Human Factors Approach in KNKT Aviation Investigation Analysis Presented by Capt. Nurcahyo Ray Utomo Dip. TSI Head of Aviation Investigation Sub Committee Komite Nasional Keselamatan Transportasi (KNKT), Indonesia
About KNKT KNKT is an organization, directly under the President of the Republic of Indonesia, responsible to conduct safety investigation of accident on aviation, marine, railway and public road transportation. The investigation objective is to improve transport safety and not to apportion blame or liability.
I believe: No one wants to get into an accident therefore, whatever they did or decided, they believed that it would not get them into an accident. It s all about the context.
KNKT Models of accident development This model is based on James Reason s Swiss Cheese
O R L I O
O R L I O
Analysis model (simple example) Shipping company shift roster Risk control Ship master fatigue Local Condition Ship master forget to change course at correct time Individual Action Vessel grounding Occurrence
Why ORLIO? Investigation demands to understand the whole picture; This model guides the investigators to see the condition that influences the personnel (human); It keeps dig deeper and continuing to ask why ; Put our self on the position. It s all about the context.
Investigator training Investigators are provided with several basic trainings: Aircraft Accident Investigation Fundamental; Safety at Accident Site and Bloodborne pathogen; Human Factors for Transport Investigation; Investigation Analysis; Report Writing.
Human Factors training Five days Human Factors training discuss topics Human information processing; Decision making; Human error; Ergonomics; Stress; Fatigue; Workload; Culture; Crew Resources Management; Organization influence; Hypoxia; Spatial Disorientation; Automation; Situational Awareness.
Air Asia QZ 8501 investigation On 28 December 2014, an Airbus A320 216 aircraft registered as PK AXC was being operated on a scheduled flight from Juanda International Airport Surabaya, Indonesia to Changi International Airport, Singapore. The aircraft departed at 0535 LT and cruised at 32,000 feet. At 0600 LT, the first Electronic Centralized Aircraft Monitoring (ECAM) amber advisory AUTO FLT RUD TRV LIM 1 appeared.
1 2 3 4 5 After the fourth ECAM message, the FDR recorded different signatures.
The aircraft rolled up to 54 degrees and climbed to 38,000 feet with angle of attack up to 45 degrees up, then rolled up to 104 degrees and stall. Stall warning recorded until the end of CVR recording, average rate of descend was 12,000 feet/minute and aircraft speed was very low (average 100 knots).
Aircraft history On 25 December 2014, the pilot flew with this aircraft and had the RTLU problem on the ground. After being reported to the maintenance personnel, the pilot saw the engineer pulled the Flight Augmentation Computer (FAC) circuit breaker (CB) to reset the system.
Maintenance report The A320 equipped with Post Flight Report (PFR) capable to display the aircraft system malfunction on previous flight. The pilot tends not to write on the maintenance log book considering that maintenance personnel may directly check to PFR. The maintenance personnel did not record the maintenance action, since no pilot report.
Maintenance issue Lack of the maintenance management to detect the re occurrence of failure, Lack of pilot awareness the consequences of not writing the failure in the maintenance log
Analysis Un commanded aircraft roll Electrical interruption RUD TRV LIM SYS message handling Side stick inputs Pilot recognition of stall Crew Resource Management Maintenance handling on aircraft system problem
Accimap AirAsia QZ 8501 Regulatory surveillance O Training need analysis Internal audit Hazard identification R L I O SOP Pilot upset recovery training Pilot pressure/ stress RTLU failure/ (Technical failure) Uncommanded roll Pilot witnessed maintenance action Following SOP without success Maintenance management Instruments indication Unrecoverable stall Resetting circuit breaker Defect report system Pilot understanding to aircraft system Dual input Aircraft crash into the sea Autopilot disengaged Aircraft stall
THANK YOU KOMITE NASIONAL KESELAMATAN TRANSPORTASI NATIONAL TRANSPORTATION SAFETY COMMITTEE Transportation Building 3 rd floor Jl. Medan Merdeka Timur No. 5, Jakarta - 10110 INDONESIA Telp. (021) 384 7601, 3517606 ; Fax (021) 351 7606 Website : http://knkt.dephub.go.id/knkt E-mail : knkt@dephub.go.id