Avianca Flight 52: a Case Study on Human Error Essay

810 Words Apr 14th, 2013 4 Pages
Relevant facts/ Background

Avianca Flight 52 touched the ground for a final time on January 25 1990, 16 miles from JFK airport in Cove Neck, Long Island, N.Y., completely out of fuel. The Boeing 707-321B was carrying 158 people coming from Medellin, Columbia, in which 85 people survived. The crash of Avianca Flight 52 was the largest rescue operation in New York prior to 9/11.
There was a severe blizzard on the north-east coast of the U.S. causing bad weather with a low pressure system and wind shear. JFK airport authorities had been told to keep a higher landing rate than safe at 33 planes attempting to land per hour, on one runway - the typical rate being 52 in good weather, with all runways open. The airport was experiencing a rate
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Causes and factors

During the chase to point the blame on someone, Avianca stated to investigators that the phraseology used by their pilots was correct as per their training -whether it matched the standard English phraseology used by IATA countries or not they were only following what they thought to be proper protocol.
Investigation by the NTSB found many holes in the events leading up to the crash, due to both active and latent failures by the crew, ATCs, and airport management. The leading causes can be attributed to airport mismanagement, inconsistent training for pilots that should have English proficiency, and overall poor communication between ATCs and the flight crew. Repetitive flaws in a system run by human beings shows a clear link in the lack of Risk Management, causing communication gaps referred to as holes in the Swiss Cheese model for human error.
CRM stipulates training crew in assertiveness, inter-personal communication, leadership and decision-making, to name a few key attributes these pilots were in need of addressing prior to the incident. There was no problem of experience as both the pilot and co-pilot had flown that route before, and the pilot had 27 years of experience flying for Avianca. The implementation of Crew Resource Management techniques in the previous years

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