Aircraft Accidents: Investigating Human Error

Abstract

On August 15, 1995, at approximately 2000 hours, a flight of two (2) United States (US) Army UH-60A BLACKHAWK helicopters departed from Royal Air Force (RAF) Akrotiri (in southern Cyprus) for the US Embassy in Beirut, Lebanon utilizing Night Vision Goggles (NVG). Not long after departure, with both aircraft at approximately 800 feet above ground level (AGL) over the Mediterranean Sea, the second aircraft radioed the first aircraft informing them their“#l engine was on fire.” Approximately 45 seconds later, the lead aircraft impacted the water at over 200 knots killing all four crewmembers and destroying the aircraft. After learning of the mishap, the US Army Safety Center (USASC) dispatched a team to the site. The Accident Investigation Board would utilize its 3 $W$ approach to answer three questions: “what happened?”, “why did this happen?”, and “what can we do to prevent it from happening again?”! The investigation would be conducted in four phases and focus on three areas: material factors, environmental factors, and human factors. It was determined that the aircraft crashed because of human error. However, why the human error occurred was not determined. In order to answer this question, two exhaustive studies were initiated. The studies focused on the design of the cockpit controls (completed 1997) and the pilot's reactions to a single engine failure in a twin engine aircraft (completed 1999). The studies took years to complete with no conclusive evidence as to why the wrong engine was shutdown resulting in the UH-60 accident off the coast of Cyprus. Investigating human error can be a long and arduous process and sometimes one is not able to determine the “smoking gun” for “why” a human error was made. As seen in the Cyprus UH-60A accident, the smoking gun was never found as to why the operating engine was shut down. It is incumbent of all in aviation to be cognizant of possible human errors in order to prevent future tragedies. We must continually strive to make aircraft operations safer while ensuring that new and improved cockpits do not unknowingly induce human errors that could have fatal consequences.