Avianca Flight 52: a Case Study on Human Error

Relevant facts/ Back build Avianca flying 52 touched the ground for a final time on January 25 1990, 16 miles from JFK airdrome in Cove Neck, Long Island, N. Y. , completely out of fuel. The Boeing 707-321B was carrying 158 people coming from Medellin, Columbia, in which 85 people survived. The crash of Avianca Flight 52 was the largest rescue work in New York prior to 9/11. There was a good blizzard on the north-east coast of the U. S. causing bad atmospheric condition with a low pressure system and wind shear.JFK airport administration had been told to keep a higher landing ordinate than safe at 33 planes attempting to land per hour, on one runway the typical rate being 52 in good weather, with all runways open. The airport was experiencing a rate of 27% missed approaches, with 39 planes waiting in prop patterns for clearance to land and dozens waiting to take-off. Sequence of razets The 707 had been placed in holding patterns for a total of 1 hour and 17 transactions du ring three separate occasions over the U. S. east coast.There were 6 unalike air traffic controllers that had snuff itd directions to Flight 52 after they entered U. S. airspace, adding confusion and un-transmitted messages, stock-still at the same time not providing any more essential information such as weather conditions. The Flight Engineer failed to communicate the urgency of the low fuel situation to the pi lap and co- fender after they passed the engineer of no return and had to remain committed to JFK by not having plenty fuel to get to their alternate airport at Boston, 342km away from JFK.He overly failed to emphasize the importance of landing in their first attempt beca utilise they would not put on enough fuel to loop around and try again. some other discrepancy was how the co-pilot used the words Low Fuel and Priority quite a than MAYDAY and Minimum Fuel while communicating to ATCs. There was a lot of crucial information left out or misinterpreted and not so im portant information repeated, which could sacrifice easily been avoided without the language barriers in place.In monetary value of the Swiss Cheese posture there were some holes in the conversations mingled with ATCs and the flight crew, 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 someone, Avianca express to investigators that the phraseology used by their pilots was correct as per their training -whether it matched the well-worn English phraseology used by IATA countries or not they were just following what they thought to be proper protocol.Investigation by the NTSB found many holes in the events leading up to the crash, due to both active and possible failures by the crew, ATCs, and airport management. The leading causes can be attributed to airport mismanagement, unconformable training for pilots that should have English proficiency, and overall poor communication b etween ATCs and the flight crew. Repetitive flaws in a system run by human beings shows a clear link in the lack of gamble 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 name 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 implementation of Crew imagery Management techniques in the previous years must not have been as streamlined as int finish, 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 decease b y human error. References AskCaptainLim. com comments. Aviation, Air scoot. 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. , John 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 National Geographic, Cineflix Productions. Air Crash Investigation series, Episode 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_Flight_52