Essay Example on Lion Air Flight 610: First Major Incident of Innovated Plane

Introduction

Lion Air Flight 610 was a domestic flight that was scheduled to fly from the Soekarno-Hatta International Airport (WIII) to Depati Amir Airport (WIPK). Contrary as intended, the planed developed severe mechanical damage after departing at WIII and crashed into the Java Sea 13 minutes later (Koto, 2019). The number of people on board was 189 and included two pilots, 11 passengers, and six flight attendants. In reality, this was the first significant event that involved a newly innovated and developed Boeing 737 MAX series of planes that were introduced by 2017. Additionally, various aviation reports and assessments have shown that it is the deadliest incident in the 18-year history of the Lion Air, based on the fact that it surpassed the 2004 crash in Surakarta that claimed the lives of 25 persons on board. Additionally, it is the second deadliest aircraft accident coming behind the Garuda Indonesia Flight Accident. As part of the preliminary assessment to unmask the possible causes of the accident, the government of Indonesia deployed a tasked team to perform a rescue operation. Notably, the team found the debris early the same morning of the accident and recovered several human bodies from the 280km wide area. The first victim was identified two days after the aftermath. In the same way, the flight data recorder was also found days later, as well as the recovered analysis.

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Before the departure, it is evident that the Cockpit Voice Recorder (CVR) was able to capture the records of the entire flight crew preflight discussion and briefing that mentioned that some of the equipment such Deferred Maintenance Item (DMI) of Automatic Directional Finder (ADF) being unable to be serviced (Koto, 2019). However, the CVR failed to mention the discussion of the crew about the previous challenges faced by the aircraft. While it is evident that the official reports linked the mechanical problems associated with the Cockpit were the primary causes of the incident, it is worth noting that the human-centered factors significantly contributed to this incident (Morais et al. 2019). Broadly, the interaction between the pilots, the flight crew, and the engineers with the machines and themselves played a significant role in the Lion Air Flight 610 accident. This paper will provide an analysis of how human factors played a part in the Lion Air Flight 610. Broadly, it analyses the roles of various parties involved, such as the pilot, crews, and engineers.

Disregard of the Situation and Awareness

The investigation report to unmask the accident's causes revealed that the pilot was exceedingly aware of the possible conditions that could lead to accidents if not addressed. After the flight, for instance, the captain's initial response as the PF, to the activation of the stick shaker during liftoff and the cautions that would later follow did not comply with the aviation regulations. For example, it was a requirement to maintain the pitch 15 degree as well as the take-off thrust that existed. However, after the captain transferred the control to the FO, he checked the flight instruments and established that they were erroneous.

A closer look at the situation reveals that the captain's decision to transfer the control before the crosscheck of the tools offered an indication that he was fully aware of the repetition of the previous challenges that were experienced about the SPD and the ALT flags, as well as the replacement of the AOA sensor on the plane. There were several instances whereby the aircraft did not demonstrate the required positive climbing, especially during the acceleration and clean-up. Following the instructions from the deadheading crew on the observer's seat that the plane was diving downwards, the pilot instructed the FO to command and direct the plane purposely to retain its appropriate climb line (Morais et al. 2019).

The FO suggested that the aircraft was considerably heavy hold back, which implied that the FO was unable to navigate and control the plane when it began immediately. The nose-up trim was released. An assessment of the aircraft revealed that the pilot was prompted to cut-out the Stabilizer Trim and thus made the plane under control, thus enabled the flight team to fly the plane generally through the use of the manual trim (Morais et al. 2019). To a greater extent, therefore, the pilot was able to project the future action of the elements within the environment. Besides, they were aware of the situation, because the previous accidents in airline history had been contributed significantly by similar problems. It is critical to note that accurate mental models are essential in aviation to help the users or captain, in this case, utilize the systems for their intended purposes (Morais et al. 2019). The fact of the Lion Air Flight 610 was an implication of improper use of the system, that often n lead to accidents (Koto, 2019).

Wrong Decision to Continue to Fly

The preliminary investigations revealed that the crew was aware that the aircraft had developed problems, and the prevailing circumstances at that time were not favorable to continue flying. Ideally, this was an apparent attempt of trying to gamble with the aviation regulations. While it is evident that the flight crew was able to control the aircraft to its appropriate flying path, the captain proceeded to declare urgency call (PAN PAN) to Denpasar Approach Controller and reported about the challenges they were facing (Morais et al. 2019). He further conducted a Non-Normal-Checklist of Airspeed. This action resulted in the aircraft pitching down, prompting the captain to return the cut-out position consequently (Koto, 2019).

It is at this point that the captain was supposed to request the control tower about the need to return to the ground to avoid any potential accident. However, the captain defied all the flight requirements and decided to continue the flight. This happened even though he was aware that the existing conditions could be catastrophic. The deadheading pilot had further advised him weather returning to the station would be appropriate, but all these did not work. The pilot continued to activate the stick shaker throughout the entire flight. The reliable PFD was also placed on the FO side as the plane was being flown on the manual trimming. As this happened, the captain developed the confidence to reach his destination because he was able to control the aircraft at that time and that the weather was also conducive.

According to the Quick Reference Handbook, it is not possible to develop a checklist for all the conditions that can be perceived and in a situation where multiple failures are bound to occur. Under these circumstances, the flights may require the need to make a combination of the elements of more than one checklist. In all situations, therefore, the pilot must conduct an assessment of the situation and utilize sound judgment to determine the most appropriate and safest course of action. In the same way, the FCTM asserts that the pilot-in-command must decide to continue flying as planned or return in a non-normal situation. While this regulation may seem like a justification for the pilot's decision to keep flying in this case, it was wrong. On this flight, the decision to continue operating was based on the "land-in-the-suitable airport" requirement, which was subsequently absent in the checklist (Koto, 2019).

Upon the decision to fly, the crew informed the approach controllers that they had managed to operate and navigate the aircraft to its appropriate flying path. This was an indication that they had managed the situation. Upon contacting the Upper West Madura Controller, they called and transmitted an urgency call (PAN PAN) with the additional information that they were facing instrument challenges and requested to maintain the flight level 280 (Morais et al. 2019). A closer analysis at this request reveals that the entire flight crew was aware of underlying system problems within the aircraft. They were informed that they could not proceed with the flight at an RVSM (Reduced Vertical Separation Minima) level. After being transferred to the Upper West Semarang, the team mentioned the challenges they were facing again, giving the additional information. They later asked for an uninterrupted descent path profile. Ideally, all these actions were indications that the crew was aware of the underlying aircraft conditions, which required more simplified path management until approach and landing were achieved (Koto, 2019).

Historically, the decision to continue with flight under these circumstances has always contributed to the plane crash in most airlines. Consequently, the decision to continue a flight with stick shakers remaining activated throughout is not common. The Boeing records analysis demonstrated that the events associated with the stick shaker activation during or briefly after the departure on Boeing 737 aircraft took place 27 times from 2001 to 2018 with the majority of the crews in the cases choosing to make returns to the airport (Koto, 2019).

The previous action in the Lion Air Flight 610 presented the fact the captain knew the need to use all the available resources to alleviate the issue to complete the flight to the required destination despite the rise in the workload and traumatizing situation. A severe problem of lack of communication is therefore portrayed as a factor that played a significant role in this case. Investigation revealed that a lack of clear and effective communication between the flight crew significantly contributed to the struggle to command the aircraft (Morais et al. 2019). Based on the fact that there were various faults in the aircraft system in the previous day before the accident, the plane should have been grounded. Additionally, it is evident that the co-pilot was further not familiar with the recovery approaches and had encountered difficulties as part of his training. Even though the pilot-in-command was able to lift the nose of the plane for more than 20 times, the first officer in charge was incapable of completing the checklist, deactivating the MCAs. Reduced task performance and reduced verbalization led to the inability to communicate or control the plane, leading to its crash (Koto, 2019).

Engineering Errors and Decisions

Morais et al. (2019) reports that the investigation further revealed that the engineering decisions made as part of the flight constituted a severe human error that led to the crash and subsequent loss of lives for all the people on board. The engineer in Manado provided the suggestion to the flight crew to continue the fight. He believed that the problem rectification would be appropriately performed in Denpasar. This was also in consideration of the fact that SPD and ALT flags did not appear on the Pilot's PFD (Koto, 2019).

There are thus higher possibilities that the plane was realized with the known possible recurring problem. In this sense, it would have been grounded instead of check-up. However, the engineer at Denpasar viewed that the issue had emanated recurrently and opted to replace the left AOA sensor. Broadly, this replacement proved to address the problem faced previously. However, the installation of the AOA sensor was not conducted as per the guidelines indicated because it misaligned by 21 degrees and resulted in multiple other problems.

Inadequate Training

According to Morais et al. (2019), the flight crew's inadequate training has been reported to be a significant cause of the accident in this case. Studies have shown that training forms an integral component of safe-machine interactions.