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Human Factors In Aviation

by John M. White |

Cessna 182 N23739 Accident PhotoOn the left we see the remains of a once beautiful aircraft meant to safely transport oneself from point A to point B safely... save for the interdiction of human factors in aviation. On July 20th, 2011 the pilot of N23739 departed Meridian Mississippi bound for Columbus Georgia at 4:21pm CDT along with a passenger. The pilot accepted the local controllers offer of flight following with a discrete squawk and received some vectors around rain when the pilot asked the controller for some weather information. The controller informed the pilot that his radio transmissions were unreadable and asked the pilot to try a different radio.

Small Change, Big Trouble

After a short discussion of weather the pilot was instructed to contact Atlanta Center but never contacted Atlanta Center. The controllers continued to track the aircraft while attempting repeatedly to contact the pilot, all to no avail. Apparently this is where the human factors in aviation came into play. As the pilot flew into darkness he changed his transponder from the discrete code given him earlier and began sqwaking 1200.

Continued Flight

After passing the original destination of Columbus the aircraft turned to the North East and flew in that direction for another 2+ hours. Approaching Harnett Regional Jetport in Erwin, NC, the pilot's home base, the pilot lined up with the runway 5 localizer. By now it was dark out, and the pilot-activated runway lights at the airport were dark. The pilot made a number of maneuvers around the localizer several times and after crossing the localizer for the last time began a 270 degree turn over dark wooded terrain to rejoin the final approach course.

The Ground Rushes Up

At this point the human factors in aviation caught up with the pilot has he began to lose altitude and gain speed, finally intercepting the localizer... but sadly at ground level. The aircraft plowed through trees at a high rate of speed shredding a trail of wings, tails and struts before plunging into the Cape Fear river 1/2 mile from the runway threshold.

Post Crash Investigation

N23739 Avionics Stack Showing The Transmitter Select Set To PADuring the post crash investigation it was discovered that the airplane's King audio panel was set to PA - the passenger address system which, as the Cessna manual explains, is "unused" in the Cessna 182. Because it was set to PA neither of the two valid com positions explaining how the pilot accidentally disabled his transmitters. This explains why the runway lights at Harnett Regional Jetport were dark and the maneuvering to get lined up with the runway in the dark. Apparently one of the human factors that occur in aviation is accidentally flipping a switch without realizing the consequences thereof.

The NTSB Determination

As we would expect the NTSB finding of probable cause was simply that the pilot became disoriented over dark terrain. The NTSB could have mentioned the pilot's lack of currency (12 hours in the preceding 12 months, no flights within the previous 8 months and 5 years since his last biennial check ride. No doubt a number of factors led to the unsuccessful flight of N23739 by it's 79 year old instrument rated pilot, but one of the human factors in aviation is that small mistakes early on in a flight can often times have disastrous results. A series of minor decisions combined with a small errors eventually led to the final result... an aircraft accident. In the meantime keep your wings straight and level Hersch! Please share "Human Factors In Aviation Lead To An Aircraft Accident" with your friends using the buttons below. Thanks!     Until next time keep your wings straight and level Hersch! JetAviator7+ ps: Don't forget to sign up for updates via email for "All Things Aviation" here!

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