United Express Flight 6291 Crash: Human Factors Review
This article discusses Atlantic Coast Airlines / United Express Flight 6291 and a few of the human factors that aided in the crash.
On the night of January 7, 1994, Atlantic Coast Airlines flight 6291 (doing business as United Express flight 6291) crashed 1.2 miles from runway 28L at Port Columbus International Airport, Columbus, Ohio (which now goes by John Glenn Columbus International Airport). The Jetstream 4101 was en route from Washington Dulles International Airport to Columbus, Ohio. The flight had been cleared for an instrument landing and ended up crashing into a commercial storage warehouse. The pilot, copilot, flight attendant, and three passengers were fatally injured with the remaining three passengers surviving with minor or no injuries.
Looking deeper into the accident, there seemed to have been multiple causes for the crash. Some of the major causes included a poorly planned and executed approach and also the flight crew’s inexperience in a “glass cockpit”, aircraft type and seat position (NTSB).
Atlantic Coast Airlines provided information on the captain and first officer of flight 6291 to further analyze the situation that had been leading up to the crash. The accident report conducted by the National Transportation Safety Board gave some history on the captain of the flight. The captain of flight 6291 was 35 years old with 3,660.4 hours of flight experience with 1,373.4 hours of experience being in turboprop aircraft. At the beginning of his aviation career, he began Atlantic Coast Airlines training but failed his initial second-in-command simulation check ride in 1992. It was reported he had issues with instrument approaches and holding procedures. Ultimately, he eventually ended up completing training and took on second-in-command duties that same year. Previous instructors of the captain of flight 6291 described him as an average student. He failed his first Jetstream-4101 type rating (the accident aircraft) also with difficulties in instrument approaches, emergency procedures, and judgment.
Looking at the last 90 days of the captains' flights, it was reported that he had completed 24 approaches to 10 airports with only one of them being flown in frozen precipitation. It was also noted that this was his first flight into CMH. That being said, the night of the accident was his first time in 90 days landing at this airport on top of landing in the dark with instrument meteorological conditions.
The first officer has a much different profile from that of the captain. He was 29 years old with a total of 2,432.9 flight hours (110 hours being in a turboprop and 32.1 being in a Jetstream-4101). He had previously worked with a different airline where past instructors described him as being an above-average student, even with having so little experience. He had passed both his oral exams and second-in-command flight check-in one try.
The day flight 6291 crashed, the flight crew was well trained, the aircraft was properly certified, and the crew had been correctly briefed of the inclement weather in Ohio. This accident was the cause of human factors, poor judgment, and human error.
Human errors and human factors are mistakes that can cost lives, especially in the aviation industry. Human error and factors are often mistaken for each other, although they have very different implications. Human error is to perform a human mistake, such as misinterpreting information or forgetting to complete a step in a procedure. These simple mistakes can cause huge problems down the road. Human errors are so valid that they make up 70–80% of aviation accidents (Campbell).
Human factors, on the other hand, are the possibility of problems based solely on the fact that a human is present in the operation, such as problems in communication, how well a person was trained for a specific task and how much your body can take in a certain environment. Since there is no simple way to prevent human factors, one must use precautions such as common aviation language in order to limit the amount of confusing and unnecessary communication, having better methods of training in order to ensure people are properly qualified for the job and tools that aid your body to function normally in high altitudes as they do on the surface of the earth.
There are plenty of human factors that can be applied more specifically towards flight 6291. An example of a human factor that had an influence on the crash, according to the NTSB’s findings, is how the pilots failed to monitor the airspeed during the approach which leads to a dangerous and unrecovered stall. This could have been due to the stress overload the pilots were experiencing from the chaos of the altitude alarms and the distraction from the stick shaker. The textbook states that each individual has a personal stress limit, and once that limit is exceeded, stress overload occurs. Distractions coming from the cockpit along with the inclement weather conditions in the area could have lead to coning of attention, which is when “increasing stress, the attention scan closes into a smaller field of awareness”. The pilots must have started focusing on just a few things rather than the important things that would have kept the airplane safely in the air.
Another human factor that could be linked with the accident is the inexperience of the flight crew in a “glass cockpit” automated aircraft, aircraft type and seat position. This is a direct example of a human factor in which lack of experience was a leading cause of the deadly accident. A way to combat this lack of inexperience is by having a higher quality training experience. In the NTSB accident report, it is reported that the airline and the FAA were at fault for not requiring “adequate approach criteria”. If the airline and FAA had required such criteria and offered a way to teach it, then maybe the pilots would have been better prepared to handle such an approach.
In order for that to happen though, it is vital to understand this relationship man has with flying. This interface, called the SHEL model, helps us better understand the relationship between human factors and the environment around us. The acronym stands for software, hardware, environment, and liveware, where software is the procedures and rules which have to be followed, hardware is the aircraft, its systems, and equipment, environment is the man or machine system that operates, and liveware is the crew who operate the aircraft and interact with other personnel.
Liveware sits in the middle of the SHEL model because it is what controls and interacts with the rest of the functions. An example of liveware interacting with hardware would be the pilot controlling the airspeed or direction of the plane: The pilot being the liveware and the controls of the plane being the hardware. An example of how liveware interacts with the environment would be how the weather affects pilots during or before their flight. Cold weather can be troublesome since ice conditions pose a threat to the control of an aircraft. An example of liveware interacting with software would include any procedures, checklists, manuals or symbology required to fly the plane. This would be the pilot’s checklists and procedures that are set in place to ensure a safe flight. The last component to the SHEL model would be liveware interacting with other liveware. This is the interaction between the flight crew and anyone else who effects the flight in any way. This consists of anyone from inside the aircraft, to the communication with ATC, engineers, and staff. The safety of every flight involves all those participating in the aviation industry. That is why understanding the relationships between the systems, environment and the people who work with them is very important.
The study of human factors and how they relate to accidents is very important in knowing how to better yourself when flying. In aviation, it is not only the pilot’s job to be well trained and knowledgeable about what they are doing but also those who contribute in a flight such as air traffic controllers or engineers. Everyone within the aviation industry must be conscious of what they are doing to ensure the safety of the passengers and everyone else onboard the aircraft.
United Express / Atlantic Coast Airlines flight 6291 serves as a reminder of how important human factors are. The crews' unfavorable responses quickly lead to stress and anxiety in the cockpit, which lead to a decrease in performance.
Since human factors are hard to have under control at all times, it is important to be aware of how you as an individual react to certain situations. In the case of flight 6291, the pilots did not handle the stress of the approach in the inclement weather well, which ultimately lead to their focus being on other things; this led to the fatal stall of the engine. The negative response to the stall may have come at a point where the pilots had become overstressed and were not thinking as clearly as they would have been. If the pilots would have had a better understanding of how they as individuals react to situations, their chances of getting out of the stall under those stressful conditions may have been higher.
References
Campbell, R.D., & Bagshaw, M. (2002). Human Performance and Limitations in Aviation. (3rd ed.). Oxford: Blackwell Science.
Palcho, Timothy. (2017). Physiology and Human Factors of Flight [Powerpoint Presentation]. Kent, OH.
NTSB. (1994). Stall and Loss of Control on Final Approach Atlantic Coast Airlines / United Express Flight 6291. NTSB. Retrieved from https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR9407.aspx
Federal Aviation Administration. (2015 June 11). Regulations and Policies. Retrieved from https://www.faa.gov/regulations_policies/
About Natalia
Natalia Welton-Torres grew up in Columbus, Ohio and studied Aviation Management at Kent State University. Natalia is interested in all things aviation-related, animal-related, and can always be found with a coffee in hand.
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