Accident Timeline Analysis Colgan Air Flight 3407
pdf
keyboard_arrow_up
School
Utah Valley University *
*We aren’t endorsed by this school
Course
2130
Subject
Industrial Engineering
Date
Dec 6, 2023
Type
Pages
3
Uploaded by CommodoreElectronManatee46
Jocie Harding
Accident Timeline and Analysis Colgan Air Flight 3407
The Normal Accident Theory (NAT) would highlight the complex systems aviation has.
NAT views risks and accidents as products of failures within complex systems. The interactions
between these systems can also cause unfavorable outcomes. NAT could suggest that these
kinds of outcomes are inevitable because you are dealing with such complex systems that have
a lot of factors within them. In the case of Colgan Air Flight 3407, NAT would look at the
environmental system and the factors like icing that occur in that system as a precondition for
unsafe acts. And the errors humans can make when not fully prepared for flight like fatigue as
unsafe acts due to not being able to handle the situation in the appropriate way. Like how
Captain Renslow was unable to react in the correct way to the stick shaker that was signaling a
potential stall. NAT would emphasize that the crew's inadequate training and physical/mental
ability would contribute to the systematic complexity of the situation. One thing to take into
consideration with NAT, is the potential for a stagnant view on accidents, which can promote
less growth in improving safety in aviation. Meaning that they think these outcomes can be
impossible to fully avoid.
High Reliability Theory (HRT) on the other hand suggests that accidents can be
prevented. HRT would suggest implementing more safety protocols and provide an environment
that promotes continuous improvement. So, when talking about Colgan Air Flight 3407 in the
eyes of the HRT, they would focus on the human errors and how they can be preventable. Also
including the organizational factors including practices and policies. This encourages training
programs and more regulations. An example of more regulations that could have been improved
upon to prevent Colgan Air Flight 3407, would be management and supervision over pilot
fatigue. That way the human errors made during Flight 3407 would’ve been more preventable
had these regulations been in place at the time. HRT also promotes more communication
between crew and management. Overall, HRT pushes airlines to always be improving their
safety regulations and learn from accidents.
In comparison, NAT has a more established way of looking at accidents than HRT. This
is because HRT has a stance of promoting improvement so that accidents can be prevented
and minimized. The approach from NAT can be seen as: accidents are unavoidable. But can
implement learning opportunities on inherent risks. This impacts our learning and understanding
because to just use one theory is to leave out important aspects of safety. While HRT may
seem more favorable because it fosters accountability and encourages airlines to improve
safety measures, being able to emphasize the complexity of systems in aviation makes NAT
important. If the aviation industry learns to combine both NAT and HRT, accidents would
happen less and the learning that would come from them would impact upon future pilots,
enhancing overall safety in aviation.
Colgan Air Flight 3407 Timeline and HFACS Classification:
Day(s) leading up to the flight
The captain and first officer make long commutes to the airport because of money and
not being able to afford getting a hotel, this causes fatigue. Classification: Preconditions for
unsafe acts, substandard conditions of operators, adverse mental and physiological states
(fatigue).
Before flight
Crew members did not disclose their fatigue to the airline management. Classification:
Preconditions for unsafe acts, substandard practice of operators, crew resource management
(not communicating).
Crew did not receive adequate training about aircraft, specifically the first officer.
Classification: Unsafe supervision, inadequate supervision (failure to provide training, guidance
and track qualifications) and planned inappropriate operations (provided inadequate rest for
crew).
Flight departs on February 12, 2009 at 9:18pm from Newark, New Jersey
The plane starts to experience icing conditions descending in Buffalo, New York. Icing
on an aircraft causes more drag, slowing airspeed. Crew members do not check to make sure
the de-icing system is working and do not check their airspeed. They start the checklist late and
continue outside conversation during the checklist. Classification: Unsafe acts, errors, skill-
based and decision (failed to prioritize attention, improper procedure).
The stick shaker is activated, indicating a stall might happen. Classification: Unsafe acts,
errors, skill-
based (didn’t input the right controls for airspeed).
Captain improperly responds to the stick shaker by pulli
ng up when he should’ve pushed
down and increased power to prevent a stall. Therefore, causing the plane to stall. The first
officer then responds incorrectly by not communicating how to pull out of a stall and retracting
the flaps, reducing the lift even more. Classification: Unsafe acts, errors, skill-based (not
recovering from stall).
Plane crashes in Clarence Center, New York at 10:16pm
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help