Increasing Learning from Accidents: A Systems Approach...
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Increasing Learning from Accidents: A Systems Approach Illustrated by the UPS Flight 1354 Birmingham Airport Accident Shem Malmquist Nancy Leveson James Perry Gus Larard Darren Straker
Transcript of Increasing Learning from Accidents: A Systems Approach...
IncreasingLearningfromAccidents:ASystemsApproachIllustratedbytheUPSFlight1354BirminghamAirportAccident
ShemMalmquistNancyLevesonJamesPerryGusLarard
DarrenStraker
Outline
• WhatHappened• WhydiditHappen?
– NTSBConclusions– CASTConclusions– Comparisons
WhatHappened?(fromNTSBreport)• OnAugust14,2013,0447CDT,UPSflight1354,anAirbusA300-600,
crashedshortofrunway18duringalocalizernonprecisionapproachtorunway18atBHM.
• Captainandfirstofficerwerefatallyinjuredandplanedestroyedbyimpactandfire.
• Variableinstrumentmeteorologicalcondi\onswithavariableceilingprevailedonapproachcourse.
• FlightcamefromLouisvilleabout0503EDT
• NOTAMineffectindictedrunway06/24,longestrunwayatairportandtheonewithaprecisionapproach,wouldbeclosedfrom0400to0500CDT.– Becausefightscheduledtoarriveat0451,onlyashorterrunwaywitha
nonprecisionapproachwasavailabletocrew.
– ForecastedweatheratBHMindicatedlowceilingsuponarriverequiredanalterna\veairport
– Dispatcherdidnotdiscussthelowceilings,thesingleapproachop\ontotheairport,orthereopeningoflongerrunwayabout0500withcrew.
– Duringflight,informa\onaboutvariableceilingsatairportnotprovidedtoFC
ATIS
• BirminghamAirportinforma\onPapazeroeightfivethreeZuluobserva\onwind
calmvisibilityonezero.skycondi\onceilingonethousandbroken.seventhousandfivehundredovercast.temperaturetwothree.dewpointtwotwo.al\metertwo
ninerninerseven.localizerrunwayoneeightinuse.landinganddeparOngrunwayoneeight.noOcetoairmenrunwaysixtwo-fourclosed.alldepar\ngaircrabcontacttoweroneoneninerpointninerforclearancetaxiandtakeoff.advisecontrolleronini\alcontactyouhavePapa.
• Beforedescent,whileondirect-to-KBHMlegofflight,captainbriefedthelocalizerrunway18non-precisionprofileapproach.
• Firstofficerenteredapproachintoairplane’sflightmanagementcomputer(FMS).
• Intendedmethodofdescent(a“profileapproach”)
• glidepathgeneratedbytheFMStoprovidever\calpathguidancefromthefinalapproachfix(FAF)tothedecisional\tude
• Runway18decisional\tudeof1200bmsl
• Airtrafficcontrollerclearedtheflightforthelocalizer18approach.
• CrossedFAF200feethigh
• About7secondsaberthefirstofficercompletedtheBeforeLandingchecklist,thefirstofficernotedthatthecaptainhadswitchedtheautopilottover\calspeedmode;shortlythereaber,thecaptainincreasedthever\caldescentrateto1500fpm.
• Firstofficermadetherequired1000-b-above-airport-eleva\oncallout,andthecaptainnotedthatthedecisional\tudewas1200bmslbutmaintainedthe1500fpmdescentrate.
– AlthoughtheapproachviolatedthestabilizedapproachcriteriadefinedintheUPSflightopsmanual,theydidnotperformago-around.
– Astheairplanedescendedtotheminimumdescental\tude,thefirstofficerdidnotmaketherequiredcalloutsregardingapproachingandreachingtheminimumdescental\tude
– TheCaptaindidnotarrestthedescentattheminimumdescental\tude.
• Theairplanecon\nuedtodescend.
• At1000bmsl(about250babovegroundlevel,anenhancedgroundproximitywarningsystem(EGPWS)“sinkrate”cau\onalertwastriggered.
• Thecaptainbegantoadjustthever\calspeedinaccordancewithUPS’strainedprocedure.
• Hereportedtherunwayinsightabout3.5secondsaberthe“sinkrate”cau\onalert.
• Airplanecon\nuedtodescendatarateofabout1000fpm.
• Firstofficerconfirmedshealsohadtherunwayinsight.
• About2secondsaberrepor\ngtherunwayinsight,thecaptainfurtherreducedthecommandedver\calspeed,buttheairplanewass\lldescendingrapidlyonatrajectorythatwasabout1nau\calmileshortoftherunway.
• Thecockpitvoicerecorderthenrecordedthesoundoftheairplanecontac\ngtreesfollowedbyanEGPWS“toolowterrain”cau\onalert.
GiventhisdescripOon:
• Whatcause(s)wouldyouascribetotheaccident?
• Arethereanyaddi\onalques\onsyouwouldwantanswered?
NTSBConclusions• ProbableCause:
– Flightcrew’scon\nua\onofanunstabilizedapproachandtheirfailuretomonitortheaircrab’sal\tudeduringtheapproach,whichledtoaninadvertentdescentbelowtheminimumapproachal\tudeandsubsequentlyintoterrain.
• ContribuOngtotheaccidentwere:1. Flightcrew’sfailuretoproperlyconfigureandverifytheFMScomputer
fortheprofileapproach2. Captain’sfailuretocommunicatehisinten\onstothefirstofficeronceit
becameapparentthever\calprofilewasnotcaptured.3. Flightcrew’sexpecta\ontheywouldbreakoutofthecloudsat1000b
abovegroundlevelduetoincompleteweatherinforma\on.4. Firstofficer’sfailuretomaketherequiredminimumcallouts5. Captain’sperformancedeficienciesduetofactorsincluding,butnot
limitedtofa\gue,distrac\on,orconfusion,consistentwithperformancedeficienciesexhibitedduringtraining
6. Firstofficer’sfa\gueduetoacutesleeplossresul\ngfromherineffec\veoff-duty\memanagementandcircadianfactors.
System’sApproach• Looksnotonlyathowpilot’scontributedtoaccidentbutwhythey
believeditwastherightthingtodoatthe\me.• Safetytreatedasacontrolproblem,notafailureproblem
– Whywerecontrolsnoteffec\veinthiscase?– Howcantheybeimprovedforthefuture?
Hazard:ControlledFlightintoTerrain(CFIT)– Usedtobemostcommontypeofaccident– Muchhasbeendonetoreduceoccurrence– Whydidn’tthesecontrolsworkthis\me?
controlstructure
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
ControlsforCFIT• Airportphysicalcontrols
– ILS– PAPI
• MSAWandATC• AircrabElectronics
– FMS– EGPWS– Autopilot– Displays
• Capt.Flying,PilotMonitoring• UPSDispatcher• UPSDispatchmanagement• Airbus/Honeywell• Ind.Pilot’sAssocia\on• FAA(FlightStandards,AirportSafetyandStandards,ATO,Cert.)
ComparisonofFactorsIdenOfied
• NTSB(probablecause,contributorycauses,findings)vs.CAST
• CASTfoundsomecontribu\ngfactorsnotiden\fiedbyNTSB
• CASTiden\fiedallofNTSBfindings
• CASTiden\fiedseveraladdi\onalfindings
FAAOfficeofAirportSafetyandStandards
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
Flightcrew-Electronics
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
• AstheLOCwasprovidinglateralguidancetheaircrabcoulds\lltrackthedisplayedfinalapproachtrackdespitethelackofwaypointsequencing.
controlstructure
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
Contextualfactorsexample
HowdidflightendupflyingtheLOC?FromPilotinterac\ons• CrewmissedNOTAMFrompilotinterac\ons• LOCapproachshownearlierinchar\ngsequenceFromATC-Pilotinterac\ons• Controllerofferedit
DispatchrecommendaOons
• Dispatchersshouldproac\velyprovideinforma\ontoflightcrewsregardingthestatusofapproachesandwhyapar\cularrunwayandapproachislistedinflightplan.
• Ensurethatdispatchersconsiderifacrewmightbefa\guedandhowthatmightimpactthepilot’scogni\veprocessessodispatchercanactproac\velyaccordingly.
• Reviewworkloadfordispatcherstoensuretheycanprovideactualjointauthorityforindividualflights.Currentworkloaddoesnotallowfortheindividualizedanen\ontodetailsthatcanpreventaccidents.
• Providecomputerassistancethatdoesnotencouragerelianceandunques\oningacceptanceofoutputs.
FAA
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
FAArecommendaOons
• TheFAAshouldconsiderevalua\ngthecommunica\onsandcoordina\ondeficienciesimplicatedinthislossandwhethertheyaremorewidespreadthantheyarebelievedtobe.Wasthisjustaone-\meeventorarecommunica\onandcoordina\ondeficienciesmorewide-spreadthanbelieved?
• Therolesofdispatchandpilotsandhowtheyinteractneedtobeclarified.
Systemicfactors
Ind. Pilots
Assn.
FAA
ATO
Airport Management
Airport PhysicalCFIT
Controls
AirportOps
BHM
ATC UPS
Dispatch
Dispatch
Mgmt
Management
OEMs
FlightCrew
Electronics
Aircrab
OASS AFS Cert.
SystemicFactors• SafetyCulture(cargopilots)• Safetyinforma\onsystem• Dynamicsandchangeover\me• Communica\onandCoordina\on
amongcontrollers
SystemicrecommendaOons
• FAAandcargoaircrabpilotassocia\onsshouldinves\gatewhethertheac\onsofthecargooperatorindustryhasledtomoresuspicionandlesstrustbythepilotsofthosecarriers.
• TheFAAandcargoaircrabpilotassocia\onsshouldins\tuteastudyofwhethercargoaircrabaretreateddifferentlybyairportsandwhetheranydifferencesresultinhigherriskforcargoaircrab.
SystemicrecommendaOons
• Iden\fyandimplementchangestotheinforma\onsystemtoensurethataccurateweatherinforma\onisavailablewhenneededandtothosewhoneedit.
• TheFAAandotherindustrygroupsshouldstudywhethertheincreaseincargoopera\onshaschangedorincreasedthelevelortypesofhazardssuchthattheyarenolongeradequatelymi\gatedbycurrentproceduresandcontrols.
• Subjectchangesintheprovisionofcri\calinforma\ontoahazardanalysis.
Summary
• U\lizedGroupChairfactualreports
• Contribu\ngcontrolac\ons(factors)easilyiden\fiablefromcontrolstructure
• Recommenda\onsstemmedfromcontribu\ngcontrolac\ons.
