major human factor that results in the terminal events

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The study looks at and describes the key human component that leads to the terminal events. The methodological approach consisted of a critical study of the case of Flight 1420, as well as a survey of the literature. The information gathered came from either a primary or secondary source. The Human Factor Analysis Classifier was applied to the case, and it was discovered that exhaustion and a loss of situational awareness were the two primary human factors that contributed to the error. The flaws led to poor decision-making and, as a result, the plane disaster. Human factors were found at various levels of the Human Factor Analysis Classification groupings. The flight crew, the organizational framework, and even the weather surveillance department exhibit this errors that contributed greatly to the causation of the accident.


The case study being analyzed is that of flight 1420 which crashed during landing. A majority of the passengers were injured, while a smaller number either died or escaped injury. An analysis of the case by the National Transportation Safety Board determined that the major causes of the accident were related to the competence of the flight crew. Although plane crashes are not very common, the severity of a single crash warrants significant effort in the regulation of the aviation industry. The Human Factors Analysis and Classification System (HFACS) is one of the methodical frameworks that usefully break down the causes of error into manageable classes to guide prevention strategies. This research identifies two main human factors as contributory agents in the accident of flight 1420.


The research is a combined case study and critical review of literature. The primary method of collecting the information was the use of secondary sources. Information is obtained from highly cited sources such as magazines, journals, and reports published between 2014-2017.

Case Analysis and Literature Review

Flight crashes are often more disastrous than road carnage because of the number of potential casualties and the severity of the accident itself. Safety and risk mitigation in the aviation industry are therefore fields that are often subject to scholarly inquiry. In the causation of flight crashes, several factors are often involved. These factors may be mechanical, human, environmental or physical. This analysis considers the human factors involved in the crash of flight 1420 in respect to the HFAC framework to identify the two main factors involved in the causation of the plane crash.

The HFAC framework delineates four levels of human error that can adequately cover all the possible sources of error (Shappell & Wiegmann, 2000). By applying the framework to the aviation industry, active and latent sources of human error can be identified and countered even before they cause damage. The four levels of error include operator actions, prevailing conditions that facilitate the unsafe actions by the operators, inadequate supervision, and organizational factors (Shappell & Wiegmann, 2000). Each category will be analyzed to illustrate that loss of situational awareness and fatigue are the main human factors that contributed to the crash of flight 1420.

Loss of situational awareness refers to the distraction of the crew members or any other party that is actively involved in the safety or direction of the flight. Situational awareness is especially important in the aviation industry where a lot of variables have to be monitored, and precision is key to the realization of safety. However, the operators will often experience lapses in situational awareness due to environmental or intrinsic factors. Fatigue often sets in after long periods of exertion. The detrimental effects of fatigue are often manifest as poor or irrational judgment and may often contribute to loss of situational awareness.

Level 1: Unsafe Acts

The actions of the operators are a potential source of error in the causation of flight crashes. The actions can broadly be defined as either errors or violations. Errors that are skill based often relate to the execution of a complex task that needs special qualification. In the crash report of flight 1420, there is little evidence of any skill-based errors. The pilot and the crew handled the flight expertly. In the absence of the adverse conditions, the flight would have landed safely. However, there is clear evidence of both perceptual and decision-making errors. Perceptual errors refer to the wrongful interpretation of the environmental stimuli presented to an individual from the environment. In the case of flight 1420, the controllers at the meteorological tower exhibit perceptual errors in their interpretation of the environmental situation. The pilot voiced concerns over the bad weather twice. However, the operator was unaware of the situation and okayed the landing (McDonnell, 1999).

According to Griffioen, (2012) meteorological reports are very crucial in guiding the operations of an airport. This is because adverse weather conditions are hazardous to the air traffic. Airports should be keen on hiring employees who can easily understand and interpret the weather reports given by meteorologists. Acceptable standards for an airport are to have a meteorological department for easier communication and generation of more reliable reports. Misty weather conditions affect the vision of pilots during takeoff and landing times. A pilot should always have a clear view of the runway during the takeoff and landing as well. A competent meteorological department will always give weather reports on the standard conditions for the days that follow, and this is why it is recommendable to have a meteorological department at the airport as clearly argued by Crash, (2010). However, in the case of the flight 1420, a loss of situational awareness is responsible for the failure to generate accurate information from the meteorological department.

Level II: Preconditions for Unsafe Actions

In this level of the framework, certain environmental, personnel and intrinsic factors are considered as being responsible for the actions of the operators. Most aircraft accidents are caused by simply having misinformed employees. This aspect cuts across all the departments of the airline as any slight misplacement of information or incorrect conveyance of information leads to a wrong message being relayed. This results in poor or even bad decisions being made by employees. The result of a bad decision from the cabin crew as well as the control center personnel would lead to the pilot being misguided, and this lead to increased risk of plane crashes. The review shows that the personnel was adequately trained and had several other successful flights. It is, therefore, unlikely that personnel’s qualification was to blame for the crash of Flight 1420 (McDonnell, 1999). However, other situational awareness factors feature in the allocation and deployment of the personnel. For instance, the emergency response was severely delayed. There should be strengthened aircraft rescue and firefighting units, so as to control airport accidents hence reducing the number of casualties. Crash and detection technology should be enhanced to facilitate immediate response upon collision detection. Also, it will facilitate timely post accidental inter-emergency response thereby reducing flight damage and casualties. Consequently, fewer losses will be incurred by the aviation industry. The recent technology in the airport is a milestone achievement in the sector since it enhances conversion of non-frangible structure to frangible, it has provided best safety measure to the airport facilities hence less loss is incurred.

The most relevant group of factors in the case of flight 1420 is the condition of the operators. These individuals are relied upon to ensure the safe and efficient operation of an aircraft. However, the flight crew shows an increased rate of errors and impaired decision making during the incident, which led to the accident. Coupled with the fact that the crew had been operating the flight for the past three days, fatigue features as a probable human factor in the causation of the accident. The poor decision-making by a well-certified pilot to engage the landing mode in the midst of a storm that he had expressed objection about hints at the eagerness to land and impaired decisionmaking. This error got the crew engaged in a losing battle when they should have taken a different course of action.

Level III: Unsafe Supervision

Unsafe supervision refers to management that is either not performing the oversight role to satisfactory levels or ignoring it altogether. The fault of the oversight management lies in the inadequate preparation for emergency situations. The management demonstrates a low level of risk awareness. Had the emergency response been swifter, the cost of the crash could have been greatly reduced. All other elements of unsafe supervision were absent. Inadequate supervision is not evident as the per the report. All personnel were adequately facilitated and were aptly qualified.

Level IV: Organizational Influences

This level of the HFAC framework considers system-wide factors that are related to the human element. They are organized into three main classes. These include the resource management, organizational climate, and the operational processes. At the system-wide level, barely any human error is readily visible. However, the actions of the pilot and the insistence of the weather correspondent might hint at the possibility of a flawed organizational climate that encourages performance without cutting the workers some slack. This pressured environment forces the workers to push themselves even in adverse conditions of fatigue as was the case with the plane crew, or against hostile environmental factors. A conducive environment encourages communication of the same. It is, therefore, recommendable that all employees should be able to communicate clearly and fluently to ensure that no information is lost or misinterpreted as stated by Robert Sumwalt, (2000).


In conclusion, the analysis reveals a loss of situational awareness and fatigue to be the two main human factors in the causation of the plane crash. Fatigue was a dominant factor in causing human error on the part of the plane crew. They exhibited impaired judgment and poor decision-making. Situational awareness was very prominent in the organizational structure and in the actions of the weather correspondent.


McDonnell, D. (1999). Aircraft Accident Report: Runway Overrun During Landing American Airlines Flight 1420. Washington D.C.: National Transportation Safety Board.

Shappell, S. A., & Wiegmann, D. A. (2000). The Human Factors Analysis and Classification System–HFACS. Office of Aviation Medicine.

Griffioen, H. (2012). Air Crash Investigations: The Deadliest Single Aircraft Accident in Aviation. Boston: Mabuhay.

Robert Sumwalt, ‎. W. (2000). Aircraft Accident Analysis: Final Reports. New York: McGraw-Hill.

May 10, 2023

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Learning Biology

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