Singapore Airlines Flight 006 - Report Example

Singapore Airlines Flight 006 The Flight SQ006 crash is an aviation event that is worth remembering. This paper sought to describe this event with a focus on its critical points alongside aviation fundamentals associated with the event. Introduction Since the first Aircraft was invented, a lot has been witnessed in the field of aviation that has seen the number of accidents reduce to a manageable level. However, aircraft accidents occurring due to human errors and other common mistakes are still being witnesses within the aviation industry. With a view to elucidate on this issue, this paper sought to describe the Singapore Airlines Flight 006 or SQ006 at Changi Airport in 2000. Main Body Singapore Airlines Flight 006 or SQ006 was a flight for passenger, which was scheduled from Singapore Changi Airport to the Los Angeles Airport through Chiang Kai-shek Aiport. It was reported that in on 31st Oct 2000, Boeing 747-412 attempted to take off from a wrong runway and crashed into construction equipment which was on a runway. At the time when the accident occurred, there was a heavy rainstorm alongside strong winds which were due to typhoon Xangsane prevailing over the airport. The Boeing 747-400 aircraft started off from the airport having been cleared for departure on runway 05L. However, the aircraft took deviated from the right turn entering a wrong runway (05R) which had been closed for purposes of repairer. Because of obscured visibility following the prevailing harsh weather conditions, the flight crew failed to see clearly the construction equipment that was parked on a runway over one Kilometer away from the place at which the takeoff began. The pilot realized that the equipment was on runway when it was too late to have the aircraft swerved away from accelerating towards equipment as the aircraft’s nose had already left the ground. Just after 33 seconds after taking off of the aircraft, roll started. The aircraft collided with the obstructing equipment with the impact causing the aircraft to break into two leading to the explosion of the filed fuel tank. The fire that followed destroyed the aircraft forward section and the wings. This led to the death of many passengers that were seated in the aircraft’s middle section. Though the accident was attributed to poor visibility, human error was the major contributor in this case. The question is why then do human errors occur, and what causes them? This is the focus of the present act. Flight crew errors cannot be reversed without evaluation of the root causes followed by definition of specific factors. Although referring to human error in most cases is thought to be synonymous to pilot error, this could mislead actual root causes of aircraft crash. This poses challenges to air accident analysts and investigators in unraveling the causes. However, what is important to safety officers is to seek means of identifying the sequence of events leading to accident and designing mitigation programs to prevent recurrence (Robson, 2009). A number of frameworks have been proposed to identify causal agents of air crashes (Troy, 2000). But none has offered a comprehensive scheme to identify and analyze human error both from theoretical and practical perspectives. For these reasons, intervention measures have overtly failed to point to specific human factors responsible of aircraft accidents. In turn this has made it impossible to objectively assess and quantify human factors. Wiegmann & Shappell (1997) argued that an effective a scheme should be data-based and needs-driven in formulating safety programs. James Reason had earlier proposed the “Swiss Cheese” human error model that was appealing in establishing the causal events (Reason, 1990). In the model, Reason outlined four sequential human error causes. From the event sequence cause of “Unsafe Acts” can be worked backwards and identify operational flaws that ultimately leads to the accident. One example of predisposing unsafe act is failure to scan cockpit’s instruments while in Instrument Meteorological Conditions (IMC) or IMC penetration without authority from the Visual Meteorological Conditions (VMC) leading to abrupt and deadly consequences (Birnbach & Longridge, 1993). From the model above such acts are represented as ‘punched holes’ in the cheese. To effectively avert events leading to active failures, safety officers must address the latent failures. Latent failures are typically dormant and may go undetected for hrs, days, or longer until the day they unsuspectingly strike finding flight crew unprepared and adversely triggering the active failures (Horngren et al. 2008). As aforementioned, factors predisposing unsafe acts are brought about by: poor leadership, lack of coordinated communication channels, mental fatigue and others which are well addressed through CRM training programs (Shun, Lisk, McLeod & Johnston, 2009). The predisposing unsafe acts leads to decision making based on already flawed operations or error prone processes. It is worth noting also that CRM practices can also be ineffective if organizational culture is unchanged. For example, poor team selection may result to accidents despite CRM training. If inexperienced or below average flight hour pilots paired on a route with known bad weather or terrain at night then there will be no surprise when aircraft crashes. Even if the accompanying aircrews have varsity experience coordination and communication errors will occur because intervention and mitigation decisions may require high standards of system experience (Hobbs, 2008). To analyze such mishaps, Human Factors Analysis and Classification System (HFCACS) model is used in conjunction with Reason’s active and latent failure (1990) concept. The four failure levels described in HFACS include: Preconditions to unsafe acts, unsafe acts, organizational influences, and unsafe supervision. Unsafe aircrew actions are categorized as violations and errors (Shappell & Wiegmann, 1997). This group of human errors is attributed to physical or mental activities of each individual leading to failure in attaining set outcomes. On the other hand, violations are willful acts done in disregard to existing flight safety regulations and rules. This is one source of human errors that majority of aviation safety directors overlook yet can be predicted and prevented in earnest (Helmreich, Merritt & Wilhelm, 1999). The Active failures precipitating unsafe acts directly contribute to about 80% of aviations accidents. In a highly automated flight operations, flight crew often overlook basic flight skills by executing them without fully conscious. Slight distraction while executing such actions leads to attention failures despite the flight crew necessary qualification and skills. These types of errors are known as skill-based errors and are linked to numerous breakdowns in fixation of tasks, visual scanning patterns, procedural miscommunication, and failure to activate system controls on time. On the other hand, memory failures unlike attention failures are forgotten, skipped or omitted on the checklist when crew are working under emergencies. Decision errors are associated to personality behavior in operational processes. They are often known as ‘honest mistakes’ because the flight crew chose either to act, poorly acted, or did not act on a situation in appropriate time intentionally. Perceptual errors arise from variations in world perspectives as a true to human nature. This could be due to misjudgment, illusionary visions, or disorientation of spatial data regarding airspeed, attitude, or altitude. The acts may be involuntary or erroneous response leading to “black-hole” experiences such as flying a perfectly working airplane into a water body or terrain. Errors amounting to violations happen within flight regulations and guidance rules set by the organization. Therefore, violation errors are an act of willfully disregarding the set regulations and rules governing flight safety. This type of errors is rare but do happen. The errors are further classified into two categories depending on their etiology. 1) Routine violations which are habitual in nature and can be tolerated. An example is flying consistently at higher speed limits than that recommended by civil authorities. 2) Exceptional violations which as name suggests are exceptional because they are treated in isolation. To establish how the unsafe acts occurred, it is necessary to investigate the underlying causes. This step involves determination of conditions predisposing to unsafe conditions. The two conditions investigated regularly are: substandard practices or substandard operational conditions. Performance of flight crew can be adversely affected by reconditions for unsafe acts in several ways. Among causes of substandard operators conditions include effects on mental states of flight crew (Kaplan & Anderson, 2004). This could result from fatigue, lack of situational awareness, distractions, and poor fixation of tasks. Personality attributes are also included in this category such as complacency, overconfidence, and lack of motivation. The other category is the physiological states of flight crew. Errors that would adversely affect crew performance under this category are associated to physiological or medical conditions which may preclude unsafe operational procedures. Earlier we mentioned disorientation of spatial data and visual illusions attested to perceptual errors. The same could occur if the pilot or crew is under medication accompanied by myriad of abnormalities ultimately affecting their execution of critical CRM tasks such as leadership, coordination/communication, inadequate briefing, failure/under utilization of available resources, and failure to respond to traffic calls or automated alert system. In contrast, substandard practices by operators may lead to unsafe tasks if flight personnel face deficiencies in personal readiness and or engage willfully in crew resource mismanagement. The errors leading to fatalities are closely linked to poor coordination both within and between air traffic control and aircrafts, poor facilities, control system maintenance, or other subordinate personnel in charge of ground operations. Personal readiness is critical for smooth transition or shift handoffs. There are rare but possible cases where personnel report to work unprepared both mentally and physically. Under such circumstances, the personnel will engage in violations of organizational set rules and regulations. Although errors associated with lack of personal readiness may not constitute “unsafe act” per se because they rarely occur in the cockpit, they may indirectly trigger active failures with adverse consequences. In the event of failure or wanting organizational culture or poor leadership, the latent failures may be attributed to inappropriate planning of operations, supervision inadequacy, and failure to mitigate existing problems on time. The impact on crew performance include: failure in giving necessary guidance (chain of command), observing operational doctrine (standard procedures), reporting of unsafe situations (risk management practices), identification and initiation of corrective measures (safety programs) among many other administrative and supervisory functions in the organization. It emerges from the discussion that HFACS (Human Factor Analysis and Classification System) aviation safety framework bridges existing gaps between theoretical approaches (Reason, 1990) in the analysis of causal events for air craft accident and the practical identification and mitigation of actual human factors. Crew performance is indeed adversely affected by human error, but the underlying causes of human error are often overlooked during investigations of aircraft crashes. We have demonstrated that a number of factors contribute towards human error ranging from personal issues, poor leadership and failure of organization structures with reference to the Singapore Airlines Flight 006. However, HFACS and other approaches only add to the long list of taxonomies of human error. Future frameworks should work towards proving the usefulness of identified causal events within a practical setting in order to enhance flight crew proficiency. This would provide tangible evidence on how to reduce aircraft accidents utilizing safety programs that are data-driven. References Alexander, A.L., & Wickens, C.D. (2005).3D Navigation and Integrated Hazard Display in Advanced Avionics: Performance, Situation Awareness, and Workload. Aviation Human Factors Birnbach, R., & Longridge, T. (1993). The regulatory perspective. In E. Wiener, B. Kanki, & R. Helmreich (Eds.), Cockpit Resource Management pp. 263-282. San Diego, CA: Academic Press. 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