The crash of Delta Air Lines Flight 191

Introduction 

  • Aviation  accident  indicate  that  majority  of  aircrafts  mishaps  are  due  to  errors in  judgment. It is  important  for  pilots  and  aircraft controllers  to  develop  techniques and  material  that will  improve  the  decisions making  of the  pilots.  Training  programs  using  prototype  versions  have  demonstrated  substantial  reductions of  pilot  errors  rate in the recent   past  decades.

The delta airline crash of August 2, 1985

Delta Airlines Flight 191 served from Fort-Lauderdale-Hollywood Airport.  The  plain  was  bound  for  Los  Angeles  International  Airport  in  California by  way  of  Dallas-Fort Worth International  Airport.  Delta  Air  lines  Flight  crashed  in the  afternoon  of  August 2,  1985 while  on  routine  approach  to  Dallas-Fort Worth  International  airport.  126  out  of  152  passengers were  killed including  8  crew  members out  of  11 on  board.  One person on the ground was killed.  This   is  one of the  few  commercial  air  crash  in   which  microburst  which is  a meteorological  phenomena  induced  by wind  shear  was  the  direct  factor  of  contribution  to this  air crash.The aircraft was N726DA, a Lockheed L-1011-385-1 Tri-Star, which was one of Delta fleet.


This  aircraft  at  the   time of  the  crash was being  piloted  by  Captain  Edward Conner,  Second Officer Nick  Nassick  and First officer  Rudolph  Price(Magnuson,  2005). There was thunderstorm as the aircraft flew over Louisiana which forms directly in its path.  Heading  over the planned  destination route,  the  aircraft  began its  descending  procedures  on  the  Louisiana  skies .  Captain  Connors  had recognized  the  thunderstorm that  was forming  and  decided  to  change  the  plane  to avoid  the  turbulent weather. At Dallas -Fort Worth International airport there was an isolated thunderstorm with a generally poor weather.  Noticing this, the copilot and the captain preceded through it resulting to the aircraft being caught up in a microburst.At 800 feet above the ground, the airspeed increased without any intervention from the crew.  The  first  officer  had motioned  to captain  Connors  that  he  had seen  lightening in one of the clouds  ahead of  them.


The  aircraft  was supposed  to land  at  276 km/h  speed   but  instead  the  airspeed  increased  to 320 km/h .  This  speed  was due  to wind shear   which  Prince  tried  to stabilize  the  aircraft  speed  but failed. Suddenly  the speed  reduced  from  320  to 246  km/h  then the  speed  further  dropped  to 220  km/ h .  Price pushed the throttles forward to give the aircraft a temporary lift.  The aircraft  also  experienced a  downdraft  more  than  30 feet  per  second  in addition  to sudden  tail wind. This downdraft reversed itself severally before the final crush of the airplane.a  lengthy  investigation the  National  Transports  Safety  Board  deleted  that  then accident  was  caused by a combination  of  extreme  weather  phenomena  associated  with  microburst  wind shear and  pilot error.  The accident was caused by the inability of the radar equipment to detect wind changes and the microburst. It only detected thunderstorms. As a results of the  airborne  wind  shears  alert  a  diction  system  was installed  on many  commercial  airlines of the United States.


Aeronautical decision making and judgment

Decisions making  is  characterized  as  an  act  of  choosing   between  alternatives  under an uncertain condition (Tsang,  Vidulich, p 203). This is an important concept in aeronautical decision making because wrong decisions making can lead to a crash. The  Delta Air Lines Flight 191 at Dallas Fort Worth Texas raises  concerns  about the crew  decisions  making in  the  landing  in  the  midst  of severe  thunderstorm. This flight  penetrated  over  heavy  storm despite  Prince noticing  the  lightening  in  one  of the cloud ahead of  them. The wind shear caused the high speed   and its fluctuation by -44Kts + 20Kts.


The severe  turbulence  and  heavy  rain caused the aircraft to  strike the ground killing  most on  board  and  one  on  the ground. We  can  say that the probable  cause of  the crash  to  be real  time  shear  hazard information and  the decisions  of  the flight crews to  continue the  approach  into  a  cumulonimbus cloud with  lightening and  to initiate a  rapid change of  direction.Decision making of the pilot had been paid much attention by the National Transportation safety Board reports.  A  pilot  must  acquire  and seek information  from  any  sources  that  is  available  within  his  reach.  The  pilot  has  to  make  any  determination  in regard  to the quality  and  quantity  of  information  and  with  enough  information,  the  pilot  will be at  a good  position to  make  reasonable and  reliable decisions. This  is  through  personal  processing  of  data  by the pilot in  predetermining the ways  of  getting  and  reaching  a wise decisions  from  the few  alternatives  he  has.


This  process of reaching  a wide  discussion  involves  the judgment  of the pilot on  probabilities in  an  attempt  to come  to a wise  decision  when faced with certainty. The decision  making of a pilot  must  reflect on normative  characterization  which  the most  essential task of  a  pilot is  to choose  the best  option  available  for  him having  in  mind  the possible  outcomes   attached to each  choice.  Therefore, the essential and most vigilant aeronautical decision maker is prone to error. This  is  seen  in the field  of  aeronautical  decisions making  which  was founded  by  Holland  and  Wickens  in 2000. The correct  decisions has been  derived from  a  normative  analysis  of  a  situation and  the incorrect  decision is  based  on  the process  of  Heuristic.  The  pilots  in delta  airline  followed  the heuristic  approach  rather  than  the normative approach leading  to largely  incorrect  decisions. To enable  pilots  have the tactics  of  using the normative  approach in  decision making they have  to follow  available  the model which  outlines the consequence of information processing  activity.


This process first begins with cue sampling through the assessment of the situation. The second step is to generate options. This will, require the EDM to be creative and fast in thinking. The third  option is to wisely make  a decision  which  will  automatically be  followed  by  an  action.The uses of heuristic processes are presumed to affect particular stages in the decisions making process. For example,  at the point  where  a  decision is  formulated ,  there will, be  the operation of  framing which  will subsequently affect the confirmation  bias of  cue  sampling.This is the point at which the pilots have to be very careful in their decision making process.  They have to choose between several options and the expected utility of an option. Expected  utility is  derived  from considering the options  in  multiplying  and turning the values of  each potential  outcome  by the likelihood of  occurrence.Generally a pilot has to avoid stress when faced with a critical situation that requires an immediate decision. This is because stress has been found to reduce both decision confidence and optimality.


Conclusion

People including the pilots have difficulty in making judgments especially under situation of uncertainty. This is because of the faulty decisions that we take when processing the necessary data.  To solve such problems,  people  have to be  trained   on  how  to use the available  alternatives and  to follow  the correct  routines  in  processing information although  few  such  studies  are available.


 

  Reference

Magnuson, 2005, Like a Wall of Napalm.  Retrieved from

http://www.time.com/time/magazine/article/0,9171,1050423-2,00.html

On June 9, 2010

Tsang, P & Vidulich, M (2002) Principles and practice of aviation psychology Rutledge publishers.





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