SOLUTION: Flight 255 Aircraft Accident Case Study Essay
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Overview of the Flight 255 Air Accident
It is exactly 25 years since one of the worst airborne accident happened on the soil of the United States of America. On August 16, 1987, aircraft Flight 255 bound for Arizona was involved in a crash that killed 156 people and left one person alive. Among the dead were 148 passengers, 6 crew members and 2 persons on the ground. Five people on the ground were injured, with one person seriously injured and four persons suffering minor injuries. The survivor of the crash was a four year old girl by the name of Cecelia Cichan, now 29 years and married. The aircraft belonged to Northwest airline and was headed for Arizona from Detroit Metro Airport.
According to NTSB (1987) the aircraft that was involved in the air mishap was a McDonnel Douglas DC-9-82, US Registry N312RC. It had 149 passengers and 6 crew members on boards. The craft was being piloted by Captain John R. Maus aged 57 years and David Dodds aged 35 years. According to the history of the flight, the aircraft started journey on August 16, 1987 operating as flight 750 after been picked at Minneapolis. It was being flown to Michigan with on the journey stop at Detroit Metro Airport. It arrived at Saginaw at about 1840 daylight eastern time, and was scheduled to make flights to Santa Ana, California with two enroute stops at Detroit and the other one at Phoenix. The aircraft was scheduled to be piloted by the same crew that flew it in. Now operating as Flight 255, it left Saginaw N312RC at around 1853 Eastern Time. Flight 255 arrived at Detroit Metro Airport at 1942 Eastern Time. It is reported that the journey to Detroit Metro Airport was uneventful. At the gate of Detroit Metro Airport, the aircraft made successful 180” turn to its designated arrival gate. After passengers had disembarked the plane, routine checkup of aircraft and cabin maintenance logbook was done by one of the Northwest mechanic, nothing unusual was detected on either logbooks. Before the flight, it was reported that the captain conducted the usual walk-around inspection the plane. He ascertained to the transportation agent that everything was in order for the flight to take off. Tentatively at around 2029 Eastern Time weight tabulation was handed to the crew, and about 2032 flight 255 started its journey by departing the gate. At around 2033 the flight crew started the engines and the ground crew detached the tow bar from the craft. Details emerged that communication between the ground controller and the flight crew was going smooth and at about 2035 the ground controller gave the flight crew of flight 255 the green light to way out the ramp using taxiway Charlie, commonly referred to as C, then taxi to runway 3C, and thereafter switch radio frequencies to 119.45Mhz, which they were to use to communicate with the ground controller. However, it is reported that the first officer despite being alerted to change radio channels he did not, he only repeated the taxi clearance statement. Recordings from the aircraft indicate that the captain sort advice from the first office on whether they could use runaway 3C for takeoff. Something that first officer confirmed and alerted the captain of flight 255. Runaway 3C, which is the shortest of the three runaways at Detroit Metro Airport is used by aircrafts recording takeoff weights of 147,500 pounds and 145,100 pounds, with flaps set at 110. Flight 255 could use the runaway since it was below the recommended takeoff weight. The aircraft was at 144,047 pounds. The aircraft is reported to have missed the turnoff at taxiway C, but it was later redirected by the ground controller to runway 3C. communication at this point is reported to have been all right as the ground controller manager to contact the first officer and directing him to runaway 3C and alerting the first officer to switch to a new frequency, which he obliged. The aircraft started experiencing problems from the moment the engine was powered as the flight crew had failed to engage the automatic throttle system; luckily, they latter managed. Witnesses accounts reveal that the takeoff of flight 255 was problematic as it was confirmed that the takeoff roll was longer than of other similar aircrafts, the rotation commenced at between 1200 and 1500 feet from exit of runaway 3C, the rotation of the aircraft was at a higher pitch angle than is usually the case with other similar aircrafts, the plane’s flaps and slats were extended and lastly the plane’s tail almost struck the runaway. Once the plane was airborne, it is reported that plane started rolling from right to left, with bank angles swaying from 150 to 900. During the rolls, the left wing hit a light pole in a car lot, continued left rolling hit a light pole of another rental car lot and lastly smacked the rooftop wall of the second rental car lot. After hitting the rooftop the plane left rolled to the ground, slip along the road till it hit a railroad guard and exploding into flames. The McDonnel Douglas DC-9-82 was destroyed completely by the ground impact and engulfing fires.
Analysis and Evaluation of Fight 255 Air Accident
Due to enhanced aviation technology, aviation safety has tremendously improved, making air travel the safest mode of transport. Nevertheless, there are still cases of aviation accidents despite automation efforts in the industry. Due to the advanced aviation technologies such as automation employed in airplanes today we can conclude that the aircraft accident involving McDonnel Douglas DC-9-82 was caused by human error. This view is upheld by research conducted to investigate the causes of aircraft accidents. It was reported that most of aviation accidents are caused by human error (Kern, 1998; Strauch, 2004). Wiegmann and Shappell () point out that aircraft over the years have continued to be more reliable, and therefore it is human error that is contributing to aviation accidents. Aviation experts and aviation safety analysts report that human error in aviation as any human actions that compromise the effectiveness or safety of aircraft system (Wickens, Gordan & Liu, 1998). Human error may occur due to the following: humans operating the aircraft system; humans who designed and developed the aircraft system; humans who supervise the aircraft crew and humans who trained the aircraft crew. Kern (1998) observes that aviation accidents are caused by two categories of human error; namely, omission and commission. Error of omission is attributed to flight crew members failing in executing their obligatory tasks. Errors of commission, on the other hand, occur when crew members such as flight crew members execute their required tasks wrongly. Other forms of human errors that cause aviation accidents include slips, lapses, mistakes and violations (Strauch, 2004). Strauch (2004) continues to observe that in aviation, human error can manifest as pilot or flight-deck error, maintenance error or as air traffic control error.
In the accident involving McDonnel Douglas DC-9-82, it is evident that the crew members failed in execution of their obligatory tasks before takeoff and during takeoff. It is reported that the aircraft had one of the most sophisticated technology. Therefore, most probability human performance of the flight crew, air controllers or maintenance engineer compromised the efficiency and safety measures of the plane’s system. The cause of the airplane accident is poor takeoff of the aircraft that resulted to the flaps hitting the long pole of the rental car lots. It is the duty of flight crew members to ensure that flaps and slats of an airplane are well positioned for takeoff. Similarly, it was the inspection task of flight-255 crew members to ensure that the airplane’s flaps and slats were appropriately extended for takeoff. Flight crew of the ill fated plane failed to do a thorough TAXI checklist. Among the things they were supposed to check and verify was correct positioning of flaps and slats and the configuration of the plane for takeoff. The flight crew member are believed to have been properly trained according to the required standards. This was therefore an error of omission that cannot be explained. It is normally the duty of the first officer to position and extend the flaps once the airplane has started taxiing and cleared the ramp. However, in this case the first officer was engaging initiating change of runaways, consequently diverting his attention and delaying him from extending the flaps. Even once airborne the flight crew members failed to notice that the flaps had not been extended properly. This may be attributed to human error. Besides, it is incomprehensible why automatic alarms failed to notify the flight crew members that the flaps were not properly extended. This raises issues of the reliability of the automatic alarm to alert crew members of any improper setting. It is difficult to ascertain whether the automatic alarm failed or was it manually interfered with. Probably, improper settings of the flaps of the ill fated flight 255 were caused by mechanical errors and human errors.
Cockpit discipline of the flight crew members of flight 255 come into sharp focus. The captain was not in control of the other crew members as should be the case. The captain failed to ensure that checklists were accomplished as per the set procedures and guidelines. Information collected before the flight indicated that the flight officer was the one who signed the flight release document. This was, and is, against Northwest Airlines procedures and aviation industry regulations; instead it is the captain who is obligated to sign the flight release documents. Therefore, flight officer was burdening himself with roles of the captain and his duties. This may therefore have compromised on performance of his duties. It was also reported that initially during the taxi-out, the first officer did not abide to the ground controller request of changing radio frequency, obstructing communication between dround controller at taxiway Charlie or C and flight crew. This behaviors by the flight crew members of flight 255 may have probably caused the crashing of the plane as their performance fell below the set standards of air carrier flight crew. It is evident that human error, both of error of omission and error of commission, by the flight deck caused the air mishap.
Conclusion and Recommendation
From the above analysis and evaluation of the ill fated flight 255, it can be surmised that the airplane accident was caused by human error and mechanical error. The following human errors caused the airplane accident: error of omission, error of commission, mistakes, violations and lapses. The first officer failed to ensure that the flaps and slats of the airplane were properly extended, and instead was engaging ground controllers in changing runaways; these represents error of omission and error of commission respectively. The flight crew failed to ensure that the TAXI checklist was accomplished properly, which represents violation and mistakes. Automation has allowed airplanes systems to detect and alert flight crew members of failure of any part of the aircraft system. However in the case of flight 255, the automatic alarms failed to alert the flight crew of improper settings of flaps and slats. This shows that the automatic alarm system may have malfunctioned due to mechanical problems or lack of electrical power.
Due to the cited errors, which include mechanical and human error, which caused the fatal crash of flight 255, there is need for aviation industry players to ensure that they review their safety standards and training standards. Flight crew members should be trained on cockpit discipline and management to ensure that every crew members understands and executes his role as per the laid down industry standards. This will prevent human errors, mistakes and violations in the future. Secondly, there is need for safety and mechanical evaluation of automatic alarm systems to ensure that failure are detected and corrected. Thirdly, players in the aviation industry should convene a meeting of flight crew members to seek better and friendly way of accomplishing the checklist since the conventional method may be failing. Lastly is the strict enforcement and adherence to checklist procedures by inspectors. This will minimize cases of human error and mechanical error as witnessed in flight 255.
References
National Transportation Safety Board (1987). Aircraft accident report: NorthWest Airlines, Inc. McDonnell Douglas DC-9-82, N312RC Detroit Metropolitan Wayne County Airport Romulus, Michigan. Washington DC.
KERN, T. (1998). Flight discipline. New York: McGraw-Hill.
STRAUCH, B. (2004). Investigating human error: Incidents, accidents and complex systems. Aldershot, England: Ashgate Publishing Ltd.
Wickens, Christopher D., Gordon, Sallie E., and Liu, Yili (1998). An Introduction to Human Factors Engineering. Addison-Wesley Educational Publishers Inc., New York, New York.
Wiegmann, D. A. & Shappell, S. A. (2000). Human error perspectives in aviation. The International Journal of Aviation Psychology, 11(4), 341-357