Runway Overrun and Collision of Southwest Airlines Flight 1248 - Case Study Example

Part 1: Introductory Analysis of Southwest Airlines Flight 1248 Accident On December 8, 2005, a Southwest Airlines passenger plane encountered a fatal landing in Chicago. The plane was flying from Baltimore in Washington DC to Nevada, through Chicago, Illinois and Salt Lake in Utah. After flying from Baltimore International Airport, the Southwest Airlines Flight 1248 was supposed to make a stop at Chicago Midway International Airport before proceeding to Utah and finally to Nevada. Upon arriving at the skies of Chicago Midway International Airport, the plane encountered a snowstorm. In spite of the snowstorm, the flight’s pilot made an effort to land (NTSB, 2007). The plane unsuccessfully landed when it slid off the Chicago Midway runway and crashed into automobiles along an adjacent intersection lane. The slid-off resulted in the death of Joshua Woods, a six-year-old child. Admittedly, this was the only fatality incident involving the Southwest Airlines. Prior to the landing, the pilot had circled over a small area adjacent to the airport. Conventionally, the pilot circled the area in an effort to ascertain whether a smooth landing would be possible (Hans, 2007). As a result of the snowstorm, the sky visibility had reduced to approximately one mile. Personnel managing the Chicago Midway’s Instrument Landing System were in constant communication with the pilot. At around 1915 hours CST time, the personnel managing the Instrument Landing System assured the flight’s captain that the snow on the runway had been cleared. However, there was actually about 8-inches thick snow lying on the runway. Because of the eat-southeast winds blowing at 20 km/h, the snow accumulated shortly after the officials had assured the pilot of a clear runway. In response, the pilot jokingly said, “I picked a bad day to stop sniffing glue” The comment was an allusion of the crash-landing movie called Airplane. While still hesitant, the pilot attempted a landing, not knowing that the runway from the touchdown point to its end was shorter than required. Based on the weather, the plane needed at least 5400 feet of runway (Sandra, 2009). However, flight 1248 touched town at a point where there was only 4,500 feet of the runway remaining. Alternatively, the National Transport Safety Board, NTSB, had recommended that the plane fly to Chicago O’Hare International Airport. The O’Hare Airport had longer runways compared to the Midway Airport. However, the flight’s pilot, under advice from the Southwest Airlines management, was afraid of additional expenses that the O’Hare landing would impact on the company. Because of the shorter runway, the Southwest Airlines flight 1248 skid past the runway barrier and crashed onto three cars on an adjacent intersection commonly filled with evening traffic. The crash resulted in 1 death, 5 critical injuries and 12 people sustained minor injuries. Part 2: Problem Analysis using SHELL Diagram The fatal landing of Southwest Airlines Flight 1248 resulted from numerous factors including environmental factors, human error and software hitches. In terms of software hitches, the flight’s pilot and runway officials relied on runway regulations, supervisors’ commands and decisions from the safety board. Runway regulations require that prior to landing; pilots should circle outside the airport while waiting for runway hitches to improve. This explains why the captain of Flight 1248 circled outside Northwest Indiana prior to attempting the landing. Supervisors’ commands include those from runway officials and the flight’s company. Managers of Southwest Airlines were afraid of additional expenses associated with the O’Hare landing. Flight 1248 pilot agreed with the expenses issue, especially because airport officials assured him that the runway was cleared from snow. Combined effects of these software components played an instrumental role in influencing the flight’s fatal fate (NTSB, 2007). The second component of SHELL diagram is H for hardware. With respect to the Southwest Airlines Flight 1248, hardware components of the incident include the runway control instruments, the aircraft’s mechanical capability and the runway’s structural characteristics. Based on the instruments from Chicago Midway’s landing system, the airport officials assured the pilot that the runway was clear of snow. This misinformation was worsened by the runway’s structural characteristics. First, the runway was short, thus could not allow a sizable plane to land during snowstorm emergencies. In addition, the runway bordered an intersection full of traffic. In this context, a longer runway complemented with absence of the intersection would have eliminated the fatal fate of Flight 1248. Lastly, the hardware component of plane’s mechanical capability was influential (Hans, 2007). Technically, a plane’s reverse thrust levers are used for emergency braking. Because of mechanical reasons, Flight 1248 pilot reported that he could not apply the reverse thrust levers since the levers were restrained in the original position. The third letter of the SHELL diagram is E for environment. Environmental conditions play a significant role in airport control and operations. In fact, both the software and hardware components of the SHELL diagram operate within a given environment. Among the environmental factors surrounding Flight 1248 incident include the weather aspects of visibility and the snowstorm. In addition, external factors like organizational economics fall under the environmental umbrella. According to statistical reports from Chicago Midway International Airport, the runway’s visibility had reduced to less than 1 mile, which is substantially below the normal visibility range of at least 21 miles. Additionally, the snowstorm was driven by south easterly winds blowing at a speed of 11 knots. Based on these prevailing conditions of weather, the plane required a longer runway for successful landing (Hans, 2007). Economically, both the pilot and the Southwest Airlines management were concerned about additional expenses resulting from missed flight connections and related hitches. Consequently, the option for Chicago O’Hare Airport was disregarded. The last component of the SHELL diagram is L for live ware. Live ware stands for human elements of the flight control and operations. Observably, there are two L in the diagram. This insinuates that the human element of flight operations and control plays a central role in determine a flight’s fate. The first L is for the cabin crew while the second L represents the ground personnel of the aviation system (Henry & Smith, 2010, P. 57). With respect to the cabin crew, the captain for Flight 1248 was aware of the unfavorable conditions on the ground. Actually, the captain, representing concerns of the cabin crew, was hesitant of the landing and alluded of a possible accident. In this case, the pilot would have considered the O’Hare Airport landing. With respect to the ground crew, one can acknowledge that there was poorly constructed communication from ground personnel to the cabin crew. Professionally, the ground crew is not supposed to provide ambiguous information to the cabin crew (Henry & Smith, 2010, P. 57). However, the ground crew misinformed the flight’s captain on the subject of cleared snow. Professionally, the ground crew should have acted autocratically by directing the flight’s captain to consider an alternative landing option. Part 3: HFACS in Analysis of Human Error After an accident, investigations are required to unearth the nature and causes of the incident. Normally, mechanical errors could be the primary causes of aviation accidents. In addition, environmental conditions play a significant role in influencing occurrence of aviation accidents. Moreover, human error remains at the central position of accident causations. Mechanical operation and control of airplanes are done by humans. In addition, deciphering the conditions of aviation environments is primarily done by humans, either instinctively or with the use of relevant instruments (Douglas, 2011). During investigations, the causes and degree of human error must be understood before developing conclusions and subsequent recommendations. Technically, professional tools like the Human Factor Analysis and Classification System, HFACS, prove instrumental in investigating human errors. Applying the HFACS in the Southwest Airlines Flight 1248 will be useful in analyzing the roles of distinct human errors in the plane’s fatal accident. Human Factor Analysis Classification System contains four fundamental levels. Level 1 deals with acts that are deemed unsafe, and has potential to change the intended operation of aviation instruments. The second level checks on the preconditions influencing unsafe acts. The preconditions can either be environmental or personal in nature. These conditions increase chances of unsafe acts in emergency situations (Douglas, 2011). The third level of HFAC system deals with the concept of supervision. Theoretically, subordinate employees and staff members must remain under supervision of experienced members from the professional workforce. Supervision enables effective decision making during dilemma situations, and swift correction of mistakes before accidents occur. Finally, the last level involves evaluation of organizational influences. Admittedly, the organizational culture and command structure influence the manner in which employees like cabin crew execute their duties. Supervision In analyzing the human error of Southwest Airlines Flight 1248, we will focus on the last two levels of HFACS; supervision and organizational influences. Apparently, the cabin crew of Flight 1248 was under inadequate supervision. Prior to landing, the pilot alluded about a possible crash. Despite the allusion, the airport official in charge of landing supervision disregarded the pilot’s joke. Another incident of inadequate supervision is on the deployment of reverse levers. Based on flight data, the levers were not deployed until the last 18 seconds before the crash. Technically, minimum supervision failed to inform the captain that reverse thrust levers should be deployed immediately upon touchdown. Under strict circumstances, a supervisor is tasked with ensuring that subordinate employees succeed in their tasks. In the face of doubts, supervisors are supposed to advice the subordinates objectively. However, the airport officials failed to adequately advice the captain of Flight 1248, leading to the crash landing. Besides inadequate supervision, the Flight 1248 incident also suffered from inappropriately planned operations and supervisory violations. Despite the limited visibility coupled with snow-filled runways, airport officials and members of the National Transport Safety Board proceeded to authorize the landing. In this case, the supervisors planned and approved execution of a mission that was beyond the captain’s capability. In terms of supervisory violations, the supervising officials disregarded existing regulations relating to emergency landings. Before the landing, officials at the Chicago Midway International Airport advised the cabin crew of Flight 1248 to circle around and wait for the snowstorm to subside. Later, the same officials disregarded their earlier request for prolonged await and allowed the captain to land. In this case, the direct disregard to existing regulations amounts to supervisory violation (Sandra, 2009). Organizational Influences The first component of organizational influences involves the organizational climate, commonly referred to as the organizational culture. With respect to the flight’s fatal fate, it emerged that Southwest Airlines favored their economic interests over the safety of passengers and commuters on the adjacent intersection. The National Transport Safety Authority proposed the idea of landing at Chicago O’Hare Airport, a larger airport than the Chicago Midway Airport. Despite the enhanced safety aspect, landing at the Chicago O’Hare Airport would involve additional expenses to Southwest Airlines. In this case, the profit maximization culture of Southwest Airlines influenced the cabin crew of Flight 1248 to initiate an experimental landing at Chicago Midway, a risky place when compared to the Chicago O’Hare. Apparently, the solid hierarchical structure of Southwest Airlines could not allow the captain to independently make the decision. There is a remote yet distinct possibility that based on the economic culture of Southwest Airlines, the captain and cabin crew of Flight 1248 were afraid of causing increased expenses by diverting the landing destination to the safe Chicago O’Hare International Airport. Aside from the influence of organizational climate, the fate of Flight 1248 was determined by management resources and organizational processes (Douglas, 2011, P. 74). Data from the flight recorder feature the flight’s captain mentioning that the plane’s reverse thrust levers had failed to deploy. Later, the same recorder has the first officer admitting that the reverse thrust levers had no functional problem, thus the officer deployed the levers. Admittedly, the organizational process of training seems inadequate and inefficient. It is unnatural for a well-trained captain to say that the reverse thrust levers were faulty only to be corrected by a first officer, especially when the reverse levers were the last option that would facilitate a relatively safe landing. It means that because of the ineffective organizational training processes, the captain lacked technical knowledge and experience regarding the use of reverse thrust levers (Douglas, 2011, P. 81). With respect to management resources, there should have been emergency landing manuals or audio instructions for the cabin crew. However, absence of such instructions explains why the important thrust levers were deployed late, leading to the flight skidding past the runway barrier. Part 4: Solutions from Two-Pronged Analysis The two-pronged attack is an effective model of developing solutions to human errors. Undeniably, accidents like that for Flight 1248 may happen in the near or far future. In fact, the Southwest Airlines Flight 1248 occurred 33 years after 45 people died when United Airlines flight 553 crashed in the Chicago Midway. In order to mitigate future chances of crash landings at the airport, solutions must be developed. The first prong of the two-pronged attack involves minimization of accident occurrences, while the second prong stands for minimization of an accident’s consequences (Bradbury, 2013). As acknowledged earlier, inadequate supervision and organizational processes of training were among the influential factors of Flight 1248 fatal landing. In order to minimize such crash landings, supervisors must be objective. Additionally, supervisors should not favor economic interests over stipulated regulations. Moreover, improving professionalism of the cabin crew and other personnel would be instrumental in minimizing occurrences of accidents. With respect to the second prong, management of both the airport and the Southwest Airlines should be prepared to deal with consequences. The first way of dealing with consequences is to minimize the same consequences. Flight 1248 knocked down the barrier at the end of the runway, and strayed into the nearby intersection. Without the adjacent intersection, there would be no deaths from the crash landing (Bradbury, 2013). In this case, consequences of future crash landings can be minimized by implementing the runway safety area requirement. The safety area requirement mandates that international airports should have at least 1000 feet of extra area at the end of each runway. The 1000 feet area is meant to allow spacecrafts that overruns the runway to decelerate before straying into nearby public facilities. In case Chicago Midway Airport had this requirement in place, Southwest Airlines Flight 1248 would have decelerated to a halt before reaching the intersection. Part 5: Cost-Benefit-Risk Analysis The above-mentioned requirement for a free area at the end of each runway is technically plausible but economically unfeasible (Tevfik, 2006). Southwest Airlines and the Chicago Midway International Airports are organizations with revenue generation objectives. With respect to the cost aspect, acquiring an extra 1000 feet of land at the end of each runway would be expensive. In terms of benefits, the extra area will not generate any revenue. In terms of risks, it is highly unlikely that another flight will crash at the airport in the foreseeable future. In this case, a better solution would involve formulating a new set of emergency regulations for aviation control. Apparently, the existing set of regulations is inefficient and allows supervisors to violate rules. The new set of regulations would contain strict punitive provisions whenever a supervisor or cabin personnel violates stipulated rules. The solution regarding the new regulations is less costly compared to expanding the runways (Tevfik, 2006). In addition, strict regulations will increase professionalism of the workforce; hence improving service provisions and resultant revenues from the services. References Bradbury, J. (2013) Two-Pronged Attack: Analysis of Case Management Activities. Indianapolis: Universal-Publishers. Douglas, W. (2011) Applying Reason: The Human Factors Analysis and Classification System (HFACS). Journal of Human Factors and Aerospace Safety, 1(1), 59-86. Hans, M. S. (2007) Aviation Safety: Human Factors, System Engineering and Flight Operations. New York: Cengage Learning. Henry, P. & Smith, W. A. (2010) Safety Management Systems: Understanding Human Factors. Journal of Civil Aviation Safety, 27(4), 59-64 NTSB. (October, 2007). Runway Overrun and Collision, Southwest Airlines Flight 1248, Boeing 737-7H4, N47WN, Chicago Midway International Airport. Retrieved from http://www.ntsb.gov/news/events/2007/chicago_midway_il/index.html Sandra, K. C. (2009) Aviation Management: A Global Perspectives Approach. New Delhi: Global India Publications. Tevfik, F. N. (2006) Cost-Benefit Analysis: Theory and Application. Pittsburg: SAGE Publications. Read More