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The Dryden project involved an Air Ontario Fokker F28 aircraft. The plane had departed from Thunder Bay for Winnipeg but landed at Dryden for refueling. After it, it lifted off from the airport but, unfortunately, it did not reach any altitude. The plane crashed just beyond the runway killing twenty-four of the sixty-nine people who were on board. The paper analyzes gaps in the defenses of the Dryden project using the James Reason’s Swiss Cheese model. It also discusses external threats to the safe flight and crew errors. It analyzes the fact that the application of good communication and crew resource management could have helped in the prevention of the air disaster applying the human factor analysis and classification system model to the case scenario.
To understand gaps in defenses that led to the crash, one needs to apply the Reason’s Swiss Cheese theory. The theory traces the root causes of an accident to errors at the levels of organization. Accidents are a result of multiple factors intertwining within the entity (Merlin, 2013). Using the analogy with cheese, Reason posits that each slice of it is a defense method against an accident, while each hole presents a gap in the mechanism and an opportunity for a failure. Thankfully, in the next layer, holes are in a different dimension and it is possible to eliminate the problem on time. However, if the system of defenses allows holes to continue lining up, an accident is bound to happen. The solution lies in identifying the holes (weaknesses) in advance and preparing a defense plan (Xavier, 2005).
The first category of gaps in the defenses of the Air Ontario Fokker F28 aircraft comprises organizational errors. These are of a latent nature, which means they lie dormant until the time they are triggered (Xavier, 2005). The management of Air Ontario failed to exercise its responsibility of ensuring that the proper equipment and procedures were established and put in place. The passenger list was missing due to inadequate planning and documentation. At Dryden, there was no ground power unit to restart the aircraft. The plane therefore depended on its auxiliary power unit, a small extra engine in the rear of an airplane that provides compressed air to start the main engines (Xavier, 2005). Unfortunately, due to the lack of planning by the management, it failed to work implying that aircraft’s engines could not restart. Another organizational error occurred when having equipment capabilities and strength, Air Canada, a parent company of Air Ontario, distanced itself from operational aspects of the latter. It failed to ensure that the aircraft was in an excellent condition (Xavier, 2005).
The second type of gaps in the defense was supervision errors of a latent nature. There was a lack of oversight as seen in the poor planning of the flight schedule. According to the report by the Commission of Inquiry into the crash, some personnel like ground employees were not properly trained and failed in the dispatch process (Luxhoj & Kauffeld, 2003). Supervisors also tolerated violations by the employees such as using aircrafts with maintenance problems.
Personal/social gaps were the third type of errors in defense. The day of the flight was Friday, the start of school holidays. The plane was full carrying ten extra passengers at Dryden after the failure to prepare a passenger list. The pilot and other crewmembers concentrated on taking passengers home for the weekend. They seemed to forget the fact that the aircraft was full. It meant that the amount of fuel that the plane could carry during the journey without exceeding its allowable weight was limited (Luxhoj & Kauffeld, 2003).
The fourth category of gaps in the defense mechanisms of Air Ontario included active errors that caused the accident. One of such errors was hot fueling of the aircraft at the Dryden Airport. The pilot was not supposed to fuel the plane because the engines were running, and there were passengers on board. However, because Transport Canada, the country’s aviation regulatory body, had not forbidden the act, he went ahead and fueled the plane (Xavier, 2005). Another error was in the failure by the pilot to de-ice the aircraft. The weather was cold and wet with snow falling. However, de-icing was forbidden while the engines were running by both Fokker, a manufacturing company, and Air Ontario (Luxhoj & Kauffeld, 2003). The pilot did not de-ice the aircraft, and consequently it did not manage to reach an altitude.
The regulation authority of airlines in the country, Transport Canada, erred by allowing Air Ontario to expand into the operation of complicated aircrafts. The body failed to detect deficiencies in the aircraft. The authority had also never demanded compulsory licensing and efficient training of flight dispatchers (Luxhoj & Kauffeld, 2003). Extra passengers also posed a threat to the security of the aircraft. On the ill-fated day, the Air Ontario Systems Operations Control (SOC) failed to update the original flight release. After refueling the plane at Dryden, ten passengers were added. The pilot suggested offloading these passengers and their luggage as the aircraft was overweight for take-off (Luxhoj & Kauffeld, 2003). However, SOC overrode his decision and instead reduced the weight by fuel off-loading. The weather was also a threat. The meteorological department predicted that it would be wet and snowy. The combination of slush on the ground and snow that froze into ice hindered the performance of the aircraft (Xavier, 2005).
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The flight crew erred in their lack of communication. A flight attendant had noticed snow on the plane’s wings just before take-off. However, she failed to report it. On survival, she testified that she had reported a similar case in the past, and the then pilots rebuffed her. She therefore decided to remain quiet this time (Xavier, 2005). The crew also erred in their intentional non-compliance with procedures. The pilot flew a plane that he knew had a defective auxiliary power unit. He also hot-fueled the plane while the engines were running at the airport that lacked the proper ground power unit. The crew erred in their operational decision making when they made a decision to dispatch in bad weather. The team also committed procedural errors. They erred in flight deck operating procedures, for example, when they failed to update the delayed flight list and gave misleading dispatch orders (Merlin, 2013).
Good communication with the crew and passengers could have prevented this accident. Two off-duty airline pilots traveling in the aircraft as passengers failed to report the evidence of snow on the wings. Being pilots, they should have anticipated the danger. They claimed that they assumed the crew were aware of the snow on the wings and would de-ice the plane. They believed the pilot would conduct this at a remote de-icing area on the airport, just as Air Canada, its parent company, had always done (Xavier, 2005). Had the pilots and the flight attendant communicated the information, then probably the disaster would have been prevented. Crew resource management could have also been used to prevent the disaster. Its aim is educating the crew on communication and interpersonal skills ensuring that the crew operates as one unit instead of a combination of individuals (American Psychological Association, 2014). Had the team applied crew resource management techniques, the flight attendant would have felt comfortable addressing the pilots about the ice on the plane’s wings. It would have probably led to the pilots de-icing the aircraft, thereby preventing the disaster.
The model expands the Reason’s Swiss Cheese theory to describe holes that lead to a failure. These gaps apply to four levels of human failure, namely, the organization, unsafe supervision, preconditions for accidents, and unsafe acts. The model then identifies causal factors of these four levels of failure (Luxhoj & Kauffeld, 2003). They include errors in resource management, unconducive organizational climate, and inconsistent organizational practices. For unsafe supervision, causal factors include inadequate supervision and supervisory violations (Luxhoj & Kauffeld, 2003). Preconditions for unsafe acts are advanced mental and physiological states and the lack of crew resource management. On the level of unsafe acts, causal factors involve routine violations and decision errors.
The model applies to the Air Ontario case. Here, all four levels of failure can be applied. On the organizational level, the accident causal factors are organizational processes. There was a lack of standardized operations, as well as manual and incomplete information from the crew regarding the take-off in cold weather. Another causal factor was Air Canada’s resource management. Being the owner of Air Ontario, Air Canada did not provide its subsidiary with enough personnel and training. It left dispatcher training to Air Ontario, who did not have enough training resources leading to dispatchers being underqualified and preparing incorrect flight releases (Luxhoj & Kauffeld, 2003).
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On the unsafe supervision level, one of the causal factors was inadequate supervision. The airline underwent critical changes in its operational activities from June 1987 to March 1989. The vice president and the director of flight operation offices were separated. It caused instability and supervision problems due to the lack of management continuity. Employees did not know whom to report to, and this was an obstacle to training required after the introduction of a new aircraft type (Luxhoj & Kauffeld, 2003). Planned inappropriate operations were also another causal factor. Both pilots of the plane were newcomers for that type of an aircraft. Their pairing to operate the airplane was therefore inappropriate.
On the preconditions for unsafe acts level, causal factors included crews’ adverse mental states. According to the Commission of Inquiry report, aircraft pilot Captain Morwood exhibited symptoms of stress upon landing at Dryden (Luxhoj & Kauffeld, 2003). In addition, such factors such as the unserviceable auxiliary power unit and inexperienced dispatchers could have frustrated the crew and the pilot. On the level of unsafe acts that had finally caused the accident, causal factors included decision errors such as the pilot’s decision not to de-ice the aircraft. Another factor was the violation of routines by the pilots. Normally, the crew followed the eighty-knot test where during a takeoff, each pilot was supposed to look out of the window at eighty knots to see whether the snow had been blown from the wings. In the case of Air Ontario, the aircraft pilots failed to perform this necessary step (Luxhoj & Kauffeld, 2003).
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Before the invention of such theories as the Swiss Cheese and HFAC models, pilots had been always solely blamed for the occurrences of accidents. Investigations conducted after the aviation accidents had always arrived at the same conclusion. They failed to recognize that other factors had probably led to the accident. However, currently these theories, among others like crew resource management help specialists to expose errors that lead to accidents. Such measures result in the reduction of the latter. Hopefully in the future, with the continued application of these theories, the number of accidents caused by human factors and errors will decrease significantly.