Human Factors Analysis

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Utah Valley University *

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2130

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Information Systems

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Dec 6, 2023

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Human Factors Analysis David Hernandez Utah Valley University Global Campus AVSC 2130 – X51 Professor Messerschmidt September 12 th , 2021

The SHELL model is representative of the human interactions of each component in a system. The acronym stands for software, hardware, environment, liveware and liveware. Liveware which is the center of the model can be thought of as the ergonomics behind a system. According to the Civil Aviation Safety Authority, how the liveware interacts with the software, hardware, environment and other liveware can be used to determine how individuals behave and determine if there is a breakdown between two components which can result in human performance problems (2014). According to the NTSB’s accident report, there were four components that were thought to be responsible for the crash. A failure to monitor airspeed, the flight crew having banter not related to the task at hand, the captain’s failure to handle the situation appropriately, and Colgan Air’s procedures it had set in place for managing approaches during icing conditions (2010). Of these they are showing a liveware-to-hardware relationship, a liveware-to-liveware relationship, a liveware-to-environment relationship and a liveware-to-software relationship, respectively. When you read the report about the crash, it shows that there was in fact a trigger warning built into the aircraft’s hardware system that is supposed to warn the pilot in icing conditions to increase their speed accordingly to counteract the drag forces of the built-up ice. According to the research done by the NTSB, all of those systems were fully activated at the time of the stall, therefore showing that there was a liveware-to-hardware malfunction due to the pilot not seeing the warning on the dashboard. In the National Geographic re-enactment video, it says there was “A violation of a rule called the ‘sterile cockpit’, which bans non-essential conversation during critical phases of the flight.” ( Colgan Flight 3407 ). This would be an example of a liveware-to-liveware issue, where the crew specifically interacted with each other when they knew it was wrong to do so. This

could also be considered a liveware-to-software issue, where there may have been either a misunderstanding or a blatant disregard for a rule in an employee manual. Either way, it is quite obvious that this was a major mistake causing distraction at the time of failure. The captain’s failure to manage the situation appropriately came in multiple forms. First and foremost, according to his training when he noticed the trigger warning he should have put the nose down and gained speed instead of lifting the nose up, increasing drag and slowing the speed of the aircraft causing an inevitable stall. Secondly, it was obvious according to the NTSB research that the captain was very fatigued at the time of the flight. The captain through experience should have known that he was not in shape to handle an aircraft on this given day. Both of these things show a failure of human reaction to the environment around him. Lastly, the procedures put in place by the airline for how they handled situations with the ref speed indicator were inadequate and the pilots were poorly trained on how to use it appropriately. In the NTSB report it was even said by one pilot who worked for the company that “he had turned the ref speeds switch to the off position after descending out of icing conditions but had planned to “mentally” add 20 knots to the airspeed if ice had resumed on final approach” (2010). This shows that there was an obvious breakdown in liveware-to-software because of either a lack of understanding of employee manuals and procedures, or an inadequate rule written by the company on how to appropriately use the technology. In conclusion, there were many factors that played into Flight 3407 crashing that evening in New York. You can see that human error can be affected by many different variables throughout a system. Not only were the pilots tired, but they were not following there training, they were disregarding rules such as a “sterile cockpit”, and they were following procedures that were poorly written to begin with. It is never a good thing when these fatal accidents happen, but

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