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Safety Intervention: American Airlines Flight 1420
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Safety Intervention: American Airlines Flight 1420

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December, 2005 ...

December, 2005

Final Presentation for the Safety Interventions course for the Work and Organizational Psychology (WOP) program at Maastricht University (UM).

Our assignment was to design an intervention program to make organizational changes. We chose American Airlines, because we were both very interested in aviation and investigating the various human factors significant to the crash of flight 1420.

Project partner: Sjir Uitdewilligen

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  • Welcome! We are Sjir and Brian, and we will tell you about our intervention. It is not a health intervention , but one to improve safety conditions
  • Here is a short outline of our presentation: Since our intervention is complex and multi-faceted, as well as the problem, we will focus on the main part of the problem and our intervention. To keep this interesting, we will try At the end, we will field any questions anyone may have.
  • Here is what happened: On July 11, 1999, around midnight AA flight 1420 , flying from Dallas, Texas to Little Rock, Arkansas, tried to land into an approaching thunderstorm. The aircraft lost control on the runway and crashed into airport structures, killing 11 people and injuring the other 134 on board.
  • Here is simplified timeline of what happened: The flight crew notices the thunderstorm , but sees a “bowling alley” configuration (show on right diagram), where they will try to get between storm fronts and land. This task puts the pilots under time pressure and increases their cognitive workloads , because they have to pay attention to this storm and keep the aircraft stable. The flight crew begins their approach to the runway. By now, the aircraft is difficult to control , and the captain remarks that the situation is “a can of worms.” Air traffic control in Little Rock informs the flight crew of windshear, which exceeds the maximum allowable amount. From this point, continuing the approach is against AA policy and the crew should have diverted to their backup airport. At this point, the flight crew forgets to arm the spoilers , a system that will allow them to decelerate after landing. This is part of the landing checklist , but both pilots were cognitively overwhelmed by the situation. The aircraft lands and loses control immediately on the runway. It cannot decelerate , because the spoilers are not deployed. The aircraft races over the end of the runway and crashes into some lighting fixtures and a gangway. This causes the aircraft to break into multiple pieces, starting fires and killing 11 people.
  • Here is simplified timeline of what happened: The flight crew notices the thunderstorm , but sees a “bowling alley” configuration (show on right diagram), where they will try to get between storm fronts and land. This task puts the pilots under time pressure and increases their cognitive workloads , because they have to pay attention to this storm and keep the aircraft stable.
  • Here is simplified timeline of what happened: 2. The flight crew begins their approach to the runway. By now, the aircraft is difficult to control , and the captain remarks that the situation is “a can of worms.”
  • Here is simplified timeline of what happened: 3. Air traffic control in Little Rock informs the flight crew of windshear, which exceeds the maximum allowable amount. From this point, continuing the approach is against AA policy and the crew should have diverted to their backup airport.
  • Here is simplified timeline of what happened: 4. At this point, the flight crew forgets to arm the spoilers , a system that will allow them to decelerate after landing. This is part of the landing checklist , but both pilots were cognitively overwhelmed by the situation.
  • Here is simplified timeline of what happened: 5. The aircraft lands and loses control immediately on the runway. It cannot decelerate , because the spoilers are not deployed.
  • Here is simplified timeline of what happened: 6. The aircraft races over the end of the runway and crashes into some lighting fixtures and a gangway. This causes the aircraft to break into multiple pieces, starting fires and killing 11 people.
  • This presentation will focus on the main risk behavior: failing to discontinue the approach . Had the pilots diverted to another airport, they would have not made any of the other mistakes. As you can see, the key determinants for this particular risk behavior are: Risk awareness- knowing that the weather conditions were too dangerous for landing Attitudes and social norms- According to a study done in Dallas, TX, most pilots will land in bad weather. Reinforcement- In some cases, pilots are punished for taking too long to complete a mission, and there is no incentive program in place to reward safe flying habits. Some additional determinants here are lack of skills, lack of knowledge, and fatigue , but to keep this under 15 minutes, we will not discuss these during the presentation.
  • Turning these things around, our safety behavior becomes discontinuing unsafe approaches. Performance objectives: Pilots should realize when it is not safe to land American Airlines pilots should develop safe social norms American Airlines should reinforce safe behavior
  • This is in accordance with Reason’s Swiss Cheese model , which sees errors as made possible by a number of underlying factors. The unsafe act of continuing the landing was made under the preconditions of stress and fatigue, witt lack of good supervision in an organizational climate that was not optimal about having safety as its first priority.
  • Top down approach from the highest organizational level trough the supervisors to the pilots themselves.
  • Unfreeze : creating the awareness for the need for a climate change: The accident itself already functions as a trigger to create awareness, Furthermore, to convince the management we plan meetings with financial and reputational specialists emphasising the costs of accidents for the companies reputation and financial position. Move: Than management should communicate their dedication to safety towards the employees for example through newsletters. And posters will be made emphasizing safety. Workshops will be organized in which pilots are made aware of the risks of landing in bad weather by means of presentations and discussions in which they discuss experiences of their own dangerous situations. Refreeze: A reinforcement system will be used in which the flight crew is praised by their supervisors for safe behavior and reprised for unsafe behavior during the debriefings of the flight.
  • This would be the ideal planning group . This way, both main change agent groups are involved, AA managers and pilots . Furthermore, changing and incorporating national safety policy is no problem, when there is an FAA safety official on board.
  • Here is our plan for implementation: First four months: Change managers’, supervisors’, and pilots’ attitudes about the importance of safety through fiscal reports and initial workshops . Change airline flight procedures to directly address risk behaviors Following three months Managers will allocate resources to improving safety. We will develop themes for initial phases of a poster campaign. We will also work with technical advisors to develop guidelines for periodic, function-specific safety workshops. Following five months: Create and activate safety work groups for all functions and at all levels of the organization Petition FAA to change international flight regulations to directly address risk behaviors Plan incentive program (rewards/punishment) for safety. Hang posters at all airline facilities Final year of implementation phase: Implement planned incentive program Safety work groups will hold the planned safety workshops . Every two months, a new theme for the poster campaigns will be used, and safety workgroups will swap all old posters for new ones. Safety work groups will train all new personnel with new safety procedures and give them special safety workshops, as they are hired
  • First poster series Theme: Your decisions touch lives Emotional appeal against bad decision making One poster meant to arouse guilt, risk perception, and willingness to change Personal story of Joshua, a victim of AA 1420 Specifically mentions landing in bad weather Other poster designed to enhance self-efficacy and change-efficacy Personal quite by Captain Ortega, experienced pilot with positive safety attitude Specifically mentions diverting in bad weather

Transcript

  • 1. Safety Intervention: American Airlines Flight 1420 Sjir Uitdewilligen and Brian Pagán Maastricht University Faculty of Psychology
  • 2. Outline
    • What happened?
    • Who?
    • Why?
    • How to prevent recurrence
    • Evaluation
    • Questions
    AA Flight 1420
  • 3. What happened?
    • 11 July 1999
    • American Airlines 1420
    • Land in bad weather
    • Ran off runway and crashed
    • 10 passengers and captain dead
    • 134 injuries
    • (National Transportation Safety Board, 2001)
    AA Flight 1420
  • 4. Timeline
  • 5. Timeline AA Flight 1420
    • Pilots see “bowling alley” pattern in thunderstorm
    • Time pressure
    • Increased workload - divided attention
  • 6. Timeline AA Flight 1420
    • Pilots begin approach
    • Aircraft difficult to control
  • 7. Timeline AA Flight 1420
    • ATC informs of excessive windshear
    • Against AA regulations
    • Should have diverted to other airport
    Risk behavior
  • 8. Timeline AA Flight 1420
    • Pilots forget to arm spoilers
    • Part of landing checklist
    Risk behavior
  • 9. Timeline AA Flight 1420
    • Aircraft touches down and loses control on runway
    • Cannot brake
    • Spoilers not deployed
  • 10. Timeline AA Flight 1420 The aircraft races over the end of the runway and crashes
  • 11. Who?
    • At-risk population: customers, employees, and stakeholders of American Airlines (AA)
    • Problems: physical trauma, psychological trauma, financial losses
    • Quality of life issues: death, handicap, inability to work, reputation and legal costs, loss of market share
    AA Flight 1420
  • 12. Why?
    • Risk behavior: failing to discontinue approach
    • Key determinants:
      • Risk awareness (“cowboy attitude”)
      • Unsafe social norms
      • Reinforcement of unsafe behavior
    • Additional Determinants: Skills, knowledge, fatigue
    AA Flight 1420
  • 13. How to prevent it?
    • Safety behavior: discontinue unsafe approaches
    • Performance objectives:
      • Pilots demonstrate awareness of risk
      • Pilots show positive safety attitude
      • Develop safe social norms
      • Reinforce safe behavior
    • Key determinant: organizational safety climate
    AA Flight 1420
  • 14. Reason’s Swiss Cheese Model AA Flight 1420
  • 15. Learning/Change Objectives
    • Management: communicates dedication to safety
    • Management: apply company resources to safety issues
    • Supervisors: reinforce safe behavior
    • Pilots: express awareness of dangers related to landing under adverse weather conditions
    • Pilots: express positive attitude towards discontinuing approach
    AA Flight 1420
  • 16. How? AA Flight 1420 Determinant Method Strategy Organizational norms Pilot attitudes Safety Climate Change: - Unfreeze - Move - Refreeze
    • Convince management
    • Communicate organizations dedication to safety
    • Workshops
    • Reinforcement/ Socializing
    Risk awareness - Risk information - Critical incident technique - Fear arousal - Presentation - Guided discussion - Posters Reinforcement -Praising/Rewarding - Flight debriefing procedures
  • 17. (Ideal) Planning Group AA Flight 1420 Gerard Arpey CEO, American Airlines Nadine Richards FAA Safety Official Jeff Schrager Pilot & Supervisor American Airlines Melissa Ward Pilot, American Airlines Sjir Uitdewilligen Psychologist Brian Pagán Psychologist
  • 18. 24-month implementation plan AA Flight 1420 0 months 4 7 12 24 Executive Module Change managers’ attitudes with fiscal analysis and report Change supervisors’ and pilots’ attitudes with initial safety workshops Augment AA flight procedures about arming spoilers and discontinuing approach Executive Module Create potential for change: managers make plan to allocate resources for safety Executive Module Create main change agent by forming and activating safety work groups Petition FAA to implement similar augmentations to flight regulations Plan incentive program Executive Module Implement incentive system for safety     Support Module Develop initial poster themes, motifs, and design Work with technical advisors to develop workshop/seminar guidelines Operational Module Hold safety seminars/workshops   Operational Module Affect global AA attitude change by displaying posters   Operational Module Replace posters every two months Train new AA employees regarding AA safety procedures and how to be safe  
  • 19. Poster Examples
    • Theme: Your decisions touch lives
    AA Flight 1420
  • 20. Process evaluation AA Flight 1420 0 months 12 24 88
    • Diffusion/exposure
    • Surveys of:
    • - Poster viewing
    • Workgroup attendance
  • 21. Process evaluation AA Flight 1420 0 months 12 24 88
    • Implementation
    • Reports of:
    • Pilot debriefings
    • Workgroup reports
  • 22. Process evaluation AA Flight 1420 0 months 12 24 88 Adoption: Interviews with supervisors and pilots
  • 23. Process evaluation AA Flight 1420 0 months 12 24 88 Maintenance: Follow up interviews, Debriefing reports
  • 24. Effect evaluation AA Flight 1420 0 months 12 24 88
    • Determinants:
    • Scores on safety attitude questionnaires
    • Scores on perceived organizational norms questionnaires
  • 25. Effect evaluation AA Flight 1420 0 months 12 24 88
    • Unsafe acts:
    • Incident reporting system (ASAP)
    • Number of approaches under bad weather conditions
  • 26. Effect evaluation AA Flight 1420 0 months 12 24 88 Quality of life: Airplane accidents, injuries, deaths
  • 27. Effect evaluation AA Flight 1420 0 months 12 24 88
    • Organizational outcomes:
    • Questionnaires measuring company’s reputation
    • Market share
    • Profit
    • Stock price
  • 28. Questions?
    • National Transportation Safety Board. (2001). Runway Overrun During Landing, American Airlines Flight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999 (Aircraft Accident Report No. NTSB/AAR-01/02). Washington, DC.
    • Raes, A. M. L., & Solinger, O. N. (2005). Individuals in Organizations: About group processes and organizational change (Lecture). Maastricht: Maastricht University.
    • Shappell, S. A., & Wiegmann, D. A. (2000). The Human Factors Analysis and Classification System - HFCAS (No. DOT/FAA/AM-00/7). Washington, DC: Office of Aviation Medicine.
    AA Flight 1420