Avianca Flight 52: a Case Study on Human Error

Relevant facts/ Background Avianca leakage 52 touched the ground for a final age on January 25 1990, 16 miles from JFK airdrome in Cove Neck, languish Island, N. Y. , completely out(a) of fuel. The Boeing 707-321B was carrying 158 people feeler from Medellin, Columbia, in which 85 people survived. The disassemble of Avianca Flight 52 was the largest rescue exploit in New York prior to 9/11. There was a severe blizzard on the north- eastern coast of the U. S. causation bad hold up with a lower-ranking pressure system and wind shear.JFK airport authorities had been told to keep a high landing rate than safe at 33 planes attempting to land per hour, on virtuoso runway the typical rate world 52 in good weather, with all in all runways open. The airport was experiencing a rate of 27% missed approaches, with 39 planes waiting in holding patterns for clearance to land and dozens waiting to take-off. Sequence of neverthelessts The 707 had been placed in holding patterns for a total of 1 hour and 17 minutes during iii separate occasions over the U. S. east coast.There were 6 different air transaction controllers that had communicated directions to Flight 52 after they entered U. S. airspace, adding bewilderment and un-transmitted messages, yet at the same time non providing any more significant information such as weather conditions. The Flight Engineer failed to communicate the compulsion of the low fuel situation to the take flight and co-pi give out after they passed the demonstrate of no call in and had to remain committed to JFK by non having enough fuel to get to their skip airport at Boston, 342km away from JFK.He in addition failed to emphasize the importance of landing in their first attempt beca purpose they would not birth enough fuel to loop rough and try again. Another discrepancy was how the co-pilot utilise the words Low Fuel and antecedence rather than MAYDAY and Minimum Fuel time communicating to ATCs. There was a lot of crucial information left out or misinterpreted and not so historic information repeated, which could take over easily been avoided without the wording barriers in place.In terms of the Swiss lay off model there were some holes in the conversations betwixt ATCs and the flight caboodle, similarly between the flight crew and passengers, where they werent even given a warning. Causes and factors During the chase to point the blame on some i, Avianca stated to investigators that the choice of words used by their pilots was correct as per their learn -whether it matched the standard English verbiage used by IATA countries or not they were only following what they thought to be proper protocol.Investigation by the NTSB found many holes in the events leading up to the crash, overdue to two active and latent failures by the crew, ATCs, and airport management. The leading causes can be attributed to airport mismanagement, inconsistent preparedness for pilots that should have E nglish proficiency, and overall poor communion between ATCs and the flight crew. Repetitive flaws in a system run by human beings shows a clear connector in the lack of Risk Management, causing communication gaps referred to as holes in the Swiss Cheese model for human error.CRM stipulates training crew in assertiveness, inter-personal communication, leadership and decision-making, to pick up a few key attributes these pilots were in need of addressing prior to the incident. There was no problem of experience as both the pilot and co-pilot had flown that route before, and the pilot had 27 years of experience flying for Avianca. The writ of execution of Crew Resource Management techniques in the previous years must not have been as streamlined as intended, at least not for the American ATCs and those training under Avianca in Columbia.If one lesson would be learned from this it would be that had the crew received effective and efficient CRM training on time, they could have saved 73 people from an almost completely preventable death by human error. References AskCaptainLim. com comments. Aviation, broadcast Crash. Avianca flight 52 why the pilots failed to use proper phraseology. (Last updated October 19, 2008). Retrieved from http//www. askcaptainlim. com/-air-crash-aviation-34/830-avianca-flight-52-why-the-pilots-failed-to-use-the-proper-phraseology. html Cushman Jr. , washbowl H.New York Times, Archives, Collections, Fuel. Avianca flight 52 the delays that ended in disaster. (February 5, 1990). Retrieved from http//www. nytimes. com/1990/02/05/nyregion/avianca-flight-52-the-delays-that-ended-in-disaster. html? pagewanted=all&src=pm discipline Geographic, Cineflix Productions. Air Crash Investigation series, consequence S02E05 Missing Over New York. Retrieved from http//natgeotv. com/ca/air-crash-investigation/videos/deadly-delay Wikipedia. org, Avianca Flight 52. (Last updated March 22, 2013). Retrieved from http//en. wikipedia. org/wiki/Avianca_Fli ght_52