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Beech King Air 200 Crash and Human Factors Case Study

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Updated: Jul 4th, 2021

Human Errors

As established by the National Transportation Safety Board, this paper discusses the probable cause of Beech King Air 200, N501RH as related to human factors. The accident occurred because the crew lost situational awareness while making an attempt to land (Wise, Hopkin, & Garland, 2016). For instance, throughout the approach of the localizer runway, the aircraft was actually five miles ahead of what the first officer and captain believed they were. Despite having an accumulative 12,000 hours of flight experience, the crew miscalculated their position when communicating or getting instructions from the ground control tower (Strauch, 2017). Specifically, the aircraft ought to have been at an altitude of 2,600 feet and not 4,000 feet at the outer locator market (LOM). The variance of almost 1,400 feet is not negligible. This means that the plane approached the landing point when it was at an altitude of about 2,600 feet instead of the recommended 1,340 feet. The miscalculation as contributed by human error resulted in the missed approach point (MAP).

Another mistake made by the crew was a wrong climbing turn at the MAP. Actually, the first officer and the captain ought to have made a right climbing turn towards the LOM in order to level off at an altitude of about 2,600 feet, which is safe for approaching a landing attempt. However, even after passing the missed approach point, the aircraft continued to steadily descent from an altitude of 2,600 feet before leveling off at about 1,400 feet. Again, the plane climbed further ahead for about two extra miles after passing the airport by 8 miles. The miscalculation resulted in a collision with the rising terrain. These revelations indicate that the flight crew failed to properly and accurately execute the standardized approach procedure instrumentation despite constant communication with the ground control. The crew did not effectively implement the published missed-approach procedure (Griffin, Young, & Stanton, 2015).

The flight crew members were victims of human error by failing to use the existing navigation aids to constantly monitor or confirm the position of the aircraft before and during the landing approach. Moreover, the air accident investigation report indicated that the flight crew might have ignored the DME and ADF and instead relied on King KLN 90B GPS. Although the GPS is IFR-capable, its usage in pre-accident circumstances is not certified, especially in IMC (Lowe, 2016). As a result, the crew might have assumed the plane’s approach as normal despite having been on the wrong waypoint.

Another probable error in human judgment as contributing to the accident is the wrong reference. Since the flight crew over-relied on GPS in LOM navigation instead of the standard ADF. Moreover, the crew was given a landing clearance sooner than they expected and decided to continue the aircraft turn with the same altitude in the final landing approach (Strauch, 2017). The crew could have avoided this confusion if they had relied on the ADF. In addition, the data recorded on the radar indicated that the aircraft’s position at the time of attempted landing was not at the proper altitude or point.

Avoiding the Accident

The management of Hendrick Motors could have adopted several measures to prevent this accident from occurring. For instance, they could have created a standardized flight guideline manual that incorporates all the support instruments instead of overreliance on GPS. For instance, if ADF was activated, the accident could have been avoided since this instrument can give accurate information to the crew about the position of the aircraft and surrounding terrain at the time of landing (Strauch, 2017).

References

Griffin, T., Young, M., & Stanton, N. (2015). Human factors models for aviation accident analysis and prevention. New York, NY: Ashgate Publishing, Ltd.

Lowe, P. (2016). Hendrick King Air crew lost situational awareness. Web.

Strauch, B. (2017). Investigating human error: incidents, accidents, and complex systems. New York, NY: CRC Press.

Wise, J., Hopkin, D., & Garland, D. (2016). Handbook of aviation human factors (2nd ed.). New York, NY: CRC Press.

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"Beech King Air 200 Crash and Human Factors." IvyPanda, 4 July 2021, ivypanda.com/essays/beech-king-air-200-crash-and-human-factors/.

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IvyPanda. 2021. "Beech King Air 200 Crash and Human Factors." July 4, 2021. https://ivypanda.com/essays/beech-king-air-200-crash-and-human-factors/.

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IvyPanda. (2021) 'Beech King Air 200 Crash and Human Factors'. 4 July.

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