Lockhart River M23 Accident - Case Study Example

Lockhart River M23 Accident in Relation To the Failure or Use of Standard CRM Technique Discuss Lockhart River M23 Accident in relation to the failure or use of standard CRM technique. Discuss the use of automation and its application in the flight deck environment during the above accident sequence. In your opinion, what does this accident show with regard to the safety culture within the general aviation and small regional airlines component of the Australian aviation scene? Introduction The aircraft SA227-DC Metro 23, registered VH-TFU on 7 May 2005, was refuelled at Bamaga for the return flight to Cairns via Lockhart River to embark two passengers. The pilot in command reported to the ground manager before leaving Bamaga that the weather was 'bad' at Lockhart River and it might not be feasible to land there. The forecast environment at the aerodrome comprised few broken cloud base 1,000 ft above the airport for duration of up to one hour. The aircraft left Bamaga at 11:07 and ascended to the gliding altitude of FL170. Descent was started at 11:32. After 3 minutes the co-pilot informed Brisbane ATC that the aircraft was on descent, passing 10,000 ft AMSL with an expected time of arrival at Lockhart River of 11:38. At 11:39 the co-pilot announced on the CTAF (Common Traffic Advisory Frequency) that the crew was conducting the runway 12 RNAV (GNSS) approach. At 11:41 the aircraft was over the LHRWI intermediate fix and descent was resumed at 4.8 NM from the LHRWF waypoint. This was 3.1 NM before the descent point specified on the approach chart for the 3.49 degree steady angle approach path to the overlooked approach position. After levelling briefly at 3000 feet 18 degrees of flaps were chosen. The aircraft then started decline 1.4 NM before the final approach fix (FAF). This was 0.3 NM (about 7 seconds) after the descent point specified for the steady slant approach path. The standard rate of descent was 1000 ft/min, rising to 1700 ft/min. At 11:43 the Metro was over the FAF at a height of 2379 feet. The elevation at this phase ought to have been 2860 feet. The plane descended then through the phase minimum safe height of 2,060 ft. It continued to descend until it impacted to the heavily timbered ridge in the Iron Range National Park. The altitude of the first impact with trees was 1,210 ft that was about 90 ft below the peak of the ridge. None survived out of 2 crews and 13 passengers. This essay looks into various failed systems and reason for their failure and in turn the accident of CFIT. The essay will as well in addition talk about on how this accident shows the disparities with regard to the safety culture within the general aviation and small local airlines component of the Australian aviation scene (ASN, 2005). The Transair VH-TFU accident is considered as CFIT and includes a number of factors linking to human performance, local conditions, risk control and, Transair and CASA procedures. Before going into details of the safety factors recognized, the flight data and situations under which the flight was being operated need to be evaluated. The FDR data confirmed that, throughout the whole descent and approach, there was no confirmation of malfunction or break down of the aircraft engine and flight control system features and that the flight crews were precisely navigating the airliner along the instrument approach path. There were no reports send by the flight crews on the air traffic services frequencies or the Lockhart River CTAF indicative of that there was a setback with the airliner or crew. The area around the Lockhart River, weather conditions at the time of the accident were poor and required of an instrument approach procedure to attempt any landing at the aerodrome. The cloudy weather with broken low cloud between 500 and 1000 ft AMSL added to the poor visibility. This is possible to affect the terrain below the aircraft after it passed the intermediate fix (LHRWI) to be mostly buried in clouds. The FDR statistics as well showed that the aircraft came across instability through the final stage of this approach before it impacted terrain at about 1,210 ft (ATSB 2007) Communication among the crews and other noises at the time of the accident flight were not accessible to examine because of the break down of cockpit voice recorder (CVR) fitted with the aircraft. However, four important individual actions leading up to the collision were recognized. The crew started the Lockhart River Runway 12 RNAV (GNSS) approach, although the crew were conscious that the co-pilot did not have the proper validation and had little experience to manage this type of instrument landing. The descent speeds rate, and approach speeds were more than those specified for the aircraft in the Transair Operations Manual. The speeds and rate of descent as well exceeded those adequate to bring about a stabilised approach. While approaching, the aircraft descended below the level of minimum safe height for the aircraft's position on the approach. The aircraft's increased descent, and the descent below the desired minimum safe height, were not aware and/or corrected by the crew in time before the aircraft directly impacted with terrain (ATSB, 2007). Another contributing factor for the accident might be the RNAV (GNSS) approach. This is comparatively difficult; especially for the Lockhart River runway 12 RNAV (GNSS) approach case. There is a possibility for pilots to lose consciousness of their position along an RNAV (GNSS) approach. As well as, the co-pilot had less skill and practice of carrying out RNAV (GNSS) approaches. Consequently, this might have made it complicated for the pilot in command to notice any deviations while approaching and could have augmented workload of the pilot in command during the crucial segment of flight. But, both pilots were certified for the NDB approach, and hence that approach was the only one accessible to the crew when there was IMC. The crew should have carried out the NDB approach in place of the RNAV (GNSS) approach. It is not sure why the pilots might have not noticed or corrected the high rate of descent, because of more workload or a break down in crew communication and coordination. However, there was no clue in the FDR data that the crew had tried to correct the rate of descent, or the descent during the phase minimum safe height, before the impact occurred. The ground proximity warning system (GPWS) could have probably warned the crew by audio signal to the developing difficult situation. It was in fact the last resort of defence to avoid a collision with terrain, mostly if the aircraft was in IMC up until the time of impact. There was no proof that GPWS system abortive or deliberately stopped. The data from the FDR confirmed that the crew did not begin any movement that might have been the reaction to GPWS warnings. It seems that the crews were under an excessive workload during the approach and the crews’ workload would have been subjective to a number of factors. One possible cause is that the reduced time on hand to fly each stage of approach because of the increased speed than precise speeds through the approach. The co-pilot does not have the proper training and inadequate practice with RNAV (GNSS) approaches, and the high amount workload of RNAV in general. Additionally, the inadequate training in multi-crew process and Crew Resource Management (CRM), which could have elevated the workload if there, was a collapse in crew coordination even though the approach was continued. Moreover the autopilot or any vertical height indicator was not fitted in this VH-TFU. Because of that the flight crews to carry out additional tasks as well as the perceptual tasks. When flying a multi-crew aircraft, especially in high workload conditions, necessitates the two pilots to function in a coordinated way and efficiently converse mutually. The failure in crew management or communication can direct to an asymmetrical distribution of workload burden among the crew, a loss of cross-checking of data and detection mistakes, and wrong information being communicated (ATSB 2007). The probable reason for the crew to have unsuccessful levels of skill and communication was prejudiced by a number of factors, which includes, steep trans-cockpit authority gradient, ensuing large disparities among the crews in terms of age, skill, and place in Transair. Further, both pilots did not undergo the formal training in CRM skills. Moreover, the approval training offered to both pilot did not comprise flying the airliner in a multi-crew situation. Besides to the crew performances and local situations that contributed to the mishap the inquiry recognized a number of safety features involving to Transair that provided to the mishap. Especially, the flight crew education course had notable short comings, for instance superficial or imperfect ground based teaching for the certification course. According to the accessible proof pointed out that inadequate training was given to pilot on the operational features of using the GPWS, or other facet of CFIT avoidance. The Transair airline did not conduct a planned training in Crew Resource Management and working in a multi-crew settings earlier to the beginning of flight operations. The education given to pilots by Transair did not give a level of assurance that they could efficiently manoeuvre as part of a multi-crew setting, mainly all through high workload, unusual or disaster situations. Proper guidance by qualified trainers regarding RNAV (GNSS) approaches would have facilitated the co-pilot to have the required expertise to effectively contribute in a comparatively difficult approach, for instance Lockhart River Runway 12 RNAV (GNSS) approach. Further, planned training in stabilized approaches, CFIT consciousness and GPWS processes would have given the crew with a superior potential for identifying and reacting to troubles. Proper training in multi-crew procedures and CRM as well had the prospective for decreasing workload and to make the most of communication and management of activities among flight crews (ATSB). There were no planned procedures with the Transair for dynamically running safety-linked danger related with its flight operations. Moreover, the chief pilot did not reveal an elevated level of dedication to safety and appeared to be over-dedicated. For that reason, confines in Transair's managerial makeup reduced the capability of the operator to coach, confirm, and observe the excellence of the flight operations. Yet another recognized causative safety issues concerning to the regulatory mistake of Transair by the Civil Aviation Safety Authority (CASA). As a matter of fact, CASA did not supply adequate guidelines to its inspectors to permit them to effectively and consistently evaluate a number of vital features of operators’ administration methods. These features comprised assessing organisational makeup and employees’ resources, assessing the fitness of key employees, assessing managerial change, and assessing risk supervision procedures. CASA as well did not need operators to carry out prearranged or complete risk appraisals, or carry out such appraisals, while assessing applications for the first issue or succeeding discrepancy of an Air Operator’s Certificate (ATSB 2007) VH-TFU was not equipped with a terrain awareness and warning system (TAWS). TAWS offered additional information over GPWS, together with an enhanced situational awareness of the terrain because of the condition of visual information earlier to audio alerts or warnings, and incessant audio warnings with a longer period. Therefore, because of several design facilities over GPWS, there was a possibility that if TAWS was equipped with VH-TFU, the mishap would not have happened. VH-TFU lacked the Autopilot system. Autopilot could reduce flight crew workload through the flight and descend phase of flight, hence supporting the crew to carry out approach setting up and briefings. However in this case, the autopilot might not be able to uphold efficient controls of aircraft as the instability from the Lockhart River Runway 12 RNAV (GNSS). But, if it was provided on VH-TFU, it might have been useful in permitting the crew to be geared up more for the approach (ATSB 2007) The disaster of the Lockhart River M23 is one of the a leading instance which shows the lack of a planned training curriculum, and not understanding the value of human aspects and all the essentials that formulate an inclusive safety system (Brown et al 2006). The Lockhart River mishap is in no way pinpointing the safety traditions in small regional operators, but it could recommend a fundamental difficulty in the communication and sharing of information among aviation operators on the industry entirely (Brown, et al 2006). Safety traditions and systems strengthening in aviation in the past have been dealt with at many stages of the industry and as well at forums, plus the first Australian Aviation Psychology Association Symposium in 1992. Unfortunately this has not changed the industry all together, especially the small provincial operators (Brown et al 2006) The accident was almost certainly the result of controlled flight into terrain. Controlled flight into terrain generally happens at speed and as a result lots of such mishaps are deadly. According to the Advisory Circular 1 of 2009 for Air Operators the importance is the proper preparation, good decision-making, and being able to securely manoeuvre the aircraft all through the entire operating range. As CFIT implies that the aircraft is operating correctly, the key basis for such accidents is what is usually considered the pilot error. Consequently, it is the pilot's duty to make certain that he or she is trained for the flight, that the aircraft is appropriately prepared for the flight, and that the flight is flown as per the correct rules and aircraft operating limits. Ground proximity warning systems and the new terrain awareness and warning systems using GPS have the capability to lessen CFIT mishaps on takeoffs and landings. These methods present tools for pilots to use to elevate their protection while operating near to terrain and obstacles. Conversely, all pilots should identify the restrictions of his or her information base and what bits and pieces are incorporated in the database. Effort to reduce CFIT mishaps begins on the ground. Pilots need to practice to securely perform the manoeuvres necessary all through the takeoff, initial climb, ultimate approach, and landing phases of flight. Whether to use visual flight rules (VFR) or instrument flight rules (IFR), both flights has crucial flight segment. The flight segments planning and handling decides, to a large extent, the safety of the flight. Flight Safety Foundation's CFIT Checklist, offers an illustration of how to analyze CFIT risk. Making use of the checklist to appraise particular flight operations will increase pilot understanding of the CFIT risk (DGCA AC/1/2009). Through the 1980’s, keenness concerning Human Factors directed industry efforts to find answers to CFIT mishaps all the way through improved flight crew performance The DC-8 crash while approaching to Portland, Oregon, after running out of fuel, was one of the CFIT mishaps ascribed to failure in flight crew management and discipline. It caused the start of Dedicated Human Factors training for flight crews, known as crew resource management (CRM) and Line Oriented Flight Training (LOFT), accentuating the requirement for superior intra-cockpit communication, exchange of appropriate operational data and situational responsiveness boomed across the airlines. This was accompanied by the expected exhortations about cockpit discipline and professional behaviour, elusive terms which escape sound definition and only generates unimaginative solutions with rather dubious results. Along with Ground Proximity Warning (GPW) the involvement of CRM and LOFT to aviation safety has been immense; the occurrence of human error in CFIT mishaps proposes that Human Factors training alone is only an incomplete answer to CFIT incidents. Decreasing CFIT incidents needs the understanding that such mishaps and occurrences are system-created, in the sense; they are induced by inadequacy in the aviation system, together with shortages in the organization which represent it. The mishap in which a DC-10 crashed into a volcano in Antarctica since an erroneous coordinate in its computerized flight plan has been stated as an illustration of this inadequacy and the general nature of CFIT incidences. Corrective and restructuring actions intended at reducing CFIT should tackle system failures and administrative shortages, as these are the regions where the maximum gains in safety enhancement can be accomplished. (Maurino, ND). In Conclusion, aviation strengthening and safety should not be misguided to be limited only to systems and computerization; it should as well include traditional training strategies, technical expertise of systems procedure and the features of safety running of systems within the operation, especially the human factors. Understanding the human factors is an important aspect of aviation operation (Brown et al 2006). The failures caused in this VH-TFU accident were explained in this essay. The problems were mainly linked to human factors and various other safety systems mismanagement. Because of time limitation, lack of understanding and high workload, the crews were not capable to appropriately evaluate the crucial information needed to carry out the correct approach. Besides, upholding situational awareness that was essential for a secure flight, the VH-TFU crews were unsuccessful to display good situational awareness about the operational environment. The main responsibility lays on Transair for not providing adequate training and endorsement, as a result the pilots, at that particular situation were not be able to have a complete vision of the aircraft, its flight corridor, and its adherence to approach restrictions. The mishap shows the dearth in safety training within the airline, particularly the connection involving the human factors and safety management system. Conversely this deficiency in expertise can as well be observed in major airlines and not only with regional airlines. It is important to understand that the problem appears to be innate in the aviation industry because of the lack of communication and coordination involving airline operators for different reasons, together with viable advantage. However, the concerns summarized formerly are vital for improving a complete safety management education system for a creative safety tradition within the aviation industry. References ASN (2005). Accident Description [On line] Flight Safety Foundation, Available from: < http://aviation-safety.net/database/record.php?id=20050507-0 > [03 November 2009]. ATSB (2007) ATSB Transport Safety Investigation Report, Aviation occurrence report 200501977, Australian Transport Safety Bureau, Australia Brown, I., Thatcher, S. & Jones, C. (2006), Systems safety in Australian general aviation – where are we now, [On line] Available from: [03 November 2009]. DGCA, (2009) AC/1/2009, Controlled Flight into Terrain, [On line] Advisory Circular 1 of 2009for Air Operators Government Of India Civil Aviation Department, Available from:< http://dgca.nic.in/circular/ops1_2009.pdf > [03 November 2009] Maurino, D. (ND) Human Factors and Training Issues in CFIT Accidents and Incidents [On line] Flight Safety and Human Factors Study Group, ICAO, Available from: [03 November 2009] Read More