Cessna air crash (with animated simulation) Human Factor Aspects, ATSB Aircraft Accident Investigation Model,

Presented by

Noman Khan57154

MBA (Aviation Management)PAF KIET

Loss of control & collision with water involving Cessna 210; VH-EFB160 Km south-west of Darwin, Northern Territory 1st April 2013

Course: Human Factor in Aviation Industry Faculty: Wg. Com. Syed Naseem AhmedMBA (Aviation Management)PAF KIET

“HUMAN FACTOR” ASPECTS (CASE STUDY)

INTRODUCTION OF THE ACCIDENT INDIVIDUAL ACTIONS & TECHNICAL EVENT LOCAL CONDITIONS, RISK CONTROLS ORGANIZATIONAL INFLUENCES COMMENTS & RECOMMENDATIONS

INTRODUCTION OF THE ACCIDENT INDIVIDUAL ACTIONS & TECHNICAL EVENT LOCAL CONDITIONS, RISK CONTROLS ORGANIZATIONAL INFLUENCES COMMENTS & RECOMMENDATIONS

Table of content

2Tuesday, April 11, 2023

Australian’s Aviation Industry

Tuesday, April 11, 2023

Aircraft by Category - Australia

5,700 Kg

3MTuesday, April 11, 2023


SIMILAR OCCURRENCES: From 2002 to 2013: 139 Occurrences have records involving a VFR Operation encountering instrument meteorological conditions , Of these, 09 were fatal.

(Source: ATSB Database)

One of the fatal accidents occurred on 17 November 2007, when the pilot of a Cessna 337 (VH-CHU), was tracking along the coast from Moorabbin, Victoria to Merimbula, New South Wales.

ATSB findings: while maneuvering over water at low level in conditions of reduced visibility, the pilot probably became spatially disorientated and unintentionally descended into the water.

Ops Investigation – Contributing FactorOps Investigation – Contributing Factor

Introduction of the Accident Introduction of the Accident

Table of content


10Tuesday, April 11, 2023Bullo River

Emkeytee

Dundee Beach

Cape Ford

Wadeye

Anson Bay

3 A/Cs2 A/Cs

Palumpa

ON 28 AND 29 MARCH 2013;

The group of pilots flew Emkaytee to Bullo River for long Easter holidays

The flights under VFR and affected by areas of low cloud and reduced visibility

Diversion towards the coast to avoid the higher ground and weather on the direct track

ON 29TH MARCH;

Pilot of the lead aircraft in the group encountered bad weather

Diversion to Palumpa (Nganmarriyanga) airstrip, 123 km to the north of BR.

Effective communication were observed in first cruise via R/T (Weather information).

After an hour; The pilots departed in turn and slightly on the direct track to BR without further delay.

28th & 29th March. 2013


EmkeyteeDundee Beach

Cape Ford

Wadeye

Anson Bay

3 A/Cs2 A/Cs

Palumpa

@ afternoon; reassess weather as a group.

WRI indicating better conditions inland of the coast & improved at BR

Weather improvement for Darwin in the afternoon with a subsequent deterioration by evening.

Discussion & recommending a coastal track via Wadeye and Dundee Beach to avoid the higher terrain on the direct track.

All of the pilots seemed comfortable with departure that afternoon

(option of return was there)

1st April. 2013



Cape Ford

Wadeye

Anson Bay

3 A/Cs2 A/Cs

Palumpa

Pre- flight checks /planning taken; Cessna 210 pilot conduct a daily

inspection (incl. water in the fuel tanks)

Two other pilots planned to track coastal

Cessna 210 was reported to have based his pre-flight planning on the coastal track.

While the other waited until they assessed the weather airborne.

Each in the Group departed one by one.

Cessna 210, was the third aircraft to depart. (a Normal take-off). Dpt. 1415 -1500.

1st April. 2013


Emkeytee

Dundee Beach

Cape Ford

Wadeye

Anson Bay

3 A/Cs2 A/Cs

Palumpa

At about the halfway point (100 km away); encountering low cloud, rain in storms that stretched from Cape Ford SE towards the inland direct track

The pilots on the direct track diverted slightly to the east (right of track) to get around the cloud mass

existence of good visibility on the East was broadcasted & shared

Of the 3 aircraft on the coastal track;

2 pilots tracked inland in response to the weather

1 pilot maneuvered around the weather and established on the direct track

Second resumed costal track on rel. clear condition

Storms stretches from CF


@1510; At some point the Cessna 210 pilot broadcast his position and intentions;

“ approaching Cape Ford at 500 ft and that the weather ahead was gloomy”,

that was the last time anyone heard from the Cessna 210.

F-2; Weather radar image at 1505, about the time of the accident (nominal coastal track and direct track overlaid with the likely accident area circled)


The Cessna 210 had not arrivedSearch & rescue @ Cape FordSome bodies and a small amount of wreckage were found on the southern southern

part of Anson Baypart of Anson Bay, 10 km SE of Cape FordThere were no survivors. No more sightings of aircraft wreckage were made until October 2013,

INTRODUCTION OF THE ACCIDENTINTRODUCTION OF THE ACCIDENT


Wreckage of Cessna 210Wreckage of Cessna 210The wreckage found in October 2013 was spread over a few hundred meters (Figure). The airframe was extensively fragmented with elements of the wings, fuselage, and seats identified. The engine and propeller, separated from the rest of the wreckage, were damaged but largely complete. As a result of the fragmentation, submersion, and tidal action, there was little additional information available.

Stuart Sceney, his wife Karmi Dunn, and their two daughters, who all died in the crash.


The Occurrence of Cessna 210The Occurrence of Cessna 210

View from another aircraft in the group as the pilot navigated around the storms about 80 km south-east of Cape Ford

View from an aircraft in the group as the pilot navigated between storms about 40 km south-east of Cape Ford

To Improve safety

To identify and assess contributing factors

Not to blame

What?

Why?

What can we do about it?

Tuesday, April 11, 2023 19

Workload Stress Ergonomics Responses (Total Power failures?) Medical and Environments CRM and Communications Risk Controls (“Bow –Tie” Model) Organizational Influences ( Complex or

easy to detect?) Safety Culture HF Investigation Issues Human Factors in Maintenance Shell Model

Tuesday, April 11, 2023 20

Human Error (Would you have done the same thing?)

Individual Actions (Types of Errors) Perception and Memory (How are

memories stored?) Attention ( Manager of information) Situational Awareness (Timely and

accurate perception of elements of situation)

Decision Making (Titanic Ship) Fatigue ( Effects on performance) Automated Systems (Degree of

automation) Safety Management System?

Human Factor Topics Human Factor Topics


ATSB AAI MODEL ;

Ops Investigation – Findings, Human FactorOps Investigation – Findings, Human Factor


OCCURRENCE; A high degree of force involved in the collision with the water The impact is almost certainly related to an inadvertent descent into the

water

It is evident from the fragmentation and distortion ;

Pilot Qualification: Appropriately qualified for VFR

No instrument rating (3-hr instrument flying)

Purchased 12 month ago (300 hrs flying) – mostly cross-country flight for Business

CRM (proper rest)

Cautions-pilot

Ops Investigation – Human FactorOps Investigation – Human Factor


AIRCRAFT TECHNICAL EVENTS; Reliable, relatively fast, Sensitive in pitch - Lose height rapidly in a turn Hydraulic oil leak that affected the retractable landing gear. (no maint.

record) No shortage of fuel recordedEQUIPPED WITH AN AUTOPILOT - ~ S/A Essentially limited to leveling the wings without any altitude-keeping

capability. Therefore, The autopilot was not capable of providing effective protection from an

unintended descent and the wing- leveling function would probably be compromised by any severe turbulence.

Ops Investigation – Technical EventsOps Investigation – Technical Events

24

INDIVIDUAL ACTION; Refueled to full tank – add. 3hrs of reserve fuel Daily inspection conducted – incl. water in the fuel tank Plan for coastal track – higher terrain in direct track Observing the behavior of weather.

Calm & cool

Flying in unfavorable flying condition – under VFR. Why the pilot decided to continue on the coastal track – U/I Error

& Decision Making

Flying in unfavorable flying condition – under VFR. Why the pilot decided to continue on the coastal track – U/I Error

& Decision Making

Ops Investigation – Individual ActionOps Investigation – Individual Action


Bullo River


Cape Ford

Wadeye

Anson Bay

Palumpa


Cessna 210 pilot encountered bed weather & some degree of turbulence, so for avoidance of this low clouds, he would have developed a trajectory towards the water without realized the trajectory towards water due relatively featureless surface and reduced visibility

The other possibility is that pilot was aware of a descent towards the water but was unable to sufficiently control the aircraft.

As a result of one or more of those factors, the pilot inadvertently allowed the aircraft to descend and collide with water.

Ops Investigation – Individual ActionOps Investigation – Individual Action

AIRCRAFT HANDLING (SA); Pilot unawareness of an aircraft’s trajectory towards the water or

pilot inability to alter that trajectory.

Lack of familiarity with the task (IRoEx17 )Lack of familiarity with the task (IRoEx17 )


Ops Investigation – Local ConditionOps Investigation – Local Condition

Knowledge, skills, experience - Personal Factors, No instrument rating (3-hr instrument flying)

300 hrs flying on Cessna – mostly cross-country flight for Business

2 wet flying on that area only

Cautious

Task demands Environment;

Flying in unfavorable flying condition - Weather phenomenon

What aspects of the local environment may have influenced the individual actions or technical problems

Personal Factorstask demands,

SWPP Env weather


Ops Investigation – Local ConditionOps Investigation – Local Condition

Shell Model: Interfacing with Equipment & Environment; Appropriately qualified for flight under VFR Owned the aircraft for just over 12 month (300hrs) Cross-country business flying experience mostly 2 wet season flying on that area only (unfamiliarity with route?) Caution pilot Relatively fast & Sensitive in Pitch – un known to pilot


MANAGING WEATHER RISK:On the flights to Bullo River under VFR: the pilot diverted around weather and landed at Palumpa & wait for improved weatherWhy not now - WRI & Av. Weather Forecast was threatening - why the Cessna pilot decided to continue on the coastal track. Duty forecaster at the BoM (at Darwin) was not consulted by the pilots - contactable via phone. In situations where significant weather is forecast or otherwise expected, pilots are encouraged to access the BoM detailed weather briefings (via phone) to assist with understanding the conditions at the time as well as the immediate trend. This service is not utilized much by private pilots but it is available to all aviators – violation

What could have been in place to reduce the likelihood or severity of problems of the operational level

Ops Investigation – Risk Control Ops Investigation – Risk Control

Poor feedback from system (x4)Poor feedback from system (x4)


MANAGING WEATHER RISK:Tracking visually via a coastal route in marginal weather conditions can be advantageous in terms of ease of navigation and absence of elevated terrain, but can also increase the risk of spatial disorientation in the context of drastically reduced visibility make worse by a lack of surface definition when over water. (P&M)

Ops Investigation – Risk Control Ops Investigation – Risk Control


A purposeful AAI can not be concluded in “Human Error” Starting point of investigation – Last ring of entire chain look outside the cockpit and discover factors that might have

contributed to the Human Error Policies, regulations, procedures or environments Human nature can not be changed – working conditions are

changeable

Ops Investigation – Organizational Ops Investigation – Organizational InfluenceInfluence


ERROR MANAGEMENT:Error are mosquitoes - (Managing Maintenance Error: A Practical Guide By J. T. Reason)

Conflicting goals Poor Defences Poor Design Inadequate Procedures Training Deficiencies



Av. SAFETY MANAGEMENT SYSTEM



AVIATION SAFETY MANAGEMENT SYSTEM



Organizational Processes

WORK PLACE CONDITION LATENT CONDITION

ACTIVE FALIURE DEFENSES

Organizational Accident

MIIRC



Ops Investigation – Organizational Ops Investigation – Organizational InfluenceInfluenceCULTURE Organizational culture is the behavior of humans who are part of an

organization and the meanings that the people attach to their actions. Culture includes the organization values, visions, norms, working language,

systems, symbols, beliefs and habits. It is also the pattern of such collective behaviors and assumptions that are

taught to new organizational members as a way of perceiving, and even thinking and feeling.

Organizational culture affects the way people and groups interact with each other, with clients, and with stakeholders.

The attitudes, beliefs, perceptions and values that employees share in relation to safety


CULTURE Safety culture - where does your organization sit?

Safety is paramount - strong emphasis on safety as part of the strategy of controlling risks

Personnel are well trained, and fully understand the consequences of unsafe acts.

Decision makers and operational personnel hold a realistic view of the short- and long-term hazards involved in the organization’s activities

Non-punitive reporting culture – rewards based

Senior positions do not use their influence to force their views on other levels of the organization, or to avoid criticism

AAI are conducted as an “Opportunity to improvement”

Rel. Safety Info. are communicated all over



ERROR & ERROR MANAGEMENT: Making errors is about as normal as breathing oxygen (James Reason)

Error is a normal and natural part of everyday life

It is generally accepted that we will make errors daily

We make 3 to 6 errors every waking hour, regardless of the task being performed

The good news is that the vast majority have no serious consequences, because they are automatically self-corrected: somebody or something reminds us what we should be doing, or the errors we make do not involve a potential safety hazard.



Regulatory Oversight Rule Preparation - the drafting of national rules, including

appropriate consultation; Rule Enactment - the passing of laws or other appropriate orders

to give legal effect to the rules; Safety Oversight - the monitoring of safe service-provision

including verifying compliance with the rules; Enforcement - taking appropriate action to deal with cases of non-

compliance.



Regulatory Oversight

Organizational Influence

Local condition

Individual action

Occurrence Events

Risk control


INCIDENT / ACCIDENT INVESTIGHATION Make sure your investigation procedures detail clearly how human factors

considerations are included. The main purpose of investigating an accident or incident is to understand

what happened, how it happened, and why it happened,

To prevent similar events in future. Use a model (such as Reason’s model) or framework for investigations and consider human error, both at the individual and organizational levels.

Your investigators need to be trained in basic human factors concepts and design procedures to be able to establish which human performance factors might have contributed to the event.

Ops Investigation – CommentsOps Investigation – Comments


IMPROVE DEFENSES Training, Training, Training Technology, Regulation

Ops Investigation – CommentsOps Investigation – Comments



Travel

Cessna air crash (with animated simulation) Human Factor Aspects, ATSB Aircraft Accident Investigation Model,