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The following paper is intended to offer a discussion of the causes that could have led to the crash of Avianca Flight 52 in 1990. The study includes a description of the accident incident, a discussion of the causes attributed to the accident, both mechanical and human, and the safety precautions which the crew of the aircraft did not comply with.
Keywords: pilot, aircraft, accident, Avianca Flight and NTSB.
Avianca Flight 52 (1990), has been over 22 years old and flying for more than 61,000 hours, crashed on 25 January 1990 at 21:34 UCT-05:00, scheduled to fly from Bogota to New York via Medellin. The flight was registered HK-2016 and equipped with JT3D-3B engines that were also modified with a hush kit to ensure reduction of noise pollution (Lim, 2017). NTSB suggested that the crash was as a result of the flight crew failing to manage the fuel load of the airplane adequately. Moreover, the flight crew failure to communicate the fuel emergency situation to the air traffic was also associated with the plance crash. The tragedy left survivors with physical and psychological trauma which served as reminders to the victims of the ordeal.
The purpose of the report is to disclose the issues that led to the occurrence of the incident and the aftermath of its occurrence, putting in consideration the organization and safety measures in the flight. The report will elaborate technical and human factors which are associated with the crash occurrence and the risk control measures which were not practiced prior to the incident.
Summary of the incident and its aftermath
Avianca Flight 52 was scheduled to transport international passengers from Bogota, Colombia, make an intermediate stop within Jose Maria Cordova Airport near Medellin Colombia and then head to John F. Kennedy International Airport in New York. The plane departed its station five minutes earlier the schedule and successfully landed in the intermediate location for refuelling. At the intermediate position, no flight crew change was necessary, and at 1508, the plane departed to Medellin.
From the time the flight left Medellin, it was forced to hold for three times at Norfolk in Virginia, Atlantic City in New Jersey and CAMRAN respectively. The stopover at CAMRAN was the longest. Notably, the flight was instructed by the New York Air Route Traffic Control Center to hold within the region indefinitely. Between 2130 and 2133, the plane had lost engine number four and number three. Based on the estimates of the NTSB, it was during this period that the communications to the control tower that was directing the flight to land fifteen miles away were lost and the plane crashed. The crash occurred within a 24⁰ slope in Cove Neck, New York, after clipping several posts and trees. Figure 1 below shows the plane wreck, the angle and the trees that were destroyed by the incident.
Figure 1: Avianca Flight 52 Crash
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Soon after the crash occurred, communities from within the Cove Neck informed the emergency services of the incident, which was accessible via a single residential street. The plane had carried a total of 158 persons, out of which 73 of them died from the crash (Cookson, 2011). All the crew members apart from the lead flight attendant also perished when the plane air crashed. 72 of the total surviving passengers comprised of children aged three years and above as well as adults. The survivors sustained significant injuries, with only two of them having minor injuries. On the other hand, the plane had 11 infants, out of which one died, eight sustained injuries that were serious and the rest two had minor injuries.
One month after the crash, a caravan comprised of almost a thousand vehicles went to JFK protesting the issue of handling the plane. A total of $75,000 was offered to survivors and relatives of the individuals that died in the crash in on July 1990, with the United States government topping up the amount to $200,000 as compensation to the damages caused to the culprits.
Avianca Flight 52 crashed while there was communication going on. Despite the significant cause of the incident being the lack of enough fuel in the plane after the same was consumed during the holding periods, other factors may have contributed to the occurence (Lim, 2017). The airplanne crash may have occurred following several failures both technical and from human errors. The following is a discussion of these aspects explaining how they may have affected the flight and led to the crash.
An investigation by the NTSB indicated that the survey of the plane wreckage did not have a significant impact on the tail of the flight, which remained almost intact. The report from the firms showed that the wings of the aircraft were severely damaged during the impact and were thus fractured. The report suggested that no significant evidence was found to support that the control surface failed before the crash occurred. Biu.ac.il (2017) indicates that among the four engines of the plane, none of them was under power before the occurrence of the accident.
The flight data recorder (FDR) of the plane was recovered from the crash site, which after analysis by the NTSB lab, was found to be one of the older oscillographic foil models. The report from NTSB lab indicated that the type of FDR was obsolete, and since it was not changed for the flight, the device might have been taped down and became inoperative during the flight period. The plane had various problems with autopilot maintenance, which is one of the issues cited to have caused the crash.
Based on the investigations of the NTSB, the flight engineer caused a massive error by failing to have accurate results regarding the minimum landing quantity of fuel the plane required. The information suggests that, during the period when the flight was instructed to have a 360⁰ turn at 2054, the flight crew should have understood that their case was not treated as an emergency, but rather as a regular turn. However, based on the CVR records, the crew thought of their situation being treated as a priority, which was not the case (Biu.ac.il 2017). Moreover, the NTSB report suggested that the first officer failed to indicate to the communication tower that their case was an emergency, despite being instructed by the captain to do so.
The NTSB report indicated that the flight crew had received weather data in Medellin, which was about ten hours old. Moreover, there was no evidence to suggest that the team requested to be given any weather information en route or engaged with Avianca dispatchers concerning status of their fuel. Moreover, flight 52 did not communicate to FAA Flight Service Stations or the en route flight watch.
The flight crew also failed to communicate to the ACT of their fuel issue while being held at CMRN. Following continued holding, the statement was explicitily given to the flight that the crew should “Expect Further Clearance”. The directive may have confused the flight crew members, leading to protracted holding thereby consequently amounting to burning of reverse fuel. The activity consumed the plane’s fuel to the point that the pilots were unable to divert back to Boston (Barancik, Kramer, Thode Jr, Kahn, Greensher, J. and Schechter, 1992).
According to the reports from NTSB, the pilot’s failure to ensure safe landing of the plane on his first attempt was one factor contributing to the crash. Considering the problems with the management of the plane’s autopilot, the NTSB indicated that there was a reason to believe that the pilot had to fly the aircraft from Medellin manually, which may have led to exhaustion and stress. The mind state may have otherwise led to the deterioration of the pilot’s performance on the given approach.
The crash occurrence is aligned with significant outcomes of both the technical and human errors. Chin and Shelton, (1990) assert that there was a connection between relationship existing between the plant safety in the design and maintenance of the aircraft and occupational safety measures in the given industry. The plant is responsible for development of planes and materials that are not only useful in the current flight period. The facet is endowed with the responsibility of ensuring flight safety in its endeavors. Moreover, the organization has the burden of integrating advanced technologies in providing issues with communication between aircraft. The function ensures that message transmission to and from towers are not broken despite the harsh weather affecting the flight.
On the other hand, the team must meet the occupational safety of both the flight crew and personnel responsible for construction and maintenance of planes. For instance, each of the seats within the flight should be fitted with gas masks to reduce risks of gas failure. Moreover, the flight team must have protective gear that is not only inflammable but also proof to sharp objects. The team responsible for the plane’s construction should be covered for the process of design, which may be dangerous in case of any risks occurring.
Plant safety and occupational safety are essential and interrelated courtesy of the providers of safety mechanisms and outcomes of potential risks. Notably, if such occur, the catastrophies are intense and detrimental. The two principles guide the working and maintenance of planes, which is essential for effective outcomes.
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Avianca Flight 52 failed to engage risk control measures which would have assisted in alleviating the crashing risk following lack of enough fuel in the plane. One of the rules that the team failed to implement is communication to the FAA team concerning the issue the crew had regarding plane’s low fuel level. The jet was set to make stops for three different occasions which led to consumption of reverse fuel for the aircraft. Therefore, turning back to Bolton became an issue.
Despite the plane’s captain instructing the first officer to state their situation as an emergency to the air traffic, the latter failed to indicate the same, thereby leading to their case being treated as a regular issue and not given any priority over other planes. Moreover, the flight crew did not request the weather data since the team were updated before departing from Medellin. The carder’s failure amounts to one of the most significant causes of the signal and communication loss, which influenced the crash.
Significant information from the NTSB lab reports suggests that the plane’s engineer should have had an understanding of the problem with its autopilot, which he could have instructed the first officer to notify the air traffic. Moreover, the engineer failed to have accurate calculations on the issue of fuel consumption, especially when the plane was given a 360-degree diversion.
The failures the said different personnel should have been addressed and risk control measures put in place to prevent risk occurrence. According to Axelrod (1990), the aircraft may have landed safely if the pilot had taken the first chance to land seriously. Moreover, if the danger control measures were considered, there would have been a possibility of the plane landing safely thereby avoiding the crash.
There is significant evidence to show that, despite the crash occurrence, Avianca Flight team was caring and engaged in corporate social responsibility. Cushman (1990) indicates the firm’s practice of compensating survivors and the individuals whose relatives died in the crash with a sum of $75,000 for their loss was a show of mindfulness. Despite the funds being far and incomparable to the pain and suffering the individuals went through, the action was convincing to indicate that the company took responsibility for the crash.
Based on the outcomes of the crash, various proposals can be provided to ensure that such consequences do not occur again. One of the recommendations entails ensuring that planes are thoroughly checked concerning their current situation, fuel consumption and holding capacity, routes to be taken while flying and the state of a plane’s technology. The FDR should be integrated with the most recent technologies to ensure fewer chances of experiencing communication breakdown. Moreover, such an approach would help improve the mechanism of communication even during bad weather, which is essential in reducing risk occurrence in air.
Also, it is recommended that plane crew should have rigorous training on various risk control mechanisms which can assist trim the impact risks. Preparation on basic checklists and checkpoints for planes before, during and after flights is imperative to minimize risks associated with these kinds of failures. Team competency must be highly checked to avert act flying of planes without enough knowledge and experience on issues that pilots may need to address in the event of occurence.
The team in the cabin should be provided with gadgets that can act as a backup in case the normal devices fail to function properly. Each of these persons should be provided with alternative communication gadgets with a specific frequency to communicate with the towers. The approach will help to reduce loss of communication and help to reduce accidents. The devices should only be used in emergency cases and hence should remain intact until when needed.
The report has disclosed the issues that led to occurrence of the incident and aftermath of its happening by considering organization and safety measures in the flight. Significant information has been discussed concerning the crash of Avianca Flight 52, with a clear distinction of technical and human factors that may have contributed to development of the incident. Sumarilly, Avianca Flight 52 should not have crushed if various control measures would have been set in practice.
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Axelrod, D. 1990. Avianca Flight 52: Lessons Learned. Draft Report. New York State: Department of Health.
Biu.ac.il 2017. Crew Resource Management Reducing Human Error. [Online] Available at: https://www.biu.ac.il/soc/sb/stfhome/josman/790/netstuff/crm%20-%20reducing%20human%20error.htm [Accessed 29/12/2017].
Barancik, J.I., Kramer, C.F., Thode Jr, H.C., Kahn, C.J., Greensher, J. and Schechter, S., 1992. Epidemiology of fatal and nonfatal injuries in the Avianca plane crash: Avianca Flight 052, January 25, 1990. Final report (No. BNL--52386). Brookhaven National Lab., Upton, NY (United States); Nassau County Dept. of Health, Mineola, NY (United States). [Online] Available at: https://www.osti.gov/scitech/servlets/purl/10180665 [Accessed 29/12/2017].
Cushman, J., 1990. Avianca flight 52: The delays that ended in disaster. New York Times. February, 1990.
Chin, E. V., and Shelton, R. 1990. Avianca flight 52: a view from the ED. Emergency medical services, 19(5), p.18.
Cookson, S. 2011. Tell Them We are in Emergency: Linguistic Factors Contributing to the Crash of Avianca Flight 052. [Online] Available at: https://obirin.repo.nii.ac.jp/?action=repository_action_common_download&item_id=935&item_no=1&attribute_id=21&file_no=1. [Accessed 29/12/2017]
Lim, C. 2017. Avianca Flight 52: Why the pilots failed to use the proper phraseology?. [Online] Available at: http://www.askcaptainlim.com/-air-crash-aviation-34/830-avianca-flight-52-why-the-pilots-failed-to-use-the-proper-phraseology.html [Accessed 29/12/2017].
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