Term Paper: Improper Ergonomics Caused Usair 1493

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[. . .] She seemed not aware of the immediate occurrence as she at first thought that USAir plane was hit by bomb as it was landing, thereafter coming back to her sense that USAir hit the SkyWest plane, (Eric Malnic and Tracy Wood, 1991). However, she blame the rooftop lights within her line of sight that caused glare in the tower, preventing her to clearly identify small planes at the intersection; the same position SkyWest was waiting for communication. Prior to the incident she had confused the SkyWest plane to be another commuter airliner located on a taxiway just toward the end. Again, the difficulties were more when the ground radar at LAX was not functioning the very day of accident.

Investigation by NTSB unveil that the cockpit crew from USAir jet were not able to see the commuter plane since it blended in with other airport lights. It was noted by NTSB that LAX's procedures placed too many responsibility for runways on the local controllers, and this contributed to the local controller's loss of situational awareness. They as well identified that a supervisor had noted four deficiencies within local controller during previous performance review and no action was taken to repair them hence contributing to loss of situational awareness and aircraft misidentification since the deficiencies were found to be within the accident sequence.

The same NTSB investigation noted a failing system in not only ground traffic control facilities but also on air at LAX. For example radar systems on the ground worked irregularly and at the time of accident they were not functioning. Checking the spot where SkyWest 5569 was waiting on the runway, from the control tower; ground controllers' system within the tower meant to inform local controller of the flight progress strips failed to support the workload of the local controllers. Also, once an aircraft was on the runway it was not supposed to have turned on their entire external lights until it has rolled for takeoff, (Kilroy, C., n.d., 2013). However these issues at LAX became addressed after the accident.

During the accident, LAX air traffic controllers used every existing runway (South Complex runways 25L and 25R, North Complex runways 24L and 24R) for mixed landings and takeoffs. Among the recommendations of NTSB was that there should be separation of the runways where departures or landing to take place on an individual runway. As much as the recommendations were implemented another incident occurred on 19 Aug 2004, where a Boeing 747 landing on 24L passed just about 200 feet (61m) above a 737 which was holding on the same runway. This made LAX to effect some changes again where currently it uses the inboard runways (24L and 25R) for departures and the outboard runways (24R and 25L) for landing.

The Federal Aviation Administration (FAA) had issued a ruling prior to the accident requiring airlines to upgrade the flammability standards of material which are on board, but had not been considered because manufacturing of the USAir plane took place prior to the effective date of the changes. Its modernization was to take place on the following year which by 2009 there was no any aircraft operating in the United States which had not comply to the request.

Aircraft Emergency Exits

After the study of Type III exits by FAA and the way size had impacted the evacuation before LAX accident, and considering the USA1493 passengers who died following smoke inhalation as they waited to exit, facilitated the need to change the rules to 14 CFR 25.813. On April 9, 1991 the notice was issued for public rule-making (NPRM) to improve access of Type III exits which was done and by June 1992 the final rule was affected.

Airport Surface Detection

Apart from changes in regulation and policy, technology at LAX has also improved the radar systems used in controlling air traffic ground operations. During the accident the Airport Surface Detection Equipment (ASDE) radar system in use was meant to monitor ground traffic activity, particularly at night. When air traffic personnel monitor airplane takeoffs and landing visually adds additional protection in reducing the risks of runway incursion. For example, when an aircraft taxi into position to hold within the runway intersections and the tower controller is not able to see them poses a threat to the safe airport operations (Malnic, Eric & Connell, Rich., 1991). At the moment of accident the local controller cleared an aircraft to depart from the middle of runway in the night but she did not have direct visual monitoring capability,

Due to this, FAA Air Traffic Services came up with a procedural changes just after the accident via a general notice (GENOT), indicating that controllers were not allowed to authorize aircraft to taxi into position and hold at an intersection between sunset and sunrise. Aircrafts were also burred from taxi into position and hold at an intersection whenever the tower was not able to see them. Later these procedures were incorporated into FAA Order 7110.65.

When emergency briefings are conducted for passengers seated within the exit rows, it improves the ability to effectively evacuate passengers in case of an accident. Taking this into consideration, FAA came up with new operational rules requiring operators to screen and brief passengers seated within the exit rows. Operators are required by this rule to develop and implement plans for this screening and briefing. Even though USAir had already developed and implement their plan; they have made more improvement to the plan to facilitate more evacuation capability.

After the investigation for the accident found that, except for seat covering and carpeting, the entire cabin furnishing burned. The consideration was that if the cabin furnishings had not allowed fire to spread on it fast with much smoke throughout the cabin might have given passengers more time for evacuation increasing number of survivors. Therefore, it was important to enhance cabin materials flammability standards. The aircrafts had to effect theses changes in the interiors of transport category airplanes using the latest flammability standards and retrofit program for the in-service fleet.

Some of the changes that needed to be undertaken were operating procedures within control towers which provide redundancy to lapse in human performance like always having flight progress strips when coordinating aircraft movement between controller positions. Usually human senses such as hearing and sight together with the memory tend to be the main means by which traffic is controlled and managed by air traffic control tower personnel. They are supported by processes like the use of flight progress strips but when there is only one way to be used, usual distraction might bring a lapse resulting to poor judgment. For example, LAX facility for ground control operations did not require flight progress strip; therefore when the local controller identified that a strip was missing for a specific aircraft, this distraction was never accounted for by a redundant system. The implemented safety system in turn allow for occasional human lapses.

In most occasion supervisors carry out over-shoulder evaluations of controllers in making sure that the needed levels of controller as well as facility performance are maintained. Once any deficiency has been identified then corrective action need to be identified and implemented so that adequate level of safety is maintained. When supervisor carried out evaluation of the LC2 controller, six weeks before the accident discovering five performance deficiencies but no action was taken; and the investigation in LAX on the this accident showed that performance of the controller was related to the existing facility procedures which failed to allow for lapses in judgment as well as decision making; did away with human performance redundancies, (Chris Kilroy, 2013). As a corrective measure LAX went ahead and modified the local and ATC-wide procedures to make sure that redundancies for human performance were in place.

Due to these improper ergonomics Baum Hedlund firm sued the airline and the FAA for negligence arguing that air traffic controller cleared the USAir jet to land and at the same time SkyWest flight had been cleared to taxi on the same runway. In addition the firm charged the FAA with negligence following failure to provide adequate policy direction and supervision to its air traffic control facility manager.


Indeed improper ergonomics was the major cause of the accident, in addition to the inadequate facilities that were in LAX. The captains from the USAir Flight 1493 and SkyWest had little they could do when the accident was taking place because they followed the required instructions from the ground controllers and they followed as were instructed. A little distraction interferes with the level of concentration on the part of the controllers and hence commonly causes accidents that could be avoided. Therefore with the help of new technology even when controllers are distracted there is likelihood for recovery since there are support facilities which assist them to identify if the instruction they are giving is the correct one at a given… [END OF PREVIEW]

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