HFS376: Review the investigation report and identify the human errors presented. Describe how these errors relate to physical and cognitive human capabilities and limitations. Human Factors in Defence and Security assignment

Module / Subject / School:

HFS376 Human Factors in Defence and Security

Singapore University of Social Sciences

Requirements:

Please read the following case study before answering Questions 1 to 3.

Human Factors in a Military Transport Plane Crash (Case Study)
On 23 April 2020, at approximately 17:24 hours local time, the mishap aircraft (MA), C-130J-30, tail number (T/N) 11-5736, assigned to the 37th Airlift Squadron, 86th Airlift Wing, Ramstein Airbase (AB), Germany, conducted a routine periodic evaluation flight for Mishap Pilot 1 (MP1). The Mishap Crew (MC) flew a maximum effort (assault) landing at Ramstein AB and experienced a hard landing with a vertical acceleration load factor (g-load) exceedance value of 3.62 times the force of gravity (g)
and a landing sink rate of 384 feet per minute (FPM), exceeding the mishap aircraft’s maximum allowable landing limits of 540 FPM and g-load of 2.0g. Immediately upon touchdown, the MC executed a go-around and coordinated with Air Traffic Control for a visual approach, full-stop landing. The Mishap Aircraft (MA) landed safely at 17:37. There were no fatalities, injuries, or damage to civilian property. The MA landing gload exceedance resulted in significant damage to the centre wing, both outer wings, left and right main landing gear assemblies, and engines, including mounting structures. The damages are estimated to be $20, 917,089.

The Accident Investigation Board President found, by preponderance of the evidence, that the cause of this mishap was MP1’s early engine power reduction (power pull), beginning at 70 feet above ground level (AGL) and fully flight idle at 45 feet AGL. In addition, the board president found, by the preponderance of evidence, that MP1 and MP2’s failure to identify the excessive sink rate and their failure to arrest the excessive
sink rate or go-around in a timely manner were substantially contributing factors that resulted in the MA exceeding the C-130J-30g-load and sink rate landing limits.

MP3 was a current and qualified evaluator pilot in the C-130J (Tabs G-82 and K-6). MP3 had 1,586.6 total hours in the C-130J, 1,824.3 in Remotely Piloted Aircraft (RPA), 2,250.3 total primary hours, 239.3 secondary hours, 607.6 total instructor hours, and 130.2 evaluator hours (Tab T-4 to T-6). Of the 2,250.3 total hours flown, 418.1 flying hours were combat hours and 1827.2 were combat support hours (Tab T-4 to T-5).

You are required to conduct a review of the Human Factors analysis in the investigation report with the objective to propose solutions to prevent a similar accident in the air force. Using this accident as a case study, examine human capabilities and limitations in operating military transport planes in a high stress situation. Identify the possible
safety and risk management issues in defence and security operations, and examine design principles to reduce human errors both in operations and maintenance of military/combat equipment. You may refer to other reliable news reports or commentaries in your review.

Question 1a
Review the investigation report and identify the human errors presented. Describe how these errors relate to physical and cognitive human capabilities and limitations. (14 marks)

Question 1b
Explain how human limitations contributed to the cause of the plane accident. (6 marks)

Question 1c
Mission planning, pre-flight preparation, take-off and landing phases, situation awareness and decision making, detection and communication of errors are very critical parts of a flight. Given this situation, examine how stress impacts performance and what can be done to manage stress in such circumstances. (10 marks)

Question 1d
Using Crew Resource Management (CRM) principles, evaluate the team performance of the transport plane flight crew comprising the three pilots, loadmaster and other aircrew.
(10 marks)

Question 2a
Based on the findings from the report (case study), analyse the safety climate of the 37th Airlift Squadron, 86th Airlift Wing, Ramstein Airbase (AB), Germany, in particular, the attitude towards safety displayed among the airmen. Support your analysis with the evidences reported.
(10 marks)

Question 2b
The pilots failed to identify the aircraft sink rate and broke down in visual scan as a result of focusing on maintaining threshold airspeed and failure to identify the Climb Dive Marker (CDM) / aim point shift associated with the rapid sink rate. The lack of discipline to perform adequate risk assessment of critical information, and failure to identify / correct risky or unsafe practices displayed by the aircrew in deviating from established procedures were evident. Illustrate how this discipline issue relates to a
unit’s attitude towards safety and risks. (8 marks)

Question 2c
Present how a safety management system, with the implementation of education, intervention and monitoring programmes can possibly avert safety discipline issues. (12 marks)

Question 3a
All the pilots were reported to be good senior pilots. MP1 was a current and qualified C-130J pilot (Note: there is no qualification differentiation between the C-130J and C-130J-30) (Tab T-17 to T-281). MP1 had 399.1 total flying hours in the actual C-130J, 259.5 primary hours, 113.4 secondary hours, and 26.2 other hours. In the simulator, MP1 had a total of 174.3 hours, 95.3 primary hours, and 79.0 secondary hours.

MP2 was a current and qualified instructor pilot and USAF Weapons School graduate in the C-130J. MP 2 had 1,591.0 total hours in the C-130J, 445.6 primary hours, 282.9 secondary hours, 561.3 instructor hours, and 301.2 other hours.

Given the human errors discussed in this case study, propose design solutions that could have assisted the aircrew in handling the emergency during the mission flight. (15 marks)

Question 3b
Assuming the role of the incident’s unit commander, recommend the actions your unit/squadron need for improvement and to prevent future incidents. Your recommendations should be based on the findings of the investigation report and should include training or re-training options.
(15 marks)

What we score:

73%

Our Writer’s Comment

This assignment tests students on their understanding of the concepts.

Based on the assignment requirements provided, here are some comments to help students score well on this assignment:

Question 1a:

Review the investigation report and identify the human errors presented. Describe how these errors relate to physical and cognitive human capabilities and limitations. Here are some suggestions to improve your response:

Conduct a thorough review of the investigation report to identify the specific human errors that occurred during the plane accident. Provide a clear and concise description of each error, highlighting its relevance to the physical and cognitive capabilities and limitations of the human operators involved.
Analyze how physical factors, such as fatigue or physical constraints, may have contributed to the errors. Consider the impact of cognitive factors, such as attention, memory, and decision-making processes, on the occurrence of the errors.
Provide specific examples and evidence from the case study to support your analysis. Use relevant concepts and theories from human factors literature to deepen your understanding of the relationship between human errors and physical/cognitive limitations.

Question 1b:

Explain how human limitations contributed to the cause of the plane accident. Here are some suggestions to improve your response:

Clearly identify and explain the human limitations that played a role in the occurrence of the plane accident. Discuss how these limitations, such as cognitive biases, information processing constraints, or perceptual limitations, influenced the decision-making and actions of the aircrew.
Connect the identified limitations to the specific errors and their consequences described in the investigation report. Demonstrate a clear understanding of how these limitations directly contributed to the cause of the accident.
Use evidence from the case study and relevant human factors literature to support your explanations. Draw on relevant theories and concepts to provide a comprehensive analysis of the relationship between human limitations and the accident.

Question 1c:

Given the critical phases of a flight and the high-stress situation described in the case study, examine how stress impacts performance and propose strategies to manage stress in such circumstances. Here are some suggestions to improve your response:

Analyze the impact of stress on human performance in aviation and high-stress environments. Discuss how stress can affect attention, decision-making, situational awareness, and overall performance of the aircrew during critical phases of flight.
Provide specific examples and evidence from the case study to illustrate the effects of stress on the aircrew’s performance. Consider the potential consequences of stress-related performance decrements in terms of safety and mission success.
Propose effective strategies and interventions to manage stress in aviation operations. These strategies could include stress management techniques, crew resource management practices, training programs, or organizational support systems.
Justify your proposed strategies with references to relevant research and best practices in aviation human factors and stress management.

Question 1d:

Using Crew Resource Management (CRM) principles, evaluate the team performance of the transport plane flight crew comprising the three pilots, loadmaster, and other aircrew. Here are some suggestions to improve your response:

Apply CRM principles to assess the team performance of the flight crew. Evaluate their ability to effectively communicate, coordinate, and make decisions as a team during the mission flight.
Analyze specific aspects of CRM, such as communication, situational awareness, leadership, and teamwork, within the context of the case study. Discuss how these elements contributed to or hindered the team’s performance.
Provide concrete examples and evidence from the case study to support your evaluation. Highlight instances of effective CRM practices and areas where improvements could have been made.
Offer recommendations for enhancing CRM training and practices based on your evaluation. Consider the specific challenges and demands faced by the flight crew in the given scenario.

Remember to support your arguments and analysis with references to the investigation report, relevant literature, and best practices in aviation human factors.

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