pilot..................................................................................................................4
b. Issues related to the organization................................................................................................6
B. Recommendation............................................................................................................................6
a. Checklist and procedures issues..................................................................................................6
b. Knowledge and training issues....................................................................................................7
IV. References.......................................................................................................................................7

Abbreviation
Human
HF
factors
 I. Human Factors
‘Human factor is the multi-disciplinary science’ (Australian Transport Safety Bureau 2019, p. 188).

Simply explain, HF firstly is a scientific subject that summarizes the knowledge related to human beings
from other sciences such as sociology, anthropology, physiology, medicine, and engineering. This subject
mentions the capabilities and limitations of mankind, then research the way people interact with
society, machines, equipment, procedures, and the environments.

Nowadays, HF has become an indispensable part of all fields, industries, and activities. It is considered
and integrated into every stage of the production of products and systems, from design, and making to
commissioning tests and certification. In general, this science serves two purposes:

 Apply human knowledge to the design of products and systems. It makes the use, operation,
and maintenance of products, facilities, and systems…become convenient, logical, and most
importantly suitable to human capabilities and limitations. For instance, different human races
will have different forearm lengths, so the height from the seat to the buttons on the ceiling in
the cockpit must be designed to best fit.
 During operation, HF assesses the effects of the environment such as physical, psychological,
stimulants, and other factors on the performance of people. Since then, the working
environment is adjusted appropriately so that people work most effectively. For example,
Human-center-design is a very popular trend recently, instead of forcing an individual to fit the
task or device, that task or device itself must be adjusted following human abilities and
limitations.

The significance of HF is indisputable, several reasons make this science applied widely. However, two
main reasons are making HF so important even extremely important in some industries:

 Increasing overall efficiency and productivity by combining the best characteristics of both
humans and other components like machines, equipment, and procedures…while also
considering the weakness and limitations of humans.
 Diminishing the possibility of error or even in the event of an error, the system bore damage still
can function and bounce back, in other words: increasing the error tolerance and system
resilience.

II. Human Factors in Safety-critical industries, especially in

Aviation
‘Its twin objectives can be seen as safety and efficiency’ (Civil Aviation Authority of Singapore
2017, p.2).

Nuclear energy, aerospace sectors, and weapon systems are safety-critical industries where the
importance of safety is immense, and the consequences of accidents are dire. In general, HF is
extremely crucial in this type of industry for two primary reasons: safety and efficiency. Aviation is a
typical example of this industry and will be used to analyze the role of HF.

In terms of safety, HF is the most effective tool to deal with human error. Humans are not perfect, we
have a lot of limitations both mentally and physically, so people will inevitably make errors. ‘Errors are
like mosquitoes…they still keep coming’ Reason (1990, p.165). Statistically, ‘70% and 80% of aviation
accidents result from some type of human error’ – (Australian Transport Safety Bureau 2007, para. 1). It
had shown that human error is the primary cause of accidents, and can happen to anyone from highly
experienced, motivated staff to differences in gender, cultures…also small errors could lead to serious
accidents. The accident in Tenerife between KLM and PanAm is a typical example of human error
showing that it has no border (John et al. 1998).

There are plenty of reasons leading to human error such as fatigue, time pressure, unfamiliar task, lack
of training or tools,…Although it looks discrete, the human factor has proved that human error does not
occur randomly but is systematically connected to working conditions, tasks, tools, procedures… (Sidney
2001). The human factor analyses human errors and finds solutions to diminish the possibility of it.
Furthermore, it helps to design multiple layers of protection, and establish strategies for error
management so that when an error occurs, it cannot penetrate the next layer of protection and cause
an accident.

Considering the aspect of efficiency, the human factor provides strategies for working, personnel, shifts,
as well as rest, to ensure the best human performance, thereby improving the performance of the
whole system. Today aviation is well known as an industry with high safety standards, to limit errors, as
described above. This entails that the aircraft's parts, equipment, fuel, and systems must be engineered
with care, and meet rigorous standards resulting in enormous costs that demand the exploitation must
be thoroughly rational and optimal. Even the cost of operation in aviation itself is also very expensive,
such as chart fees, fees for flying into other countries' airspace, transit fees, and repair fees abroad. That
does not include the damage when an accident or pandemic occurs. Humans directly operate machines,
and systems, so to survive the airline must optimize the human work to receive the best result from
limited resources. For instance, the Covid-19 is supposed to reduce 314 billion dollars in global aviation
making several airlines bankrupt (David 2020).

III. The accident.

The ATSB's final Transportation Safety Report on the VH-ZCR accident was detailed, clear, and gives
general information. This report mainly focuses on the human factor issues identification and resolution
by applying the human model.

A. Findings and identification of human issues

From the findings summarized in the materials, there are human factor issues related to the pilot
himself and to the organization. The Dirty dozen model is applied to analyze insights of human factor
issues. This model considers the twelve of the most popular human reasons contributing to accidents.
Human factor issues will be given and then classified into the twelve reasons.

a. Issues related to pilot

1. There was only one pilot – A lack of communication, resources, and teamwork
If there was another pilot, they will use the “challenge and response” checklist methodology increasing
the “cross-check” between them resulting in the decreased possibility of errors. Moreover, the workload
is reduced and every item is double-checked.
 2. Checklist issues – Complacency
People who had worked with the pilot confirm that he tends to not use the checklist, but does the
checks by memory and sometimes skip the run-up checklist. It is impossible to determine whether the
pilot used the checklist that day, but the data shows that he skipped the run-up checklist although it was
the first flight of that day.

This may be the result of the repeated doing checklist as pilots complete the checklist frequently, they
learn by heart and do not need a physical checklist to recall. However, the error can always occur, it
seems that the pilot was confident in his memory and did not use the checklist.

3. Mis-set rudder trim – Lack of awareness

The pilot failed to recognize the wrong position of the rudder trim wheel. The first explanation is that he
did not use the checklist and forget to adjust it. Another possibility is that he did use the checklist but
since doing the checklist many times, it creates a mental model that may adjust or even override the
pilot's perception resulting in thinking that he already set the rudder trim wheel but in fact, he did not.

However, if he did use and follow the checklist sequence, the rudder trim should be checked five times.
So the first explanation seems to be suitable.

4. Misidentify the situation – Lack of awareness, and knowledge

The pilot likely had the wrong judgment on the situation. He may think the yawing is the result of
asymmetric engine power rather than the wrong setting of the rudder trim. In fact, both engines were
working properly and the pilot can totally realize that based on the engine RPM parameter. Also, it is
unclear whether he knew that he veered left before the rotation and pressed the opposite pedal to
correct.

Moreover, he may not realize that it was not a rolling turn but a skidding turn, which is related to
directional control.

5. Troubleshooting the problem – Distraction

Since he misidentifies the situation, he got confused and distracted from troubleshooting the problem
and controlling the aircraft. This is supposed to lead to a significantly longer take-off roll.

6. Limited in time and runway length – Pressure and lack of resources

Because of the longer take-off roll, the runway length available was continuously reduced, also the pilot
was put under intense time pressure since he was accelerating at high speed. Moreover, in the critical
phases like take-off, there is little time for any action.

7. Decision making – Pressure, Distraction, Lack of awareness, knowledge, and resources

All of the above lead to the serious issue of decision-making. There is no absolute right or wrong when it
goes to decision-making. However, since the pilot failed to recognize the situation, his decision directly
lead to catastrophic.

If he realized the aircraft is off the centerline before rotation and can hardly make the opposite control
to correct, he can safely abord the take-off.

Or if he realized the sideslip is caused by directional control surfaces rather than the engines, he may
make the proper correction.
Nevertheless, given his condition at that time, it was difficult to make the right decision. With a lot of
pressure and distraction, he probably thought about whether the aircraft can continue or if it is safe to
abort the take-off, does he still have directional control, or whether he has problems with the engines.

8. Do not check the take-off weight – Lack of communication and awareness

It is reported that the pilot had announced the allowed baggage weight to the passengers before the
flight, however, he did not scale the weight of baggage that morning. This results in the maximum take-
off weight exceeding the limit of approximately 240 kilograms, but the climb performance is only slightly
decreased. The position of the Center of Gravity is considered still within the limit.

Also, he did not leave a copy of the passenger/cargo manifest and load sheet at the airport as required.
Causing difficulties in the investigation process to examine the aircraft performance.

9. Possibility of tiredness and anxiety – Fatigue and stress

The data shows that the pilot had 8 hours of sleep the night before but with 2 times awakeness during
the night and it is unknown how long he stayed awake.

He had valid medical certificates and an autopsy revealed that there was no natural disease or stimulant
that could have led to the accident.

Moreover, he is an Air Operator’s Certificate holder, operating his own aviation business. The stress
from the business work was undetermined.

So whether or not the presence of fatigue and stress remains questionable.

b. Issues related to the organization

1. Inappropriate checklist – Lack of communication and teamwork
There was not enough communication and corporation between the company that operated the
aircraft, the aircraft manufacturer, and even CASA. The result in the used checklist is not suitable with
the recommended checklist from the manufacturer. It does not include the checks of supplemental
components like CVR causing the loss of valuable information.

2. Violation of the obstacle limitation surface

Act of intentionally violating the law related to HF. Although not affecting the accident, it is a factor
increasing the risk.

B. Recommendation
a. Checklist and procedures issues
1. Choose appropriate checklist
There should be a rule that the checklist used in flight must be approved by both the manufacturer, the
operator, and the regulatory body. Or the regulatory body will assign specific requirements that must
appear on the checklist.

2. Improve the checklist system flowing the human-center design

For example, using an electronic checklist that forces the user to tick, and will alert when an item is
forgotten. Or equipping the aircraft with an integrated checking system acting as a layer of protection in
case of the checklist is not completed.
 3. Strictly follow procedures and laws
The requirements, checklist, briefing, and all the materials related to the flight must be completed.

Building construction in the vicinity of airports must follow exactly the regulations.

Violations in the aviation industry need to be scrutinized and should be punished appropriately.

b. Knowledge and training issues

1. Actively enhance the knowledge of pilots, the especially senior one
There should be mandatory training sessions, to recall knowledge and sharpen the pilot skills. Training in
situational awareness and decision-making must be carefully conducted and comprehensive.

2. Learning from the accidents

The valuable information from the accident should be published widely so other pilots can learn from it.
An error recording system should be applied so that pilots know what mistakes they are prone to make.

IV. References
 Australian Transport Safety Bureau 2019, Annual Report 2018-19, viewed 18 May 2022,
<https://www.atsb.gov.au/media/5776792/atsb-annual-report-2018-19_fa_tagged.pdf>
 Civil Aviation Authority of Singapore 2017, Aerodrome Safety Publication, viewed 18 May 2022 <
https://www.caas.gov.sg/docs/default-source/pdf/human-factors-in-aerodrome-rescue-and-
fire-fighting-(arff)-services-(193kb).pdf>
 Reason, J 1990, Human Error, Cambridge University Press, Cambridge, UK.
 Australian Transport Safety Bureau 2007, Human factors analysis of Australian aviation
accidents and comparison with the United States, viewed 18 May 2022,
<https://www.atsb.gov.au/media/29953/b20040321.pdf#page=14&zoom=100,0,0>
 John, M, Michael, P, Kenneth, S, & Marc, B 1998 ‘HUMAN FACTORS: TENERIFE REVISITED’,
Journal of Air Transportation World Wide, vol.3, No.1 .
 Sidney, D 2001, The Field Guide to Human Error Investigations, 1nd,  Aldershot, Hants, England.
 David, S 2010, ‘Some of the world's airlines could go bankrupt because of the COVID-19 crisis,
according to an aviation consultancy. See the carriers that have already collapsed because of the
pandemic’, Insider, 12 May 2020, viewed 18 May 2022,
<https://www.businessinsider.com/coronavirus-airlines-that-failed-bankrupt-covid19-pandemic-
2020-3>