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Case Study: Air Florida 90
"Larry-we're going down Larry!".
First Officer-Roger Pettit
Gregory C. StampASCI 604 Human Factors (Prof. Dr. R. Tyler)
Embry-Riddle Aeronautical University
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AGENDA
Background Accident Details “How and Why” Human Factors Application Conclusion
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Background
Date: January 13, 1982 Bitter winter’s day with blizzard of snow Temperature Conditions: as low as -5ºC (? ºF) Limited Visibility: ½ mile in snow showers Cloud Ceiling: 400ft Flight Schedule: 2:15 pm Boeing 737 departure (National Airport to Fort Lauderdale, FL)
Aircraft flight hours: ? Maintenance history: ?
Passengers: 74 Cock Pit Personnel:
Pilot: Captain Larry Wheaton First Officer: Roger Pettit Both were fairly young pilots/ new at Air Florida
Airline: Air Florida had rapid growth after Deregulation Act of 1978
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Accident Details
Key Events Leading up to Crash (Timeline): Just Before 1:40pm
Closed airport to plough instrument runway Captain requested de-icing and then cancelled
after rejection of departure 2nd de-icing requested after re-opening of airport
At 3:23pm Palm 90 cleared to depart gate Captain mis-used reverse thruster to assist in push
off (violation of company policy) Palm 90 taxied into position behind New York
Air DC-9 to melt snow
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Accident Details
At 3:59pm Palm 90 was cleared for take-off from
Runway36- visibility down to ¼ mile Within less than a minute after take-off- Palm
90 loss airspeed and started descending and ploughed in 14th Street (“Rochambeau”) Bridge
Fell into Potomac River with only the tail visible
After Crash- “The Aftermath”: Rescue team impeded by icy conditions Only 6 people survived, 4 motorists died Recovered both the FDR and CVR from the
bottom of the river Critical in solving the puzzle of Palm 90”.
Discovered captain stated anti-ice switch was offwww.roadstothefuture
.com/Air_Florida_Map_M.jpg
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“How and Why”
‘How:’ Captain Wheaton positioned Palm 90
behind New York Air DC-9, use exhaust to melt the ice off fuselage and wings
Counter effect ice melted and blew back over the wings and re-frozen
Anomalies in engine instrument readings Investigation concluded:
Failure to use engine anti-ice mechanism Created large amounts of ice and snow to gather in the engines without being
melted.
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“How and Why”
‘Why:’ Exhaust from the DC-9 caused a lower than normal reading on one of the EPR gauges. Spectrum analysis of the engine sounds from the CVR indicated that the anomalies in engines out the takeoff. Investigators found that the engine de-ice system was turned
off Ice on the compressor inlet pressure probe would cause a
higher than actual thrust reading on the EPR gauges. Investigators found that ice build up in the wing leading edge and slats could cause an abrupt nose up pitch
on takeoff First Officer Pettit believed that the engines were producing
max thrust The throttles weren’t advanced to provide more power to
prevent stall
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Human Factors Application
Decision Making: Poor decision chain attributed Palm-90 accident Determine what must be done Pilot judgment error Inappropriate procedures
Crew Resource Management: Accident help initiated training in crew resource management Instill professional pilots a positive attitude and skills Improve flight crew communication.
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Human Factors Application
Communications Break down in flight crew communication First Officer Not assertive with communication to
Pilot Ex: “Pettit remarked several times that "that
doesn't seem right!" Training
Air Florida lacked the necessary infrastructure Provide adequate training for flight crew Improper supervision of flight operations. Lack of experience from both Pilot and Co-pilot
Selection
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Questions???