Discussion: Asiana Flight 214 Analysis Methods For This Modu

73 Discussion Asiana Flight 214 Analysis Methods For This Modul

Based on the report you compiled for your boss, describe the Asiana Flight 214 malfunction you analyzed and which method you selected to complete your assessment. Include why you decided this was the most applicable method for the malfunction and your primary recommendation for correcting this malfunction.

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The crash of Asiana Flight 214 on July 6, 2013, marked a significant incident in aviation history, primarily concerning automation failure during the final approach. Conducting a thorough analysis of the malfunction requires selecting an appropriate systems safety technique. For this case, Fault Tree Analysis (FTA) was the most suitable method due to its systematic approach in identifying root causes of complex failures within the intricate networks of aircraft systems.

Fault Tree Analysis is a top-down, deductive failure analysis method that visualizes the pathways leading to a specific undesirable event—in this case, the crash of Flight 214. It enables investigators to break down the event into primary causes, including equipment failure, human error, and procedural inconsistencies. I chose FTA because the incident was heavily influenced by automation system mismanagement and pilot interaction with automated systems. The method's graphical nature helps elucidate the interrelationship between various causes, making it easier to pinpoint where intervention can prevent future failures.

The primary malfunction identified through FTA was the pilots' misinterpretation and over-reliance on automation systems, particularly the Autopilot and Autothrottle, during the final approach. This over-reliance led to mismanagement of the aircraft's speed and altitude. The system malfunction stemmed from a combination of factors, including the automation system's design, pilot training deficiencies, and the cockpit's interface that contributed to inadequate situational awareness.

Applying the Fault Tree, it became evident that the automation system's design ambiguity played a critical role. The pilots failed to recognize the automation system's limits, similar to how automation surprises occur—prompting the need for enhanced human-machine interface design. This method allowed a comprehensive understanding of how errors propagated through various system layers, ultimately culminating in the crash.

Based on this analysis, the primary recommendation to prevent a recurrence of this malfunction is to improve pilot training focusing on automation management. Pilots must be equipped with skills to recognize automation failures promptly and switch from automated to manual control effectively. Additionally, modifications to automation system interfaces should be considered, making their status more transparent and reducing the likelihood of misinterpretation.

Furthermore, implementing procedural checklists that emphasize automation awareness during critical phases of flight, especially during approach and landing, is essential. Airlines should also enforce recurrent simulation training that includes scenarios of automation failure, ensuring pilots can respond appropriately under stress. These measures, combined with system redesigns, can significantly mitigate the risks associated with automation-related failures, enhancing overall flight safety.

References

• Reason, J. (1997). Managing the Risks of Organizational Accidents. Ashgate Publishing.
• Leveson, N. (2011). Engineering a Safer World: Systems Thinking Applied to Safety. MIT Press.
• O’Hara, K., et al. (2015). Human Factors in Automation. CRC Press.
• Federal Aviation Administration (FAA). (2014). Safety Guidelines for Automation Use in Airline Operations.
• Wiener, E. L., & Mann, R. E. (2016). Human Factors in the Design of Automation and Control. CRC Press.
• Ericson, C. A. (2012). Fault Tree Analysis: A Systematic Approach for Safety Diagnosis. Wiley.
• National Transportation Safety Board (NTSB). (2014). Runway Overrun of Asiana Airlines Flight 214. NTSB Report.
• ICAO. (2015). Safety Management Manual (SMM). International Civil Aviation Organization.
• U.S. Department of Transportation. (2014). Automation Dependence and Pilot Performance. DOT Reports.
• Helmreich, R. L., & Foushee, H. C. (2008). Why Crew Resource Management? An Introduction. Airport & Airline Management Journal.