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Analysis of Causes of Human Error in Aviation

Executive Summary

The report summarizes the various Dirty dozen factors that are prevailing in the aviation industry. There are twelve Dirty dozen that are prevailing in the industry. These have led to major accidents in the country. The 3 factors that have been analyzed in the report include lack of communication, lack of knowledge, and stress. These 3 factors have led to major accidents in the industry. The report further suggests training strategies like simulation, classroom training, etc. that can help in reducing the accidents that prevail in the industry.

Contents

Introduction.

Factors related to Dirty Dozen.

Analysis of 3 factors and cases.

Training strategies that can improve the effectiveness.

Conclusion.

References.

Introduction

Human errors are a factor that is the reason for the majority of accidents that happen even today in the aviation industry (Gatta, 2018). Most of the errors are done by the licensed operators or the Crew, Air traffic controllers, etc. These errors take place either because of non-compliance with the standard procedure or making decisions that are poor tactically. 'Dirty dozen' is the term that is used for 12 common errors of human. These are the preconditions that pave a way for accidents or incidents. It was a concept that was developed by Gordon Dupont in the year 1993.

This was then included in the part of the training program. Dirty Dozen provides an introduction for opening a discussion that happens in the business due to human errors (Samad, Johari & Omar, 2018). According to a report by Aviation safety magazine there are around 90% of accidents that take place due to human errors. The reports aim at studying the problems that are caused by 3 of these factors and recommend a strategy for training to enhance the effectiveness of the safety management system.

Factors related to Dirty Dozen

The various factors that are involved in the Dirty Dozen involves a list of 12. It is also used for a campaign of a poster that was developed by Maintenance and Ramp Safety Society for the training purpose. The various factors are (Mallema, 2018):

  • Lack of communication
  • Distraction
  • Lack of Resources
  • Stress
  • Complacency
  • Lack of teamwork
  • Pressure
  • Lack of awareness
  • Lack of knowledge
  • Fatigue
  • Lack of assertiveness
  • Norms

Analysis of 3 Factors and Cases

Lack of communication

Lack of communication is one of the major reasons that contribute to the accident reports and serves as an important factor for human error that causes accidents. Communication is done through a transmitter (Bajaj, 2019). There are times when the message is not clear and then the receiver makes assumptions about the instructions that have been provided. Even if only one person makes a mistake, results are catastrophic. Various accidents have happened due to miscommunication.

The disaster at the Airport of Tenerife's Los Rodeos Airport was the worst disaster that happened. Two Boeing 747s flights and KLM Dutch Airlines collided in the fog. This accident killed around 583 people and only out of the 3 planes 61 were able to survive. This accident happened due to miscommunication ( Chatzi et al, 2019). On the day of the accident the airport of Los Rodeos was covered with fog and was overcrowded due to diversion of traffic from another airport Gran Caneria where an explosion of the bomb had happened. The pilot of KLM was eager to leave and the crew has reached the legal limit for their time off on duty. This contributed to the mistake of the pilot when a communication was received of "you are clear' from the control tower (Kanki, 2019).

A second clearance was also required before the flight could take off instead the pilot started on the runway. During that time, the Pan Am flight was trying to find its taxiway that was assigned to them and it was directly in the path of KLM flight (Khan et. al, 2018). This resulted in a heavy collision and obliterated the Dutch plane that was 100 feet in the air and came crashing down like a ball of fire. With that the Pan Am flight also sliced into the pieces and caught fire. Investigation results showed that a simple error of miscommunication led to such a massive accident where almost everyone in the flight got killed.

Another major accident that took place was Garuda Airlines Flight 152 which was traveling to Jakarta to Medan. Before making down to the airport, the pilot makes its final approach to the airport of Medan and asked for help complaining of the visibility issue as there was a forest fire that was burning below (Kelly & Efthymiou, 2019). During that time, fires were causing delays and there were around 3 planes that were waiting to land at the airport. Confusion raised as the two flights were having the same flight numbers. In the chaos, the controller of air traffic pulled the Gaurda flight 152 for its regular course.

Yet the major cause of the disaster was a failure in communication between the airport and the pilot. Before the plane was supposed to land, an Airbus A 300 had landed and the controller instructed the pilot of Gaurda to take a right turn instead of left. This mixture let to the crashing of lights and killing around 234 people who were present in the flight. The time flight turned in the wrong direction, within a minute pilots were screaming as they realized that the disaster had taken place (Mathews, 2018). A simple miscommunication led to the fatal accident and killed around 200 people in a fraction of seconds.

Various other incidences have taken place due to miscommunication in the airline business. There are times when language serves as a barrier. A person is unable to understand what the other person is saying. This too has led to an accident of Charkhi Dadri Mid-air collision. In the accident pilot was unable to understand English and was looking towards another person for clearing the instruction. At the same time the person assigned was unable to understand the words particular to the aviation industry (Moura et al., 2017). This led to a heavy collision between two planes in the air and led to fatalities. Communication is a basic factor that is required, so to make sure English was set up as a language for the aviation industry in the year 2011. It is required that various steps should be taken to avoid the problem of miscommunication as the loss is largely due to this dirty dozen in the industry.

Lack of knowledge

Around 42% of the accidents caused in the aircraft industry over the years are caused by a lack of knowledge. Dues to a lack of knowledge maintenance errors occur. Around 125 of the accidents that are reported cite a reason for maintenance that occurs because of a lack of knowledge in the people working. The potential errors that can take place due to lack of knowledge includes faulty component installation, wrong parts being assembled (Dalkillic, 2017). Connection not done right, failure of lubricant, pins not being removed. These errors can lead to the potential threat of accidents.

Certain cases happened due to a lack of knowledge in the staff. The very first one of the Lufthansa Airbus A320 that crashed almost due to the wiring being reversed of the controls. The flight took off and was about to crash because the reversed wiring sidestick the control of flight. Due to the quick reaction of co-pilot whose side was not sticky the crash was able to be stopped. The investigation happened to find the reason and it was found that during a previous flight the two aileron computers were having some problem (Boyd & Stolzer, 2016).

A pin was damaged and replaced. Later it was found that the pairs of pins were accidentally switched at the time of maintenance. This led to the side sticking of the control unit. Clues might have been seen on the monitors of the aircraft screen but the pilots do not verify the indication of deflection. This might have led to a huge crash. The only problem was the lack of knowledge in the maintenance person. A simple change in pins led to the sticking of side sticks and might have caused an accident.

Another accident that took place was of Value jet airlines, Flight McDonnell DC-9 crashed just after taking off in the next 11 minutes. Flight was scheduled from Miami to Atlanta and took off on its respective time. In the next 11 minutes flights crashed due to fire in the cargo department. The fire was caused because of improper storage (Kelly & Efthymiou, 2019). There were around 110 people who were killed in the crash. An investigation happened and the reason found was that the accident happened because the person storing the cargo has no proper knowledge of how to keep the things in line. If the cargo would have been stored properly, the flight would not have caught the fire and 110 people might now have died.

An accident of the Aeroperu flight describes the same. The flight took off and shortly after the crew of the airline realized that the instruments were giving the wrong reading. This led to a lack of basic reliable flight instruments and warnings. The pilots declared an emergency and headed back towards the airport but as the location was not known the plane crashed into the ocean. An investigation was carried on and it was found that it happened because of the failure of a worker from removing the duct tape that covers the static ports. It is removed at the time of washing of the airlines but due to lack of knowledge, it was not and led to a huge accident (Purbayanti & Martiana, 2017).

These were the basic things that are to be known to the person who is working but due to lack of knowledge massive accidents took place ad lives were lost.

Stress

In the aviation industry it is common to have stress. Pilots can experience it on the flight, ground, and during the time of work-related activities. There are chances that airline pilots can be stressful due to the job they are doing. They have a load of thousands of passengers who are traveling with them (Dias, Santos & melicio, 2019). At times, there is excessive stress that jeopardizes that relevant making of decisions and can lead to an error from the pilots perspective. Various accidents have also taken place due to stress in the pilots.

Asiana airline flight 214 had an accident that took place due to stress. The flight was approaching its final destination in San Francisco. During the time of its landing, the flight got hit by the runways’ edge and the tail of it fall apart. This was followed by the burning of the fuselage that caught flames. The pilot who was flying was a trainee and was stressed about the landing on an unfamiliar runway. This led him to think that the autothrottle was working (Dismukes, Kochan & Goldsmith, 2018). This accident led to injuries and around 187 passengers were hurt. Investigations revealed that the pilot was stressed and also was not fully aware of the jet. Due to his lack of awareness, he was stressed and did an aftermath that led to a disastrous outcome. 3 passengers died too in the accident.

Another accident that happened due to stress was of American airlines flight 1420. The pilot was an experienced one and had an experience of over 10000 hours in flying. The first officer of the flight has an experience of 5000 hours of flight time. The flight was supposed to land at the airport of Arkansan. But during the time a major thunderstorm occurred in the area and the pilot in the situation decided to change the runway due to crosswind and changes in the direction of winds (Sujata et al., 2019). The pilots had to overcome the tasks and the stress that was prevailing in the situation.

In this stressful situation even after having so much experience the pilot forgot to arm the automatic ground spoiler and the system of groundbreaking. It became difficult to handle the flight and it slid away in the runway and then collided with the walkway that was large and made of steel. This led to the death of the pilot and 10 other passengers and caused severe injuries to many. Stress makes pilots forget to take the necessary steps which leads to fatal accidents.

The incident of an aircraft crash that killed the Polish president signifies the same. At the time of landing, the pilot was having difficulties due to foggy conditions. But the flight had passengers who were high status, increased the pressure on him. Pilot brought the airplane down at too low altitude that resulted in the controlled terrain of flight (Freitas, Infante & Bapista, 2019). The attempt of his landing failed and the plane crashed in the forest. This killed the pilot and all the passengers including the members of the crew. Investigation revealed that stress causes various accidents. Pilots while flying are under various kinds of stresses. This leads to fatal accidents.

These are certain Dirty dozen that lead to human errors and cause accidents in the aviation industry.

Training Strategies that Can Improve the Effectiveness

Training strategies applied properly can help in reducing the error. Training will help the person in being better prepared for the situations. It will help the person have enough knowledge about a situation and provide him a better way of dealing with it (Walter & Chuang, 2018). Training strategies regarding different dirty dozen should be different and every person should be made aware of it. It should be implemented to all and every one person.

Strategy for reducing the communication gap

Miscommunication has led to various accidents. A simple statement or a wrong direction has led to a fatal accident. The best way to reduce the miscommunication is to set up a fixed language first. The language that can be decided is English. Every person who is entering the business should be given training concerning the language skills (Chiu & Hsieh, 2016). Proper classes for every new joined should be conducted.

Another session of training should be done where people are put in a situation and then communication should take place. There are certain guidelines like everything should be confirmed twice before moving forward and if the directions are not clear then it should be repeated. It should be made as a practice. And people should be trained and given sessions regarding this. This will bring the activity in practice and remove the hindrance of communication (Heyes et al., 2019). Thus, for the communication gap, first, language training should be provided to all, and the next every step should be reconfirmed and it is to be brought into practice by giving training for this.

Training strategy for lack of knowledge

Accidents have happened in the past due to a lack of knowledge of the people in the industry. Pilot not knowing about their jet and its functioning, maintenance department not knowing about the loading of cargo. These hindrances can be reduced by Training.

  • Proper education: When a new pilot joins or a new aircraft is brought in with new technology, all the pilots should be provided training and knowledge about the aircraft. For this purpose a simulation exercise can be done. To make a pilot aware of its jet, simulation activity can help. It will provide a scenario-based practice to the pilot. Also, the session should be provided that gives every little detail about the aircraft. In the same way maintenance people should be kept on training. A supervisor should be there always when they start working.
  • Classroom training: People can also be provided classroom training where they are taught about the jets and also about loading and unloading methods in the cargo (Littlepage et al. 2016).

These strategies will help in removing the hindrance of knowledge.

Training for stress management

Stress can be reduced through exercises and prior stress management tactics. Pilots should undergo a stress management test every 6 months or 3 months. They should be counseled after 5 flights. This will help them reduce the pressure. Also, a regime for exercise should be given to the pilots and they should be trained to do so (Stokes & Kite, 2017). This will help in getting them relaxed. The counselor will also provide them the required help.

In this manner, these training strategies can be adopted and better results can be brought in by a reduction in aircraft accidents. A well-trained person will be able to do the work properly and efficiently.

Conclusion

The aviation industry goes through various accidents due to human error. These errors are called Dirty dozen. These serve as the reason that paves a way for accidents in the industry. There are 12 dirty dozen that have been identified by the industry. It includes a lack of communication, lack of knowledge, stress, lack of awareness, etc. The three factors that have been described in the study include lack of communication, stress management, and lack of knowledge that have caused various accidents in the past. Lack of communication has led to an accident where the air traffic controller has given the wrong direction, at times flight attended did not asked for reconfirmation. These have led to major aircraft crashes in the industry.

In the same manner Lack of knowledge, where a cargo person not knowing how to place the cargo or the pilot not fully aware of the jet functions has led to major accidents. Stress also is one of the major reasons for accidents. Even the experienced pilots face this and have led to accidents. To overcome these potential threats certain training exercises can take place. These strategies like providing simulation exercise, education, classroom training, stress management techniques, and a counselor to the pilots will remove the various hindrances in the aviation industry and reduce the rates of accidents in the industry.

References

Bajaj, B. (2019). Human factors in risk communication. Translation in Cascading Crises.

Boyd, D. D., & Stolzer, A. (2016). Accident-precipitating factors for crashes in turbine-powered general aviation aircraft. Accident Analysis & Prevention, 86, 209-216.

Chatzi, A. V., Martin, W., Bates, P., & Murray, P. (2019). The unexplored link between communication and trust in aviation maintenance practice. Aerospace, 6(6), 66.

Chiu, M. C., & Hsieh, M. C. (2016). Latent human error analysis and efficiency improvement strategies by fuzzy TOPSIS in aviation maintenance tasks. Applied Ergonomics, 54, 136-147.

Dalkilic, S. (2017). Improving aircraft safety and reliability by aircraft maintenance technician training. Engineering Failure Analysis, 82, 687-694.

Dias, N. G., Santos, L. F., & Melicio, R. (2019). Aircraft Maintenance Professionals: Stress, Pressure, and Fatigue. In MATEC Web of Conferences (Vol. 304, p. 06001). EDP Sciences.

Dismukes, R. K., Kochan, J. A., & Goldsmith, T. E. (2018). Flight crew errors in challenging and stressful situations. Aviation Psychology and Applied Human Factors. Retrieved from: https://econtent.hogrefe.com/doi/abs/10.1027/2192-0923/a000129?journalCode=apf

Freitas, M., Infante, V., & Baptista, R. (2019). Failure analysis of the nose landing gear axle of an aircraft. Engineering failure analysis, 101, 113-120.

Gatta, A. (2018). Rethinking human error in aviation accidents: Regulatory and standard practices in the Nigerian aviation industry. International Journal of Arts, Languages and Business Studies, 1(1).

Heyes, G., Raje, F., Hooper, P., Hudson, R., & Dimitriu, D. (2019, September). Critical Assessment of Aviation Noise Communication Strategies in the European Union. In INTER-NOISE and NOISE-CON Congress and Conference Proceedings (Vol. 259, No. 5, pp. 4377-4388).

Kanki, B. G. (2019). Communication and crew resource management. Crew Resource Management (pp. 103-137).

Kelly, D., & Efthymiou, M. (2019). An analysis of human factors in fifty controlled flight into terrain aviation accidents from 2007 to 2017. Journal of Safety Research, 69, 155-165.

Khan, W., Ansell, D., Kuru, K., & Bilal, M. (2018). Flight guardian: autonomous flight safety improvement by monitoring aircraft cockpit instruments. Journal of Aerospace Information Systems, 15(4), 203-214.

Littlepage, G. E., Hein, M. B., Moffett III, R. G., Craig, P. A., & Georgiou, A. M. (2016). Team training for dynamic cross-functional teams in aviation: Behavioral, cognitive, and performance outcomes. Human factors, 58(8), 1275-1288.

Mathews, E. (2018). A linguistic review of aviation accidents. Retrieved from https://commons.erau.edu/icaea-workshop/2018/wednesday/5/

Mellema, G. M. (2018). Application of Dupont’s dirty dozen framework to commercial aviation maintenance incidents. Retrieved from https://commons.erau.edu/edt/477/

Moura, R., Beer, M., Patelli, E., & Lewis, J. (2017). Learning from major accidents: Graphical representation and analysis of multi-attribute events to enhance risk communication. Safety Science, 99, 58-70.

Purbayanti, H. F., & Martiana, T. (2017, August). Analysis of factors that influence the risk of occupational accidents in terms of behavioral aspects (Study on Aircraft Paint Removal Workers in PT. X). In 1st International Conference Postgraduate School Universitas Airlangga:" Implementation of Climate Change Agreement to Meet Sustainable Development Goals"(ICPSUAS 2017). Atlantis Press.

Samad, A. G. A., Johari, M. K., & Omar, S. (2018). Preventing human error at an approved training organization using Dirty Dozen. International Journal of Engineering and Technology, 7(4), 71-73.

Stokes, A. F., & Kite, K. (2017). Flight stress: Stress, fatigue, and performance in aviation. Routledge.

Sujata, M., Madan, M., Raghavendra, K., Jagannathan, N., & Bhaumik, S. K. (2019). Unraveling the cause of an aircraft accident. Engineering failure analysis, 97, 740-758.

Walter, J., & Chuang, L. L. (2018). Restricted field of view during training impacts gaze strategy for aircraft handling. Retrieved from: https://www.frontiersin.org/10.3389/conf.fnhum.2018.227.00097/event_abstract

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