Decision-Making and Communication Errors Blamed for Deadly Jet Crash
Over the years, I have examined several “cockpit communication breakdowns” that resulted in endangering aircraft in flight and on the taxiway – and in too many instances resulted in crashes and fatalities. Human error has been documented as a primary contributor to more than 70 percent of commercial airplane hull-loss accidents. All airline pilots are required to receive crew resource management (CRM) training, which augments technical flight and ground training with human factors subjects. CRM training has been shown to be efficacious for flight crews to improve human factors performance. Unfortunately, in real flight operations, there are complex situational, business and economic, cognitive and physical factors that cause human factor performance problems, particularly when facing a demanding critical situation, such as in an emergency.
Last fall, one aircraft crash that received a significant amount of attention was the crash of the LaMia Charter Flight 2933 (a BAE 146 Avro RJ85 jet) that cost the lives of 71 people including members of the Chapecoense (Brazil) soccer team on 28 November 2016.
LaMia Charter Flight Crash, Image: Twitter
The aircraft had been transporting the Chapecoense soccer team to the biggest game in its history, the final of the Copa Sudamericana. The LaMia Flight 2933 charter plane, headed from Bolivia to Medellin for the championship match of the Copa Sudamericana, crashed Nov. 28 into mountainous terrain near Rionegro, Colombia. Most of the victims were members of the Chapecoense Brazilian soccer team — 19 of which were players and 25 of which were team executives. Six people survived the crash. (The South American Football Confederation awarded Chapecoense the Copa Sudamericana title following the incident.)
Colombia’s Civil Aeronautics Agency (CCAA) concluded in its investigation that the crash of the airliner was caused by a series of human errors including significant communication breakdowns. Among the many factors identified that led to the fatal crash, were the decisions to let the charter jet take off without enough fuel on board to ensure flight safety and failure not to stop en route midway to add fuel. The Civil Aeronautics Agency also stressed that neither the LaMia charter company nor Bolivian authorities should have allowed the plane to take off with the flight plan submitted.
The pilots of the aircraft knew that there was insufficient fuel for the flight plan and they were aware that the jet engines were shutting down due to lack of fuel before they communicated their critical predicament to controllers. They only reported “a total electric failure without fuel” just minutes before the jet slammed into a hillside outside Medellin, Columbia. Even then, they asked only for a “priority landing” but didn’t communicate that they were in imminent danger. Subsequent descriptions of their communication by controllers was described “in a completely normal manner.”
Kejal Vyas writing in the Wall Street Journal reported:
“Yaneth Molina, the air-traffic controller in Jose Maria Cordova International Airport, described the harrowing final minutes in an interview…with Colombia’s Caracol Radio. The LaMia flight, she said, never alerted them of any major problems before suddenly beginning an unauthorized descent for landing, looking to cut in front of three other planes that were scheduled to land before. ‘That’s when I called them and they tell me about an emergency,’ Mrs. Molina said. ‘There were 71 victims, but it was too close. They were practically on top of the other aircraft. It could have been worse,’ she said.”
Investigators concluded without a doubt that crew members of the LaMia flight were aware of the lack of fuel but only communicated with controllers about the emergency situation when it was too late. Analysis of the Cockpit Voice Recorder (CVR) revealed that during the flight the pilot and co-pilot are heard on “various occasions” talking about stopping in Leticia, a city near the borders separating Brazil, Peru and Colombia, to refuel but decided not to do so nor to communicate with air traffic controllers about their predicament.
The CCAA noted that when the plane entered Colombian airspace, it was flying into a wind, which caused more fuel to be consumed. When the pilot finally contracted the air traffic controllers to request priority to land in Medellin (six minutes before crashing), the plane had already spent two minutes with one engine shut off. Three minutes and 45 seconds before the crash all the engines had stopped due to the lack of fuel, the investigation concluded.
In a recording of the belated radio messages from the pilot, he can be heard repeatedly requesting permission to land due to a lack of fuel and a “total electric failure.” Moreover, a surviving flight attendant and a pilot flying nearby testified that they also overheard what they described as frantic pleas from the flight crew of the LaMia jet during the final moments.
Author: Dr. Robert C. Chandler
As news reports made public (Human error led to Colombia soccer plane crash: authorities) “[n]o technical factor was part of the accident, everything involved human error, added to a management factor in the company’s administration and the management and organization of the flight plans by the authorities in Bolivia.”
The flight crew was aware of the insufficient fuel and yet they did not stop at the mid-way point of the flight to refuel nor did they communicate that decision (and the anticipated low fuel situation) to the controllers. The flight crew were also aware of the imminent danger posed by the jet engines shutting down. Yet, they sought to communicate with the ground controllers only after it was too late to ensure a safe landing and literally just minutes before their aircraft plunged into a hillside.
Once again, dad decision-making and delayed and poor communication by the flight crew appears to be the substantial factors for another air crash disaster. Improving human performance can help reduce the commercial aviation accident rate, and much of the focus is on designing human-airplane interfaces and developing procedures for both flight crews and maintenance technicians to mitigate these breakdowns. Human behavior, particularly decision-making and communication needs to be a priority for flight crew training, assessment and certification.
Preventing Future Human Error Crashes
More data and additional research is needed to better enhance human performance in these contexts. Unfortunately, it is difficult to obtain insightful data in an aviation system that focuses on accountability and punitive responses to breakdowns. Flight and maintenance crews are often unduly exposed to blame because they are the last line of defense when unsafe conditions arise. The system should transcend a “blame” culture and encourage all members of aircraft operations to be forthcoming after any incident. Data collection should not be limited to any one segment of the safety chain. To best reduce the aircraft human factor accident rates, we should continue to promote and implement proactive, nonpunitive safety reporting programs designed to collect and analyze aviation safety information and implement a substantial human behavior and communication training regime to improve performance at critical moments.
We also need business, aviation industry, and regulators to support these approaches. One positive example are the efforts made by the Boeing company. Boeing currently has a focused effort to examine human performance issues throughout the airplane to improve usability, maintainability, reliability, and comfort. In addition, human factors specialists participate in analyzing operational safety and developing methods and tools to help operators better manage human error. These responsibilities require the specialists to work closely with engineers, safety experts, test and training pilots, mechanics, and cabin crews to properly integrate human factors into the design of airplanes. We need more companies in the aviation industry to support and expand such efforts.
“What should we do now?” “What should we say?”