Human Factors | Aircraft Accident - Central Airlines Flight 27 March 30, 1983

Human Factors | Aircraft Accident - Central Airlines Flight 27 March 30, 1983

Central Airlines Flight 27  March 30, 1983

About 0514, eastern standard time, on March 30, 1983, Central Airlines Flight 27, a Gates Learjet model 25 (N51CA), with two pilots aboard crashed at Newark International Airport, Newark, New Jersey, during a landing attempt on runway 4 right. 

The airplane was destroyed by the impact, and the two pilots died as a result of the accident. The airplane came to rest in a drainage ditch at the airport perimeter. A ground fire erupted near the latter portion of the impact area.

 

 The National Transportation Safety Board determines that the probable causes of this accident were:

(a) loss of control following ground contact;

(b) an un-stabilized approach, and

(c) impairment of the flight crew’s judgment, decision-making, and flying abilities by a combination of physiological and psychological factors.

History of the flight – first facts only.

On March 30, 1983, Central Airlines Flight 27, a Gates Learjet Model 25 (N51A), was operating as a nonscheduled cargo flight (canceled bank check courier) under 14 CFR Part 135 from Midway Airport, Chicago, Illinois, to Newark International Airport, Newark, New Jersey. Flight 27 departed Chicago at 0251 central standard time 1/ on an instrument flight rules flight plan; there were two pilots aboard. 

The purpose of the flight was to carry canceled bank checks to Newark and then to continue to Hartford, Connecticut. According to air traffic control (ATC) recordings, the en-route phase of the flight was routine. 

The cruise altitude was flight level (FL) 410. At 0456:11, the flight was cleared to descend, and the crew acknowledged the clearance. At 0458:20, the controller asked Flight 27 to "start your descent now, please." The crew acknowledged and the airplane began descending. 

The flight continued to receive clearances to descend and maneuvered until 0511:38 when Flight 27 advised ATC, It. . .approach control, twenty-seven, we got runway one one in sight now.

 I wonder if we can have a visual to one one? " The controller responded that runway 11 was “noise sensitive,” and the crew responded, "Okay, we'll go to four then." The controller cleared Flight 27 for a visual approach to runway 4 right and added, ??. . .not below two till on final. . . .?' The crew acknowledged and contacted Newark Tower at 0512:15.

The Newark local controller cleared Flight 27 to land and gave the winds as 340' at 9 knots. The crew's acknowledgement of the landing clearance was the last transmission from N51CA. According to associates of the pilots (including the chief pilot) who reviewed the ATC tapes, the right-seat occupant (copilot) was making the radio calls. 

It is common practice that the pilot not flying the airplane make the radio calls. The local controller stated that she first observed Flight 27% landing lights when the airplane was about 6 miles from the airport. 

She said that the approach appeared normal, "perhaps a little fast." She said she saw the airplane touchdown on the runway because the landing lights “jiggled” and the airplane made ''a little bounce.” 

The controller had looked away to log the flight's arrival on the flight strip, and when she looked back, she saw the airplane's lights roll to the right. She saw a fireball which extinguished in 10 to 15 seconds. The controller notified emergency crews about the accident, which she estimated had occurred at 0514.

 

Human Factors Specific to the Accident

I will discuss the human factors investigation areas – by using the course learning source from the training course titled “Embry Riddle University - Aircraft Accident Investigation MOOC “. This material lists for us 6 areas:

      1)    Behavioral

      2)    Operational

      3)    Medical

      4)    Tasks

      5)    Equipment design

      6)    Environmental

I will explain, the elements of each human factor area. I will use the course training resources as a reference and link to the fact mentioned in the NTSB final report.

1- Behavioral 

      a.       24-72 hours history

As we learned for the methodology for investigating “operator fatigue in a transport accident” , it focused on the operator 72 hours history and the suggestions of little sleep or less sleep than usual.

In this accident the report stated finding no.2

“ Both pilots had received the required off-duty time for rest; however, the quality of their rest is questionable because of interruptions and off duty personal activities.

 

By the interview with their families.  In this case, this element was not included as a HF cause related to the accident.

      b.      Operator behavior

There was no explanation on the report.

      c.       Life habit patterns

Several of the captain's associates reported that he had smoked cigarettes heavily until about 2 years before the accident and that he recently started smoking again. 

One associate said that it was because of the ''new company thing and other pressures." His wife and several associates stated that he had smoked marijuana, but had stopped about 2 years before the accident about the same time he stopped smoking cigarettes.

Regarding flying while under the influence of marijuana, one associate stated that the captain had stated that "he would never do it, but if he did, he said that I would never know." The captain's wife and other associates denied any knowledge that the pilot had smoked marijuana recently.

 

From this we can note this danger habit for further discussion later on in this discussion.

      d.    Life events

In the past month, the captain left his job with Jet Courier Services, Inc., and had begun flying for Hughes Charter Air amid much controversy, including the fact that both pilots (as well as others) had been terminated by Jet Courier Services, Inc. 

In addition, he had just bought a house and his wife was expecting a baby. One associate said that he was nervous about the new company because of the competition between companies and concerns about future job stability. 

However, his wife said that he was excited about the expected baby, the new house, and the professional atmosphere of the new job

From this paragraph, we can assume that the work life was not stable

Summary : Unstable work-life , Heavy Smoking habit and Smoking Marijuana

 

2- Operational

      a.       Training

According to a pilot who had flown often with the captain, he was a good pilot who exhibited command authority when necessary. "Even though I was a captain, if I did something he didn't like, he would testily tell me about it. 

Later we would discuss it on the ground.” The check airman for Jet Courier Services, Inc., who had given the pilot his proficiency check on January 19, 1983, said that he did an excellent job during the check ride.

A company ground instructor of Hughes Charter Air who recently had provided initial company indoctrination training and portions of recurrent Learjet training to the captain and copilot said that both pilots performed satisfactorily on a written test and demonstrated good knowledge of the pertinent contents. 

Also, both had demonstrated satisfactory knowledge during oral examination on Learjet systems and procedures including normal, abnormal, and emergency procedures. The instructor said, "Throughout all my dealings with these two pilots, I found no abnormalities in their behavior or ability to function as competent pilots."

I may ask, , What is wrong then!! KEEP READING

      b.      Experience/familiarity/habit patterns

The pilots' experience level USE Mentioned 

      c.       Operating procedures

No Issue

      d.      Company policies

No Issue

3- Medical

      a.        General health

No Issue

      b.      Sensory acuity

No Issue

      c.       Drug/alcohol ingestion

Tests for marijuana indicated that the captain had used marijuana in the past 24 hours. Tests for marijuana indicated that the copilot had used or had been exposed to marijuana in the past 24 hours. Both pilots had low levels of carbon monoxide in their blood, presumably from smoking tobacco.

     d.      Fatigue

The pilots probably were experiencing the effects of fatigue from several sources, which would have reduced further their performance.

 

The absence of evidence pointing to airworthiness and environmental reasons for this accident strongly suggests that actions by one or both of the pilots were the primary cause of the accident.

4- Task

a.                   Task information

No Issue

 

 b.                  Task components

No Issue

 

c.                   Task-time relation

No Issue

 

d.                  Workload

No Issue

5- Equipment design

a.                   Workspace interference

No Issue

 

b.                   Display/instrument panel design

No Issue

 

c.                   Control design

No Issue

 

d.                  Seat design/ Configuration

No Issue

 

6- Environmental

a.                   External conditions

b.                  Internal conditions

c.                   Illumination

d.                  Noise/vibration/motion

The absence of evidence pointing to airworthiness and environmental reasons for this accident.  

 

Summary :

The report strongly suggests that actions by one or both of the pilots were the primary cause of the accident. these actions were because of the active failure due to individual factors -As I Mentioned Before- which Affects negatively the human crew performance.

 

Human performance research into critical life events (death of a spouse, job change, major purchase, relocation, etc.) indicates that such factors create psychological and physiological stress. 

The stress in turn can cause degradation of human performance. The captain of N51CA had experienced several critical life events in the recent weeks before the accident. He had changed jobs, purchased a new house, moved, and his wife was expecting a baby. 

Any one of these could create manageable stress; however, the combination of them could be significantly stressful. Evidence of the adverse effects of these stresses was indicated in conversations with his close friend and by his return to the use of tobacco. 

These factors also could account for his recent use of marijuana. Although correlation of these factors directly to the cause of this accident is impossible, they could definitely affect the captain's state of mind and consequently, his judgment and decision-making.

 

In summary, several physiological/psychological factors existed in this accident scenario, no one of which might necessarily have been sufficient to degrade the pilots' performance to the point that it would cause the accident. 

However, when they are considered in combination, along with the accident circumstances and the pilots' experience level and past behavior, the evidence leads to the conclusion that these factors probably were underlying reasons for the accident. 

Consequently, the Safety Board believes that both pilots' judgment, decision-making, and flying skills were affected adversely by this combination of factors to cause the accident-both the initial bounce and the failure to recover.

 

Any aviation professional can enrich this article or correct any information in it, the purpose of publication is to promote aviation safety culture , to learn and to benefit from previous accidents.

Selected Aircraft Accident Investigation Report:  NTSB/AAR-84/11


Maged Saeed AL-Hadabi

I’m Instructor / Maged Saeed Al-Hadabi. ​ Air Cargo / IATA Dangerous Goods Regulations / Safety Management System Senior Instructor, Auditor [ Yemen Airways] . Approved IATA DGR/ SMS Instructor by Yemen Civil Aviation Authority. We hope you find Aviation Professional website not only informative, but interesting and helpful as well. Leave your comment , thank you.

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