Introduction
Aviation accident and incident rates have reached unprecedented levels despite advancements in aeronautical solutions. The National Transportation Safety Board (NTSB) reports at least one commercial aviation accident annually revealing the challenge for civil aviation safety organizations is improving the safety of the industry. While factors like weather, terrain, and lighting contribute to these accidents, human factors are more complex, making it challenging to apply a universally accepted investigative methodology (Li, 2019). Although the percentage varies, researchers concur that more than half of aviation accidents are attributed, in part, to human error (Cline, 2018; Kilic, 2019; Park & Jeon, 2020). Piper PA32RT accident that occurred in 2018 at St Ignace, Michigan, is selected as the case study to comprehend the impact of human error on aviation accidents (Aviation investigation final report, n.d.). The rapid growth in aviation industries increases exposure to risks and offering perspective on the contributing human factors would bring significant importance to improving airline service quality and efficiency.
Piper PA32RT
On August 31, 2018, a Piper PA32RT-300T, N500MJ, was involved in a fatal accident in Michigan. According to the NTSB, the airplane was operated under Title 14 Code of Federal Regulations Part 91 personal flight. Following the reports given by Mackinac County Airport’s manager, the pilot fueled the airplane with plans of returning to Mackinac Island Airport (MCD) to pick up five passengers (Aviation investigation final report, n.d.). Everything seemed intact during takeoff, but 5 minutes later, a 911 dispatch was sent. Two witnesses reported that they observed N500MJ take off from the airport and was flying almost 100 to 200 feet above the water surface of the water when it banked to the right, losing sight of the airplane (Aviation investigation final report, n.d.). After a few seconds, the witnesses heard an explosive sound or a crash into the water. The pilot sent no distress call and there no radar information was retrieved for the flight.
According to the airport manager and the statement given by the first responders, it was a very dark night, thus, no distinguishable horizon. Further, an examination of the airplane revealed no preimpact anomalies on the engine and airframe that would potentially prevent normal operation (Aviation investigation final report, n.d.). Additionally, evidence was consistent with a high-speed, nose-low impact with the water. According to NTSB reports, the pilot should have made a right turn after takeoff in the direction of the intended destination airport, which is consistent with the gathered evidence (Aviation investigation final report, n.d.). While the reason for the water impact could not be determined, there were inadequate visual cues on the overwater departure during dark conditions that would assure a significant climb rate during the departure since the pilot would be vulnerable to illusions if he failed to use flight instruments during the takeoff and initial climb.
Causal and Contributing Factors Surrounding the Accident
The NTSB determined the probable cause of the N500MJ accident as a failure from the pilot’s end in maintaining sufficient altitude upon takeoff in dark night conditions that led to a collision with the water. The NTSB serves as an independent federal agency through the Independent Safety Board Act of 1974 as mandated by Congress to determine probable cause, investigate transportation accidents and safety issues, evaluate the effectiveness of agencies within the transportation industry, and issue safety recommendations (Anderson & Scholz, 2021; Aviation investigation final report, n.d.). The Independent Safety Board Act posits on evidence admission or use of NTSB’s report related to an accident or incident in a civil action for any damages (Aviation investigation final report, n.d.). Principally, the NTSB makes public its decision through special investigation reports, safety studies, statistical reviews, safety recommendations, and accident reports.
Following NTSB’s report, the aircraft altitude was not maintained, there were personnel issues at the aircraft control, and dark night conditions adversely affected operations. The airplane wreckage was located by divers from the Michigan State Police (MSP) 44 feet of water, approximately 1 mile from runway 7 (Aviation investigation final report, n.d.). Examination of the whole airplane revealed the severity of the airframe’s damage and consistent deformations with a slightly right-wing-down and high-speed impact with the water. Impact marks and bending signatures on the pitch change stops and propeller blades were consistent with subsequent impact (Aviation investigation final report, n.d.). Additionally, the NTSB confirmed flight control continuity from the cockpit to all flight control surfaces. The propeller, engine, and airframe examination showed no preimpact anomalies precluding normal airplane operation.
An on-scene investigation was further conducted to draw on more findings. While examining the wreckage examination, MSP technicians compared a possible bird strike with a swab wreckage of bird residue but found no residue within the wreckage’s interior or exterior. However, a geese nesting was observed adjacent to runaway 7 during daylight hours (Aviation investigation final report, n.d.). The airport manager asserted that the geese are usually bedded down by nightfall. Further on-scene investigation on the area around the departure end of runway 7 revealed no deceased bird remnants. Given the inadequacy of concrete findings, the Mackinac County Medical Examiner’s Office performed an autopsy of the pilot. The natural cause of death was ruled out and instead, listed as blunt force injuries (Aviation investigation final report, n.d.). Toxicological testing was further performed by the Federal Aviation Administration Forensic Sciences Laboratory. The results turned negative for any form of drug use, but small ethanol amounts were detected, which was likely produced post-mortem given that the body was recovered some days after the accident.
Impact of Human Factors
A number of human factors contribute to aviation accidents and incidents, from a human performance to team dynamics. According to Miller’s Law, the human cerebrum can manage at least five immaterial articles within the functioning memory (Yablonski, 2020). Thus, errors are likely to occur in situations that demand high responsibility like take-off and landing. Kelly and Efthymiou (2019) implied that the fundamental idea lies in the limit and capacity of people in complex and specific circumstances. Contingent to a given circumstance, the human variable can be classified into states of being, physiological factors, mental attributes, psychosocial viewpoints, equipment contemplations, and environmental. For example, mental factors can include inspiration, insights, risk-taking, carelessness, and memory while peer pressure and self-worry fall under psychosocial viewpoints. In this view, the human factor covers the relationship between people and their environment, procedures, and equipment.
In the case of Piper PA32RT-300T, N500MJ, the primary underlying human factor was human error. The loss of visual reference and control in flight during the initial climb defined the occurrence of the accident. Most flight setbacks result from issues arising from human variables and other single components. Air traffic regulators, the flight group, the pilot, and support representatives generally fall within instances of human factors (Gawron, 2019; Li, 2019; Noort et al., 2021; Park & Jeon, 2020). Human error often results from a lack of situational mindfulness. Thus, it can be gathered that the N500MJ pilot or air traffic regulators were responsible for the accident. Pilots make several decisions while flying a plane, and are prone to commit mistakes.
As evident in the N500M crash, errors can be caused by properly trained and healthy individuals. Toxicology results revealed that the pilot was clean of any drug use, thus, no causal effect of the error. The eligibility for all aviation activities is dependent on the fulfillment of psychological, sensory, and overall health prerequisites. Studies revealed that aviation accidents and incidents have similar characteristics and are often linked to a lack of guidance, inefficient communication, and poor decision-making (Kilic, 2019; Kilic & Gümüş, 2020; Yablonski, 2020). In the case of N500M crash, the pilot lost visual reference and control in flight (Aviation investigation final report, n.d.). For these reasons, efforts should be focused on improving pilot and crew performance. Among the key concepts regarding aviation operation and safety include threat and error management and resource management that ensure efficient use of resources like information and hardware to improve performance and standardize activity (Denney et al., 2019; Majid et al., 2022). Aviation safety measures should seek to optimize seamless and overall efficiency in the collaboration between human and general environment constituents of the aviation system.
Conclusion
Despite the rapid integration of innovative solutions in the aviation industry, accidents continue to occur. The findings presented by the NTSB on N500MJ crush can be used by pilot training departments to equip pilots with the right skills and competence as per international standards to minimize the likelihood of human errors. Additionally, enforcing safety constraints by examining the interrelationship between causal factors is key. Subsequently, this will guide a more generic and comprehensive analysis of aviation accidents and incidents. Future research should focus on violations made by pilots that increase the likelihood of errors. Nonetheless, the NTSB provides a sufficient avenue for future research on aviation accidents and incidents.
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