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Safety Intervention: American Airlines Flight 1420


Published on

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

Published in: Business
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Safety Intervention: American Airlines Flight 1420

  1. 1. Safety Intervention: American Airlines Flight 1420 Sjir Uitdewilligen and Brian Pagán Maastricht University Faculty of Psychology
  2. 2. Outline <ul><li>What happened? </li></ul><ul><li>Who? </li></ul><ul><li>Why? </li></ul><ul><li>How to prevent recurrence </li></ul><ul><li>Evaluation </li></ul><ul><li>Questions </li></ul>AA Flight 1420
  3. 3. What happened? <ul><li>11 July 1999 </li></ul><ul><li>American Airlines 1420 </li></ul><ul><li>Land in bad weather </li></ul><ul><li>Ran off runway and crashed </li></ul><ul><li>10 passengers and captain dead </li></ul><ul><li>134 injuries </li></ul><ul><li>(National Transportation Safety Board, 2001) </li></ul>AA Flight 1420
  4. 4. Timeline
  5. 5. Timeline AA Flight 1420 <ul><li>Pilots see “bowling alley” pattern in thunderstorm </li></ul><ul><li>Time pressure </li></ul><ul><li>Increased workload - divided attention </li></ul>
  6. 6. Timeline AA Flight 1420 <ul><li>Pilots begin approach </li></ul><ul><li>Aircraft difficult to control </li></ul>
  7. 7. Timeline AA Flight 1420 <ul><li>ATC informs of excessive windshear </li></ul><ul><li>Against AA regulations </li></ul><ul><li>Should have diverted to other airport </li></ul>Risk behavior
  8. 8. Timeline AA Flight 1420 <ul><li>Pilots forget to arm spoilers </li></ul><ul><li>Part of landing checklist </li></ul>Risk behavior
  9. 9. Timeline AA Flight 1420 <ul><li>Aircraft touches down and loses control on runway </li></ul><ul><li>Cannot brake </li></ul><ul><li>Spoilers not deployed </li></ul>
  10. 10. Timeline AA Flight 1420 The aircraft races over the end of the runway and crashes
  11. 11. Who? <ul><li>At-risk population: customers, employees, and stakeholders of American Airlines (AA) </li></ul><ul><li>Problems: physical trauma, psychological trauma, financial losses </li></ul><ul><li>Quality of life issues: death, handicap, inability to work, reputation and legal costs, loss of market share </li></ul>AA Flight 1420
  12. 12. Why? <ul><li>Risk behavior: failing to discontinue approach </li></ul><ul><li>Key determinants: </li></ul><ul><ul><li>Risk awareness (“cowboy attitude”) </li></ul></ul><ul><ul><li>Unsafe social norms </li></ul></ul><ul><ul><li>Reinforcement of unsafe behavior </li></ul></ul><ul><li>Additional Determinants: Skills, knowledge, fatigue </li></ul>AA Flight 1420
  13. 13. How to prevent it? <ul><li>Safety behavior: discontinue unsafe approaches </li></ul><ul><li>Performance objectives: </li></ul><ul><ul><li>Pilots demonstrate awareness of risk </li></ul></ul><ul><ul><li>Pilots show positive safety attitude </li></ul></ul><ul><ul><li>Develop safe social norms </li></ul></ul><ul><ul><li>Reinforce safe behavior </li></ul></ul><ul><li>Key determinant: organizational safety climate </li></ul>AA Flight 1420
  14. 14. Reason’s Swiss Cheese Model AA Flight 1420
  15. 15. Learning/Change Objectives <ul><li>Management: communicates dedication to safety </li></ul><ul><li>Management: apply company resources to safety issues </li></ul><ul><li>Supervisors: reinforce safe behavior </li></ul><ul><li>Pilots: express awareness of dangers related to landing under adverse weather conditions </li></ul><ul><li>Pilots: express positive attitude towards discontinuing approach </li></ul>AA Flight 1420
  16. 16. How? AA Flight 1420 Determinant Method Strategy Organizational norms Pilot attitudes Safety Climate Change: - Unfreeze - Move - Refreeze <ul><li>Convince management </li></ul><ul><li>Communicate organizations dedication to safety </li></ul><ul><li>Workshops </li></ul><ul><li>Reinforcement/ Socializing </li></ul>Risk awareness - Risk information - Critical incident technique - Fear arousal - Presentation - Guided discussion - Posters Reinforcement -Praising/Rewarding - Flight debriefing procedures
  17. 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. 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. 19. Poster Examples <ul><li>Theme: Your decisions touch lives </li></ul>AA Flight 1420
  20. 20. Process evaluation AA Flight 1420 0 months 12 24 88 <ul><li>Diffusion/exposure </li></ul><ul><li>Surveys of: </li></ul><ul><li>- Poster viewing </li></ul><ul><li>Workgroup attendance </li></ul>
  21. 21. Process evaluation AA Flight 1420 0 months 12 24 88 <ul><li>Implementation </li></ul><ul><li>Reports of: </li></ul><ul><li>Pilot debriefings </li></ul><ul><li>Workgroup reports </li></ul>
  22. 22. Process evaluation AA Flight 1420 0 months 12 24 88 Adoption: Interviews with supervisors and pilots
  23. 23. Process evaluation AA Flight 1420 0 months 12 24 88 Maintenance: Follow up interviews, Debriefing reports
  24. 24. Effect evaluation AA Flight 1420 0 months 12 24 88 <ul><li>Determinants: </li></ul><ul><li>Scores on safety attitude questionnaires </li></ul><ul><li>Scores on perceived organizational norms questionnaires </li></ul>
  25. 25. Effect evaluation AA Flight 1420 0 months 12 24 88 <ul><li>Unsafe acts: </li></ul><ul><li>Incident reporting system (ASAP) </li></ul><ul><li>Number of approaches under bad weather conditions </li></ul>
  26. 26. Effect evaluation AA Flight 1420 0 months 12 24 88 Quality of life: Airplane accidents, injuries, deaths
  27. 27. Effect evaluation AA Flight 1420 0 months 12 24 88 <ul><li>Organizational outcomes: </li></ul><ul><li>Questionnaires measuring company’s reputation </li></ul><ul><li>Market share </li></ul><ul><li>Profit </li></ul><ul><li>Stock price </li></ul>
  28. 28. Questions? <ul><li>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. </li></ul><ul><li>Raes, A. M. L., & Solinger, O. N. (2005). Individuals in Organizations: About group processes and organizational change (Lecture). Maastricht: Maastricht University. </li></ul><ul><li>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. </li></ul>AA Flight 1420