Australian’s Aviation Industry Introduction of the accident Individual actions & technical event Local conditions, Risk controls Organizational influences Comments & recommendations

1. Presented by
Noman Khan
57154
MBA (Aviation Management)
PAF KIET
Loss of control & collision with water
involving Cessna 210; VH-EFB
160 Km south-west of Darwin, Northern Territory 1st
April 2013
Course: Human Factor in Aviation Industry
Faculty: Wg. Com. Syed Naseem Ahmed
MBA (Aviation Management)
PAF KIET
“HUMAN FACTOR”
ASPECTS (CASE STUDY)

2.  INTRODUCTION OF THE ACCIDENT
 INDIVIDUAL ACTIONS & TECHNICAL EVENT
 LOCAL CONDITIONS,
 RISK CONTROLS
 ORGANIZATIONAL INFLUENCES
 COMMENTS & RECOMMENDATIONS
Table of content
2Friday, May 2, 2014

3. Australian’s Aviation Industry
Friday, May 2, 2014

4. Aircraft by Category - Australia
5,700 Kg
3M
Friday, May 2, 2014

5. 5Friday, May 2, 2014
SIMILAR OCCURRENCES:
 From 2002 to 2013:
 139 Occurrences have records involving a VFR Operation
 encountering instrument meteorological conditions , Of these,
 09 were fatal.
(Source: ATSB Database)
 One of the fatal accidents occurred on 17 November 2007, when the pilot of a
Cessna 337 (VH-CHU), was tracking along the coast from Moorabbin, Victoria to
Merimbula, New South Wales.
 ATSB findings: while maneuvering over water at low level in conditions of
reduced visibility, the pilot probably became spatially disorientated and
unintentionally descended into the water.
Ops Investigation – Contributing FactorOps Investigation – Contributing Factor

6. Introduction of the Accident
Table of content
6Friday, May 2, 2014

7. 10Friday, May 2, 2014
Bullo River
Emkeytee
Dundee Beach
Cape Ford
Wadeye
Anson Bay
3 A/Cs
2 A/Cs
Palumpa
ON 28 AND 29 MARCH 2013;
 The group of pilots flew Emkaytee to Bullo
River for long Easter holidays
 The flights under VFR and affected by areas of
low cloud and reduced visibility
 Diversion towards the coast to avoid the higher
ground and weather on the direct track
ON 29TH
MARCH;
 Pilot of the lead aircraft in the group
encountered bad weather
 Diversion to Palumpa (Nganmarriyanga)
airstrip, 123 km to the north of BR.
 Effective communication were observed in first
cruise via R/T (Weather information).
 After an hour; The pilots departed in turn and
slightly on the direct track to BR without
further delay.
28th
& 29th
March. 2013

8. 12Friday, May 2, 2014
Bullo River
EmkeyteeDundee Beach
Cape Ford
Wadeye
Anson Bay
3 A/Cs
2 A/Cs
Palumpa
 @ afternoon; reassess weather as a
group.
 WRI indicating better conditions
inland of the coast & improved at BR
 Weather improvement for Darwin in
the afternoon with a subsequent
deterioration by evening.
 Discussion & recommending a coastal
track via Wadeye and Dundee Beach to
avoid the higher terrain on the direct
track.
 All of the pilots seemed comfortable with
departure that afternoon
 (option of return was there)
1st
April. 2013

9. 13Friday, May 2, 2014
Bullo River
EmkeyteeDundee Beach
Cape Ford
Wadeye
Anson Bay
3 A/Cs
2 A/Cs
Palumpa
 Pre- flight checks /planning taken;
 Cessna 210 pilot conduct a daily
inspection (incl. water in the fuel tanks)
 Two other pilots planned to track coastal
 Cessna 210 was reported to have based
his pre-flight planning on the coastal
track.
 While the other waited until they assessed
the weather airborne.
 Each in the Group departed one by one.
 Cessna 210, was the third aircraft to
depart. (a Normal take-off). Dpt. 1415
-1500.
1st
April. 2013

10. 14Friday, May 2, 2014
Bullo River
Emkeyte
e
Dundee Beach
Cape
Ford
Wadeye
Anson Bay
3 A/Cs
2 A/Cs
Palumpa
 At about the halfway point (100 km away);
encountering low cloud, rain in storms that
stretched from Cape Ford SE towards the
inland direct track
 The pilots on the direct track diverted
slightly to the east (right of track) to get
around the cloud mass
 existence of good visibility on the East was
broadcasted & shared
 Of the 3 aircraft on the coastal track;
 2 pilots tracked inland in response to the
weather
 1 pilot maneuvered around the
weather and established on the
direct track
 Second resumed costal track on rel.
clear condition
Storms stretches
from CF

11. 15Friday, May 2, 2014
@1510; At some point the Cessna 210
pilot broadcast his position and
intentions;
“ approaching Cape Ford at 500 ft and
that the weather ahead was gloomy”,
that was the last time anyone heard from
the Cessna 210.
F-2; Weather radar image at 1505, about the time of the
accident (nominal coastal track and direct track overlaid with
the likely accident area circled)

12. 16Friday, May 2, 2014
 The Cessna 210 had not arrived
 Search & rescue @ Cape Ford
 Some bodies and a small amount of wreckage were found on the southernsouthern
part of Anson Baypart of Anson Bay, 10 km SE of Cape Ford
 There were no survivors.
 No more sightings of aircraft wreckage were made until October 2013,
INTRODUCTION OF THE ACCIDENTINTRODUCTION OF THE ACCIDENT

13. 17Friday, May 2, 2014
Wreckage of Cessna 210Wreckage of Cessna 210
The wreckage found in October 2013 was
spread over a few hundred meters (Figure). The
airframe was extensively fragmented with
elements of the wings, fuselage, and seats
identified. The engine and propeller, separated
from the rest of the wreckage, were damaged
but largely complete. As a result of the
fragmentation, submersion, and tidal action,
there was little additional information
available.
Stuart Sceney, his wife Karmi Dunn, and their
two daughters, who all died in the crash.

14. 18Friday, May 2, 2014
The Occurrence of Cessna 210The Occurrence of Cessna 210
View from another aircraft in the
group as the pilot navigated around
the storms about 80 km south-east of
Cape Ford
View from an aircraft in the group as the pilot navigated
between storms about 40 km south-east of Cape Ford

15. To Improve safety
To identify and assess contributing factors
Not to blame
What?
Why?
What can we do about it?
Friday, May 2, 2014 19

16.  Workload
 Stress
 Ergonomics
 Responses (Total Power failures?)
 Medical and Environments
 CRM and Communications
 Risk Controls (“Bow –Tie” Model)
 Organizational Influences ( Complex or
easy to detect?)
 Safety Culture
 HF Investigation Issues
 Human Factors in Maintenance
 Shell Model
Friday, May 2, 2014 20
 Human Error (Would you have done the
same thing?)
 Individual Actions (Types of Errors)
 Perception and Memory (How are
memories stored?)
 Attention ( Manager of information)
 Situational Awareness (Timely and
accurate perception of elements of
situation)
 Decision Making (Titanic Ship)
 Fatigue ( Effects on performance)
 Automated Systems (Degree of
automation)
 Safety Management System?
Human Factor TopicsHuman Factor Topics

17. 21Friday, May 2, 2014
ATSB AAI MODEL ;
Ops Investigation – Findings, Human FactorOps Investigation – Findings, Human Factor

18. 22Friday, May 2, 2014
OCCURRENCE;
 A high degree of force involved in the collision with the water
 The impact is almost certainly related to an inadvertent descent into the
water
It is evident from the fragmentation and distortion ;
Pilot Qualification:
 Appropriately qualified for VFR
 No instrument rating (3-hr instrument flying)
 Purchased 12 month ago (300 hrs flying) – mostly cross-country flight for Business
 CRM (proper rest)
 Cautions-pilot
Ops Investigation – Human FactorOps Investigation – Human Factor

19. 23Friday, May 2, 2014
AIRCRAFT TECHNICAL EVENTS;
 Reliable, relatively fast,
 Sensitive in pitch - Lose height rapidly in a turn
 Hydraulic oil leak that affected the retractable landing gear. (no maint.
record)
 No shortage of fuel recorded
EQUIPPED WITH AN AUTOPILOT - ~ S/A
 Essentially limited to leveling the wings without any altitude-keeping
capability. Therefore,
 The autopilot was not capable of providing effective protection from an
unintended descent and the wing- leveling function would probably be
compromised by any severe turbulence.
Ops Investigation – Technical EventsOps Investigation – Technical Events

20. 24
INDIVIDUAL ACTION;
 Refueled to full tank – add. 3hrs of reserve fuel
 Daily inspection conducted – incl. water in the fuel tank
 Plan for coastal track – higher terrain in direct track
 Observing the behavior of weather.
 Calm & cool
 Flying in unfavorable flying condition – under VFR.
 Why the pilot decided to continue on the coastal track – U/I Error
& Decision Making
 Flying in unfavorable flying condition – under VFR.
 Why the pilot decided to continue on the coastal track – U/I Error
& Decision Making
Ops Investigation – Individual ActionOps Investigation – Individual Action
24Friday, May 2, 2014
Bullo River
EmkeyteeDundee Beach
Cape
Ford
Wadeye
Anson Bay
Palumpa

21. 25Friday, May 2, 2014
 Cessna 210 pilot encountered bed weather & some degree of turbulence, so for
avoidance of this low clouds, he would have developed a trajectory towards the water
without realized the trajectory towards water due relatively featureless surface and
reduced visibility
 The other possibility is that pilot was aware of a descent towards the water but
was unable to sufficiently control the aircraft.
 As a result of one or more of those factors, the pilot inadvertently allowed the
aircraft to descend and collide with water.
Ops Investigation – Individual ActionOps Investigation – Individual Action
AIRCRAFT HANDLING (SA);
 Pilot unawareness of an aircraft’s trajectory towards the water or
pilot inability to alter that trajectory.
Lack of familiarity with the task (IRoEx17 )Lack of familiarity with the task (IRoEx17 )

22. 26Friday, May 2, 2014
Ops Investigation – Local ConditionOps Investigation – Local Condition
 Knowledge, skills, experience - Personal Factors,
 No instrument rating (3-hr instrument flying)
 300 hrs flying on Cessna – mostly cross-country flight for Business
 2 wet flying on that area only
 Cautious
 Task demands
 Environment;
 Flying in unfavorable flying condition - Weather phenomenon
What aspects of the local environment may have influenced the individual actions or technical problems
Personal Factors
task demands,
SWPP Env
weather

23. 27Friday, May 2, 2014
Ops Investigation – Local ConditionOps Investigation – Local Condition
Shell Model: Interfacing with Equipment & Environment;
 Appropriately qualified for flight under VFR
 Owned the aircraft for just over 12 month (300hrs)
 Cross-country business flying experience mostly
 2 wet season flying on that area only (unfamiliarity with route?)
 Caution pilot
 Relatively fast & Sensitive in Pitch – un known to pilot

24. 28Friday, May 2, 2014
MANAGING WEATHER RISK:
On the flights to Bullo River under VFR: the pilot diverted around weather and
landed at Palumpa & wait for improved weather
Why not now - WRI & Av. Weather Forecast was threatening - why the Cessna
pilot decided to continue on the coastal track.
Duty forecaster at the BoM (at Darwin) was not consulted by the pilots -
contactable via phone.
In situations where significant weather is forecast or otherwise expected, pilots
are encouraged to access the BoM detailed weather briefings (via phone) to assist
with understanding the conditions at the time as well as the immediate trend. This
service is not utilized much by private pilots but it is available to all aviators –
violation
What could have been in place to reduce the likelihood or severity of problems of the operational level
Ops Investigation – Risk ControlOps Investigation – Risk Control
Poor feedback from system (x4)Poor feedback from system (x4)

25. 29Friday, May 2, 2014
MANAGING WEATHER RISK:
Tracking visually via a coastal route in marginal weather conditions can be
advantageous in terms of ease of navigation and absence of elevated terrain, but
can also increase the risk of spatial disorientation in the context of drastically
reduced visibility make worse by a lack of surface definition when over water.
(P&M)
Ops Investigation – Risk ControlOps Investigation – Risk Control

26. 30Friday, May 2, 2014
 A purposeful AAI can not be concluded in “Human Error”
 Starting point of investigation – Last ring of entire chain
 look outside the cockpit and discover factors that might have
contributed to the Human Error
 Policies, regulations, procedures or environments
 Human nature can not be changed – working conditions are
changeable
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

27. 31Friday, May 2, 2014
ERROR MANAGEMENT:
Error are mosquitoes - (Managing Maintenance Error: A Practical Guide By J. T. Reason)
 Conflicting goals
 Poor Defences
 Poor Design
 Inadequate Procedures
 Training Deficiencies
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

28. 32Friday, May 2, 2014
Av. SAFETY MANAGEMENT SYSTEM
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

29. 33Friday, May 2, 2014
AVIATION SAFETY MANAGEMENT SYSTEM
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

30. 34Friday, May 2, 2014
Organizational Processes
WORK PLACE
CONDITION
LATENT CONDITION
ACTIVE FALIURE DEFENSES
Organizational Accident
MIIRC
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

31. 35Friday, May 2, 2014
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence
CULTURE
 Organizational culture is the behavior of humans who are part of an
organization and the meanings that the people attach to their actions.
 Culture includes the organization values, visions, norms, working language,
systems, symbols, beliefs and habits.
 It is also the pattern of such collective behaviors and assumptions that are
taught to new organizational members as a way of perceiving, and even
thinking and feeling.
 Organizational culture affects the way people and groups interact with each
other, with clients, and with stakeholders.
 The attitudes, beliefs, perceptions and values that employees share in relation
to safety

32. 36Friday, May 2, 2014
CULTURE
 Safety culture - where does your organization sit?
 Safety is paramount - strong emphasis on safety as part of the strategy of
controlling risks
 Personnel are well trained, and fully understand the consequences of unsafe acts.
 Decision makers and operational personnel hold a realistic view of the short- and
long-term hazards involved in the organization’s activities
 Non-punitive reporting culture – rewards based
 Senior positions do not use their influence to force their views on other levels of
the organization, or to avoid criticism
 AAI are conducted as an “Opportunity to improvement”
 Rel. Safety Info. are communicated all over
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

33. 37Friday, May 2, 2014
ERROR & ERROR MANAGEMENT:
 Making errors is about as normal as breathing oxygen (James Reason)
 Error is a normal and natural part of everyday life
 It is generally accepted that we will make errors daily
 We make 3 to 6 errors every waking hour, regardless of the task being performed
 The good news is that the vast majority have no serious consequences, because they
are automatically self-corrected: somebody or something reminds us what we should
be doing, or the errors we make do not involve a potential safety hazard.
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

34. 38Friday, May 2, 2014
Regulatory Oversight
 Rule Preparation - the drafting of national rules, including
appropriate consultation;
 Rule Enactment - the passing of laws or other appropriate orders
to give legal effect to the rules;
 Safety Oversight - the monitoring of safe service-provision
including verifying compliance with the rules;
 Enforcement - taking appropriate action to deal with cases of non-
compliance.
Ops Investigation – OrganizationalOps Investigation – Organizational
InfluenceInfluence

35. 39Friday, May 2, 2014
Regulatory
Oversight
Organizational
Influence
Local condition
Individual
action
Occurrence
Events
Risk control

36. 40Friday, May 2, 2014
INCIDENT / ACCIDENT INVESTIGHATION
 Make sure your investigation procedures detail clearly how human factors
considerations are included.
 The main purpose of investigating an accident or incident is to understand
 what happened,
 how it happened,
 and why it happened,
 To prevent similar events in future. Use a model (such as Reason’s model) or
framework for investigations and consider human error, both at the individual
and organizational levels.
 Your investigators need to be trained in basic human factors concepts and
design procedures to be able to establish which human performance factors
might have contributed to the event.
Ops Investigation – CommentsOps Investigation – Comments

37. 41Friday, May 2, 2014
IMPROVE DEFENSES
 Training, Training, Training
 Technology,
 Regulation
Ops Investigation – CommentsOps Investigation – Comments

38. 42Friday, May 2, 2014

39. 43Friday, May 2, 2014