Human Factor Failures in Ethiopian Airlines and Lion Air Disasters

The report discusses the two human factor failures that led to the Ethiopian Airlines and Lion Air disasters, actions taken by Boeing, FAA, airlines, and pilots, and consequences to the aviation industry. The failures were insufficient reliability of MCAS automation and lack of training and inadequate automation transparency. The consequences were loss of property, death of several people and pilots, and injuries. The FAA ordered Boeing to implement design changes and planned to update training requirements and flight crew manuals in response to design change to Maneuvering characteristics augmentation system.

Essay

Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
Two Human factor failure...................................................................................................1
Actions taken by manufacturer (Boeing), regulator (FAA), airlines or flight crew.......2
Actions would have prevented these two failures from occurring...................................3
Consequences and/or costs of these failures to commercial aviation, manufacturers,
regulators, airlines, and/or pilots........................................................................................3
CONCLUSION................................................................................................................................3
References:.......................................................................................................................................3

INTRODUCTION
All the aspects of air travel is considered in the aviation industry and activities which
helps in facilitating it that involves airline industry, aircraft manufacturing, military aviation etc.
in the economy the aviation sector is growing fast pace which advise that demand for air
transport will gain by ordinary 4.3% per annum over next 20 years. The industry helps in
connecting people, cultures and business across every continent which supports in growth of
economic, facilitating international trade and promoting tourism (Bowyer, and et.al., 2022). The
Ethiopian airlines and Lion air disaster of 2018 and 2019 caused the major concern around the
world, leading the grounding of whole Boeing 737 MAX fleet. In the crashing of airline there
was death of 156 people on 10th march. The report will discuss the two human factors failures
which occurred and how it is related with the material. The actions that were taken by
manufacturer (Boeing), airlines or flight crew along with actions taken for preventing these
failures from occurring. Further, it discusses consequences and costs of these failures to
commercial aviation, manufacturers, regulators, airlines or pilots.
MAIN BODY
Two Human factor failure
The human factor defines environmental, organisational and job factors along with
human and individual characteristics that influences work behaviour in such way which affects
the health and safety. The practising of human factor is scientifically supported on derivable data
that in what way people comprehend, think, change and act while interacting with technology.
The way of technology design affects the people performance who interacts with it. The human
factor which caused to failure are as follows-
 Insufficient reliability of MCAS automation- There was design of the MCAS
(Maneuvering Characteristics Augmentation System) System on the 737 MAX which
was designed to operate from inputs of only one AOA Sensor. When it provided the
inaccurate system, it created the automated system which performed repeated, erroneous
trim actions (Byers, 2019). On the stability of vehicle, the automation put erratic effect
whereas repetitiveness is fundamental in design of safe and resilient system. In the Lion
air accident, simple maintenance errors occurred which have harmful consequences and
needs to be guarded against through the use of human factor design, principles of design
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of maintenance tasks, process and training. Moreover, to engage repeatedly 737 MAX
was designed rather than only single engagement allowed by version design for the US
air force. The automation was continue to perform inappropriate and unsafe actions that
could not been seen by pilots to over-ride manually. The basic designing of MCAS
automation contain reinforced in-assumptions in respect to automation dependability
which evidenced to be unsupported which pilots find challenging to manage aircraft
safely.
 Lack of Training and Inadequate Automation Transparency- There was lot of
automation misunderstanding as pilots were required to hold what aircraft was doing. The
aircraft were having no display to show and pilots were having no prior knowledge of
MCAS that it was acting on the aircraft trim or to help them comprehend that it was
acquiring wrong data. They were not having the knowledge of how MCAS works in
accidents. Furthermore, the air-plane pilot were unaware of MCAS and had not been
taught about it,along with in their flight manuals it was not mentioned, leaving them lost
as to reason the plane was acting strangely (Earley, 2021). They were unable to create a
correct understanding of the circumstance because they lacked a mental model to guide
them through the process. To deal with automation failures there is need to provide
effective training which not only requires written notices of automation along with actual
experience detecting, diagnosing, and responding to such incidents, which the Boeing
737-Max did not have.
Actions taken by manufacturer (Boeing), regulator (FAA), airlines or flight crew
In order to prevent accident from occurring the design of technologies and system were
improved in advance. There were several actions which was taken by manufacture, airlines and
flight crew. The Boeing was continuing monitoring for enhancement in order to ensure safety. It
was continually monitoring the performance of airlines in order to identify opportunities for
improving safety. There are analyses of in-service events through safety process which involves
Boeing experts from variety of technical disciplines and senior leaders. It also works with
customer for understanding and addressing potential safety issues (Kumar, and Prasad, 2021) .
The Boeing developed and incorporates the new technologies for enhancing safety through
research, development and collaboration. There was designing of flight deck design for helping
pilots in avoiding the safety problem. There can be review of automated system training
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programmes and make recommendations for enhancements to ensure flight crews are properly
trained in automation procedures and dependencies. Conduct system safety assessments for all
type-rated aircraft manufacturers to establish the adequacy of human performance assumptions,
particularly as it relates to pilot awareness of and responsiveness to alarms and the ability to
perform control functions manually when needed. The FAA's role is determined by a variety of
conditions, but it could include examining aviation safety issues or investigating the accident
itself and conveying the facts. The FAA took actions of implementing clear roles and
responsibilities for industry compliance assurance systems by establishing model which
prescribes AIR retention of responsibilities as function of demonstrating applicant holder. When
FAA retested and approved the 737 it needed to take the following steps before putting the plane
back into service such as installation of new flight-control-computer and display-system
software, incorporating revised flight-crew procedures, rerouteing wiring, etc. which contributed
positively and performed operational readiness flight.
Actions would have prevented these two failures from occurring
 Ensure automation's dependability- The creation of highly reliable systems is a core
principle of safety. By cross-checking many inputs, automation can endure incorrect data
and avoid single point failures. Graceful degradation should also be supported, so that if
the automation isn't obtaining good data, it can perform autonomous self-checking
behaviours and send a message to the pilot (Telfer, ed., 2018). In this situation, to read
and compare inputs from both AOA sensors the MCAS should have been designed, with
large AOA sensor disagreements utilised to disable MCAS and let the pilot understand
how it works.
 Provide automation transparency- The autonomy's current status and intended actions
must be completely apparent to the pilots. The system should give enough information to
(1) keep pilots informed about the system's operating mode, intent, function, and output;
(2) notify pilots when automation fails or degrades; and (3) notify pilots when potentially
dangerous modes are manually selected. It is vital that the automation mode and status
are presented clearly and prominently.
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Consequences and/or costs of these failures to commercial aviation, manufacturers,
regulators, airlines, and/or pilots
The effect of airplane crashes was the loss of property, death of several people and pilots.
The communication failure is also contributing in the death of people in plane crash. In the
aviation environment, miscommunication refers to any misinterpretation of the instruction by the
pilot or controller, as evidenced by the lack of readback or incomplete instruction or readback. In
many crashes, the aeroplane structure collapses, injuring the person who collides with the
airframe. Amputations, massive lacerations, and crushing are examples of these injuries. The
victims may become trapped amid the wreckage and die of fire, drowning, or traumatic asphyxia
if the structure falls. In the investigation, Indonesian authorities made several recommendations
to Boeing, including that the company redesign MCAS and provide enough information about it
in pilot manuals and training (Tettamanti, 2022). The people experiences brief sensation of
weightlessness within plane. Inside aircraft controls plays an crucial role which ensure trip is
safe. The system malfunction involves helps to control attitude, speak with air traffic control. In
the crashes the structure of aircraft collapse and individual is injured by impacting air frame
which involves injuries of amputations, major lacerations and crushing. The FAA ordered
Boeing to implement design changes and planned to update training requirements and flight crew
manuals in response to design change to Maneuvering characteristics augmentation system. The
changes will also include enhancements to the activation of the MCAS and the angle of
attack signal. Boeing stated that the upgrade was developed in response to the Lion Air crash but
did not link it to the Ethiopian Airlines crash.
CONCLUSION
From the above report it is being concluded that size, integration, automation, and
complexity of the airline industry, providing a safe, dependable, and best-in-class service has
become a strategic concern for meeting customer needs and gaining a global competitive edge.
The fast global transportation network is provided by aviation, which fosters economic growth,
employment opportunity and international trade & tourism. Within training new automation
needs to be introduced so that pilots can acquire accurate intellectual models of how it is working
as well as an awareness of its limitations and dependability in various settings, as well as
information on how to recognise and recover from anomalous events and failure conditions.
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References:
Books and Journals
Bowyer, and et.al., 2022. The Postpandemic Future of Australian Regional Aviation: How
Regional Express (Rex) Navigated the Challenges and Opportunities. Digitalization and
the Impacts of COVID-19 on the Aviation Industry, pp.73-101.
Byers, R., 2019. Anthony Fokker: The Flying Dutchman Who Shaped American Aviation by
Marc Dierikx. Technology and Culture, 60(3), pp.912-913.
Earley, L.D., 2021, April. Communication in Challenging Environments: Application of
LEO/MEO Satellite Constellation to Emerging Aviation Networks. In 2021 Integrated
Communications Navigation and Surveillance Conference (ICNS) (pp. 1-8). IEEE.
Kumar, S. and Prasad, M., 2021. Navigating the changing world of aviation industry with human
resource planning. International Journal Of Resilience In Fire Safety & Disasters, 1(2),
pp.32-35.
Telfer, R.A. ed., 2018. Aviation instruction and training. Routledge.
Tettamanti, M., 2022. Toward a Green Aviation: Financial Investments in a Promising
Sector. World Scientific Book Chapters, pp.211-228.
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