Aviation Accident Analysis: Ethiopian Airlines Crash and Human Factors

This report provides an analysis of an aviation accident, specifically focusing on the Ethiopian Airlines crash, attributing the cause to pilot fatigue and human factors. The analysis employs the Swiss-cheese model to identify layers of the situation, Perrow’s model to determine the tightness of coupling and interaction, and Taleb’s model to assess the fragility of the components involved. The report highlights the importance of understanding human factors in aviation safety, emphasizing that fatigue is a critical factor. The study uses the models to examine the crash, illustrating how pilot fatigue, coupled with organizational and operational factors, led to the accident. The report concludes that aviation accidents often result from a chain of errors, and preventing such events requires addressing gaps at all levels. The report emphasizes the significance of proactive measures and continuous improvement in aviation safety protocols to mitigate human factors risks.

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Introduction
Why are factors like stress and fatigue so important in the aviation industry? These two factors
together with the others that have not been mentioned are commonly referred to as the human
factors. The factors of human are attributed to the majority of the accidents that take place in the
aviation industry. In general, at least 80% of aviation industry accidents are caused by human
factors. The research work has indicated that over 20% of this particular percentage results from
fatigue.
Although the impacts of fatigue are closely linked to the operations of the flight, it is currently a
major concern as far as the management of the air traffic is concerned. This particular paper
presents a proper analysis of an accident that occurred due to pilot fatigue. The analysis has been
done by the use of the Swiss-cheese model that describes the layer of the situation. Perrow’s
model has been used in the determination of the tightness of the couple as well as checking for
the level of its interaction with the relevant component. In order to check for the anti-fragility or
fragility of the component, Taleb’s model was used.
Ethiopian Airline crash
It was on 10 March 2009 when Boeing 737 Max crashed leading to loss of 157 lives. The
Ethiopian Airline Flight was actually scheduled to fly from Bole International Airport in
Ethiopia to Jomo Kenyatta International Airport in Nairobi. Considering that the exact causes of
this crash are yet to be established, there is a perfect opportunity for the use of the Swiss-cheese
model in the identification of the layer occupied by the situation just before the time of the
accident.
Swiss-cheese model

The Swiss Cheese Model uses a basic concept of cheese slices to synthesize a complex system in
terms of the layers. The slices that are used are never perfect and therefore they have
imperfections or holes that enable penetration process. Every slice forms a different layer in the
system under the study. The commonly considered layers include the following:
 Layer of organization
 The training layer
 Pre-condition layer
 Unsafe acting layer.
The organizational layer usually involves the strategies of the organization that are aimed at
cutting costs in order to save money later to realize that their actions have infringed aviation
safety.
Supervision or training layer
This is a very crucial layer in flying. All safe operations are linked to superior operations. The
pilots are required to have sufficient training
Precondition layer
This layer is characterized by a lack of concentration, fatigue, and stress. This simply confirms
that no one can beat the best level of performance all the time through. The pilots will, therefore,
keep posing questions to themselves as to whether they should fly at particular times.
A layer of unsafe acting
This is the active layer. It is the failure itself.

Although the investigations are still in the process, the preliminary reports have indicated fatigue
failure from the pilot as one of the possible causes of the crash. In most of the countries, the
clock of the workers will begin the moment they arrive at the workplace and end at their
departure. The question that remains unanswered therefore is whether or not the operations of the
pilots should be different. The argument can be on a different basis but the fact will remain that
"Awake is awake ".One of the insidious factors of human operations is fatigue. Were it not for
that, drivers would have not fallen asleep while driving.
The pilot time for rest might have been a wrong hour or odd hours. During the odd hours, it
becomes very difficult for the pilot to sleep. The pilot might have contributed to his own fatigue
when his duty days were stretched to extreme lengths. This made the flight situation to be at the
precondition layer of the Swiss Cheese Model. The pilot could not make a fair judgment as a
result of the fatigue and therefore the precondition layer developed into active failure (crash) of
the Ethiopian Airline.

Swiss cheese model:
https://www.researchgate.net/profile/Eryn_Grant/publication/322537216_Back_to_the_future_
What_do_accident_causation_models_tell_us_about_accident_prediction/links/
5a5eb19daca272d4a3dfcb83/Back-to-the-future-What-do-accident-causation-models-tell-us-
about-accident-prediction.pdf
http://www.harold.thimbleby.net/NICE/li(7).pdf
Perrow’s Model
Analyzing this situation in terms of Perrow's model, the matter can be said to have been tightly
coupled. This can be interpreted that there was no slack or buffer between the two items.
Actually what happened in one phase directly affected the adjacent phase. In the case of the
Ethiopian crash, there was no buffer that could be used to substitute the pilot’s fatigue. The

pilot’s failure to respond accordingly as per the demands of the flight translated directly to crash.
This implies that there was tight coupling between the pilot’s fatigue and the crash itself. No part
of the system was allowed to express itself according to its own interest or logic.
In linear interactions, one component in the DIPOSE system will interact with one or more
components that precede it or that follow it immediately. Taking from this definition, the kind of
interaction was in linear form. The operation system of the aircraft was linearly connected to
proper and safe flight via activities of the pilot. By pilot failing to give relevant command due to
fatigue, the linear operation was delinked and resulted in the crash.
Taleb’s model.
According to Taleb, it is easier to figure out fragile things than to predict an event occurrence
which may possibly cause harm. Unlike risk which is not measurable, the fragility can be
measured. In this context, the accident was a product of fragility. The main component which is
the fatigue was responsible for the occurrence of the accident. While fatigue is observational, its
impacts or degree is not measurable. In this domain, the rules for moving to antifragile from
fragile through reduction of fragility might have been considered as a means of harnessing
antifragility though its effectiveness had not been productive. The occurrence of the crash of
Ethiopian Airplane as a result of the pilot's fatigue was an indication that one can possibly detect
antifragile by the use of asymmetry test that is to say that anything with more upside than
downside from the events that are selected randomly is considered ant fragile and vice versa is
true.
Conclusion

Aviation accidents rarely occur due to single events, it is usually a chain of errors. Although
some of these errors are obvious others are not. Prevention of the worst from happening is by
ensuring that all levels of gaps present are properly closed.

References
https://commons.erau.edu/cgi/viewcontent.cgi?article=1001&context=ww-management-science
https://www.researchgate.net/publication/
304492246_Additive_manufacturing's_impact_and_future_in_the_aviation_industry
https://www.researchgate.net/profile/Thomas_Clauss/publication/
259557847_Business_Model_Innovation_in_the_Aviation_Industry/links/
54631e6a0cf2837efdb0250a/Business-Model-Innovation-in-the-Aviation-Industry.pdf
https://www.researchgate.net/profile/Eryn_Grant/publication/
322537216_Back_to_the_future_What_do_accident_causation_models_tell_us_about_accident_
prediction/links/5a5eb19daca272d4a3dfcb83/Back-to-the-future-What-do-accident-causation-
models-tell-us-about-accident-prediction.pdf
http://www.harold.thimbleby.net/NICE/li(7).pdf