BME162 - 2022 - Participation Activity #1

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University of Waterloo *

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101L

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Mechanical Engineering

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Apr 3, 2024

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Uploaded by BrigadierMetalJay25

BME162 Winter 2022. Participation Activity #1 – Individual Activity. Due to LEARN Dropbox by Sunday, 16 January 2022 by 11:59 pm E.T. When examining the Boeing Plane Crashes using the Swiss Cheese Model, we identified active failures. However, our analysis was not complete because we did not classify these failures in terms of human error types. Regardless of the accident analysis technique used (Swiss Cheese Model, Accimap, or others), you should classify the human errors. This will strengthen your analysis and help you determine the most appropriate design change. In this participation activity, classify the active failures identified in the Boeing Plane Crash Case Study as specific human error types (slip, mistake, lapse, or violation) and explain your choice. This can be done by completing the table below. A few extra, hypothetical active failures have been included in the table for you to consider. Identified Active Failure Human Error Type Explanation Captain ceding control to first officer Slip The pilot managed to pull the nose back up by repeatedly using thumb switches, then he cedes the controls to the first officer who doesn’t respond correctly. The pilot is allowed to give control to the first officer. However, he should have seen sooner that the first officer was not responding correctly, hence why I think it is a slip. First officer making minor instead of continuous corrections Mistake The first officer did not know how to respond to the MCAS faulty correction; however, the pilot was responding correctly, and the first officer should have just done what the pilot was doing. Failure to recognize stabilizer runaway Violation The pilots were indeed aware of the MCAS system and knew how to handle it if it was triggered inappropriately. However, the pilots did not get any additional training about the MCAS system. Thus, the pilots could not solve any other type of issue that could not be fixed by the

stabilizer runaway procedure. The pilots were not fully trained on the MCAS system, Boeing intentionally didn’t provide full training for the pilots to save money, hence why I believe it is a violation. Hypothetical – Recognized stabilizer runaway but did not turn off automatic functionality Slip The pilots were given training on what do to if MCAS was triggered inappropriately, they would need to do the standard stabilizer runaway checklist which tells you to turn off the automatic functionality. Thus, not doing so would be a slip, probably due to stress. Hypothetical – Ignored sensor input that indicated dangerous nose angle Violation The sensor indicated a dangerous nose angle while the plane was taxiing before taking off. After noticing that the pilots should have grounded the plane and not continued with the flight. If there is a problem with the plane before it takes off, then not intentionally following the common sense of not taking off is a violation. Hypothetical – Intended to turn off automatic functionality but pressed button that refreshed sensor readings instead Lapse Knowing what to do but doing something else that is wrong is known as an execution failure. The intention was correct, but the execution was done incorrectly.

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