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The Colgan Air Flight 3407 Crash Case

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The Colgan Air Flight 3407 was a very interesting case to look at. On February 12, 2009, at 10:17 pm, flight 3407 crashed at a house in New York after the pilots experience a stall. Flight 3407 was scheduled to fly from Newark, New Jersey to Buffalo, New York. The NTSB reported the cockpit voice recorder (CVR) revealed some discrepancies both pilots were experience. The first officer did not have any experience with icing condition but icing was one of the reasons the plane went into a stall. On the other hand, the captain had some experience flying in icing condition. The captain was experiencing fatigue, which indeed, made him unfit to recover from a stall. With that in mind, the Human Factor Analysis Classification System (HFACS) will give insight of some errors both pilots made.

According to “A Human Error Approach to Aviation Accident Analysis…”, both authors stated that HFACS was developed based off from the Swiss Cheese model to provide a tool to assist in the investigation process to identify the probable human cause (Wiegmann and Shappell, 2003). Moreover, the HFACS is broken down into four categories to identify the failure occur. In other words, leading up to adverse events the HFACS will identify the type error occur.

The first HFACS is unsafe acts. Unsafe act begin at level one and it is divided into two catergories, errors and violation. While errors are based on skills, decision and perceptual errors the violation focuses on routine and exceptional violations. As to Colgan Air flight 3407, the unsafe act elements both pilots acted on were skill-based and decision errors. The skill-based errors were occurring when the crew failed to pay attention to their airspeed and the captain also failed to try recover from a stall. For the decision error, the co-pilot had discovered icing on the wings but failed to mention how serious it was.

The next level is Precondition for Unsafe Acts. Precondition begins at level two and it is dividing into environmental factors, condition of operator, and personnel factors. In regards to Flight 3407, the environmental factors would be the weather condition. Icing was a factor when occurred on the wings. Both pilots were experiencing fatigue during their flight. They have pushed their body to limits where as their reaction times were not fully functional. Furthermore, due to fatigues and not adequate situational awareness, the crew did not perform to their best optimal on the job.

In this essay, the author

  • Explains that colgan air flight 3407 crashed in new york after the pilots experienced a stall. the ntsb reported the cockpit voice recorder revealed some discrepancies.
  • States that hfacs was developed based off the swiss cheese model to provide a tool to assist in the investigation process to identify the probable human cause.
  • Explains that unsafe acts begin at level one and is divided into two catergories, errors and violation. the skill-based and decision errors occurred on colgan air flight 3407.
  • Explains that precondition for unsafe acts begins at level two and is dividing into environmental factors, condition of operator, and personnel factors. both pilots were experiencing fatigue during their flight.
  • Explains that unsafe supervision is the third level of hfacs and concentrates on inadequate supervision, plan inappropriate operation, fail to correct known problem, and supervisor violation.
  • Explains that the fourth level of hfacs includes resource management, organization climate, and operational process. flight 3407 may not have major impact from organization but the colgan air organization policies did play critical role.
  • Explains that the purpose of the hfacs is to assist the investigator in solving the accidents.
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    • Airplane Crashes
      analytical essay
      The cause in every accident of the BOAC Comet was a design factor. The pressurization limitations were determined wrongly. In the mid air collision in San Diego, the cause was human error of the Cessna pilot for changing headings, the Boeing for not being sure of having the right traffic insight, and the tower for not warning the aircrafts they were very close together when his warning went off. Finally, the Air Florida crash, investigators took into consideration the factors of the weather, engine performance, and pilot error.

      In this essay, the author

      • Analyzes how the boac comet, psa crashes in san diego, and the air florida crash in washington d.c. were analyzed differently, taking into consideration each possible factor.
      • Explains that the cause in every accident of the boac comet was a design factor, and the pressurization limitations were determined wrong.
      • Explains that the structure of the aircraft (hardware) failed to stand the capabilities stated by engineers (liveware).
      • Explains that the aircrew of the 727 not sure of correct traffic insight and the cessna altering his designated course.
      • Explains that the 727 and cessna were about to collide when their warning sounded (hardware) and the cessona altering its assigned heading from the tower (liveware).
      • Analyzes liveware's captain being impatient and not getting de-iced, and the first officer not speaking up.
      • Explains that in three accidents, human error was the biggest factor leading up to the event. in san diego, atc and both pilots contributed to mid-air collisions.
      • Explains that the comet dh-106 was the first jetliner to carry passengers, and that there was a singular error in the engineering of the aircraft.
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