PAS 2018 – Thinking and feeling inside the cockpit: Aviation Accident Paradigm 1

West Caribbean Airways 708: In flight YH708 of West Caribbean Airways on August 16, 2005 the crew of an MD-82 failed to take appropriate action to correct the stall of the aircraft, resulting in loss of control and 160 fatalities (all). From the official accident report, Cockpit Voice Recorder (CVR), judicial report and related sources, a number of psychological/emotional and cognitive contributing factors attributed to the crew can be observed. More specifically, the psychological state of the captain at the time of the accident could be described by psycho/physical fatigue, anxiety, low self-esteem, stress and frustration, whereas the cockpit crew resources at the time of the accident are characterized by lack of effective communication and crew dynamics. Moreover, the generation gap between the captain and the co-pilot (40 and 21 years old respectively), in conjunction with their behavioural profile resulted in submissiveness/obedience and passiveness by the co-pilot without the verbalization or manifestation of any kind of emotion in a very stressful situation. A number of operational factors seem to have contributed to the psychological state of the crew with the airline having a number of financial problems affecting the operations by creating a climate of uncertainty and stress. Prior to take off, the aircraft was long delayed owing to payment of fuel resulting also in the deterioration of the alertness and fatigue of the crew. The captain was unpaid for 6 months and was obliged to work at a family owned bar/restaurant to gain some income, while infringements in crew rest hours, flying time and leave periods, failure to provide crew with regulation training and inconsistencies in aircraft records and flight documents could also be noted. The cognitive variables attributed to the accident are: training, attention, planning, checklists, alertness, situational awareness, decision making. There is a high probability that the respective psychological variables had a detrimental effect in the neurocognitive errors resulting in the loss of control and crash of the aircraft.

The official accident report concludes that (translated from spanish):

Given the aerodynamic and performance conditions, the aircraft was taken to a critical state, which led to this loss of lift.

Consequently, the cockpit resource management (CRM) and decision-making during the development of emergency were misguided. This was caused by the following:

  1. a) Awareness of environment (or situational awareness) insufficient or improper that allowed the cockpit crew, not being full and timely aware of what was happening regarding the performance and behavior of the aircraft.

  2. b) Lack of effective communication between the cockpit crew that limited, within the decision making process, the possibility to timely choose appropriate alternatives and options and to set respective priorities in the actions taken at the time when it was established that there was a critical or emergency situation (stall condition at high altitude).

It is found that the cause of the accident is determined by the absence of appropriate action to correct the stall of the aircraft, and also in the emergency up to the impact with the ground, at an inappropriate hierarchy of priorities in implementing the procedures.

Subsequently, the operations were conducted outside of the limits and parameters set by the manufacturer’s manual performance, together with an inadequate flight planning by failing to consider meteorological aspects, in addition a misinterpretation and late of the energy state of the aircraft by the flight crew. Therefore, the evidence shows the classification of “Human Factor” as a cause of this accident.

Press here for the final Official Accident Report

west carribean MD82West Carribean MD82West Caribbean YH map

NTSB simulation of the observed thrust and parameters  versus the minimum safety requirements:
NTSB simulation

 

 

 

 

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