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The Dryden plane crash was an incident, in which a passenger plane crashed after only 15 seconds due to a failure in attaining the required altitude. The reason behind this crash is stated as atmospheric icing, thus making it rather a weather problem than human error. However, there are many preventable factors and human decisions that contributed to the accident. The plane stopped over at the Dryden Regional Airport and the wings gathered ice. Moreover, the fact that the passengers were still on board of the plane and the engine could not be turned off implied that the wings could not be de-iced. From a HFACS perspective, there is a lot could be done to prevent the accident as discussed below.
1. Gaps in Defense
Considering this case with the acknowledgement that humans are prone to errors, it can be noted that this crash could be prevented given that the conditions were set from the top of the organization’s management to the pilot in charge of the plane.
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Air Ontario was the company that owned this flight. Due to harsh competition in the air travel industry, the company had to acquire the Fokker F28-1000 Fellowship. This plane was new to the organization. Thus, it wanted to expand its fleet without undergoing the proper preparation channels. The pilots in charge of the flight may have been experienced, but they had a little experience in operating this particular type of aircraft. Thus, the company should have focused on the training of its personnel to ensure that decision-making is ethical and has positive outcomes.
The flight in question had an unserviceable auxiliary power unit, which implied that it needed to be checked and addressed or, at least, the plane could only be allowed to land where there was an external power source. In Air Ontario flight case, it could be clear for the supervisory authorities that forced stop at Dryden required the engines to be running and thus, the wings could not be de-iced despite the snow. It should have prompted them to take an alternative route of flight and prevent the crash.
Preconditions for Unsafe Acts
In this case, the precondition is technological as the pilots had not had enough experience dealing with this particular model of aircraft. There was pressure put on the pilots to fly a plane with inoperable APU and stop in an airport without an external power source in bad weather. It can be stated that the fact that the pilots were unfamiliar with the aircraft might explain their underestimation of the icing on the wings. While they took measures to eliminate the icing, they did not proper attention to this challenge. The kind of aircraft they were using limited their ability to de-ice the plane, and their compliance was fuelled by some element of ignorance.
Such acts include the risk assessment and misperception errors. The plane’s captain did not adequately evaluate the risk of ice on the plane’s wings. He was focused on minimizing the time spent at the Dryden Regional Airport and thus, forgot that the icing was the main concern in that situation. With regard to misperception, it can be stated that the pilots were not fully aware of the repercussions of having icing on the wings. They were skilled in terms of flying the plane in normal favorable weather, which led to the misperception in the snow.
2. External Threats
The weather condition required the plane to be de-iced after spending a few moments at the Dryden Regional Airport as it was snowing. The fact that the snow was expected prompted the pilots to keep the passengers on board during the hot refueling as having them off and back on again would take more time, thus, allowing more ice to gather on the plane’s wings.
Lack of an External Power Unit at the Dryden Regional Airport
It was a known factor, over which the pilots had no control. However, they could coordinate with their supervisors to reroute the plane as the weather was not favorable and the plane could not be de-iced.
3. Crew Errors
In this case, the crew made two distinct mistakes: intentional non-compliance and operational decision-making. Despite the fact that pilots could not turn the engine off and de-ice the plane, they could and should have insisted on rerouting considering that the snow necessitated de-icing and the Dryden Regional Airport did not have an external power source. The fact that they were comfortable with this situation shows an intentional will to not comply with the regulations in terms of de-icing and flying a plane with an inoperable APU.
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The operational decision-making occurs when the pilots continued the flight after the forced stop despite the thick icing on the plane. They should have checked the amount of ice that accumulated rather than assuming that everything was well. It might cost the airline more money to get another plane as was expected in such a case, but it could save the passengers’ and crew’s lives in the end. The fact that the pilots did not see this decision as a necessary one is an error of judgment on their part.
4. Good Communication and CRM
Both pilots were considerably seasoned in terms of flying as their experience constituted over 30,000 hours of flights. It means that they had the experience and confidence to make critical decisions and successfully solve that difficult situation. Good communication between them could ensure making the right choice, which in that case, was to request for another plane or a reroute to an airport that had an external power source. On the other hand, CRM could be useful in ensuring that the crew members communicate with the passengers and explain them the situation and possible delay. The passengers might be worried in the event of rerouting or changing a plane and thus, they might need the explanation of what was going on.
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