Case Study on Human Error

JFK airport authorities had been told to keep a higher landing rate than safe at 33 planes attempting to land per hour, on one runway the typical rate being 52 in good weather, with all runways open. The airport was experiencing a rate of 27% missed approaches, with 39 planes waiting in holding patterns for clearance to land and dozens waiting to take-off. Sequence of events The 707 had been placed in holding patterns for a total of 1 hour and 17 minutes during three separate occasions over the U. S. east coast. There were 6 different air traffic controllers that had communicated directions to Flight 52 after they entered U. S. airspace, adding confusion and un-transmitted messages, yet at the same time not providing any more crucial information such as weather conditions. The Flight Engineer failed to communicate the urgency of the low fuel situation to the pilot and co-pilot after they passed the point of no return and had to remain committed to JFK –by not having enough fuel to get to their alternate airport at Boston, 342km away from JFK. He also failed to emphasize the importance of landing in their first attempt because they would not have enough fuel to loop around and try again. Another discrepancy was how the co-pilot used the words â€Å"Low Fuel† and â€Å"Priority† rather than â€Å"MAYDAY† and â€Å"Minimum Fuel† while communicating to ATCs. There was a lot of crucial information left out or misinterpreted and not so important information repeated, which could have easily been avoided without the language barriers in place. In terms of the Swiss Cheese model there were many holes in the conversations between ATCs and the flight crew, similarly between the flight crew and passengers, where they weren’t even given a warning. Causes and factors During the chase to point the blame on someone, Avianca stated to investigators that the phraseology used by their pilots was correct as per their training -whether it matched the standard English phraseology used by IATA countries or not they were only following what they thought to be proper protocol. Investigation by the NTSB found many holes in the events leading up to the crash, due to both active and latent failures by the crew, ATCs, and airport management. The leading causes can be attributed to airport mismanagement, inconsistent training for pilots that should have English proficiency, and overall poor communication between ATCs and the flight crew. Repetitive flaws in a system run by human beings shows a clear link in the lack of Risk Management, causing communication gaps referred to as holes in the Swiss Cheese model for human error. CRM stipulates training crew in assertiveness, inter-personal communication, leadership and decision-making, to name a few key attributes these pilots were in need of addressing prior to the incident. There was no problem of experience as both the pilot and co-pilot had flown that route before, and the pilot had 27 years of experience flying for Avianca. The implementation of Crew Resource Management techniques in the previous years must not have been as streamlined as intended, at least not for the American ATCs and those training under Avianca in Columbia. If one lesson would be learned from this it would be that had the crew received effective and efficient CRM training on time, they could have saved 73 people from an almost completely preventable death by human error. References AskCaptainLim. com {comments}. Aviation, Air Crash. Avianca flight 52: why the pilots failed to use proper phraseology. (Last updated October 19, 2008). Retrieved from: http://www. askcaptainlim. com/-air-crash-aviation-34/830-avianca-flight-52-why-the-pilots-failed-to-use-the-proper-phraseology. html Cushman Jr. , John H. New York Times, Archives, Collections, Fuel. Avianca flight 52: the delays that ended in disaster. (February 5, 1990). Retrieved from: http://www. nytimes. com/1990/02/05/nyregion/avianca-flight-52-the-delays-that-ended-in-disaster. html? pagewanted=allamp;src=pm National Geographic, Cineflix Productions. Air Crash Investigation series, Episode S02E05 Missing Over New York. Retrieved from http://natgeotv. com/ca/air-crash-investigation/videos/deadly-delay Wikipedia. org, Avianca Flight 52. (Last updated March 22, 2013). Retrieved from: http://en. wikipedia. org/wiki/Avianca_Flight_52

Doing history essay Example | Topics and Well Written Essays - 1500 words

Doing history - Essay Example Finally, a process of purification followed. The process also involved isolation of lepers from the society with the aim of ensuring purity. The plague, however, is a symbol of modern measures for ensuring a disciplined society. Response measures to a plague symbolize mechanisms and authorities for identifying and evaluating indiscipline for adequate corrective measures. Operation of similar forces to brand those who are not disciplined and to transform them towards an organized society is then discussed (Foucault 195- 199). Foucault also discusses Bentham’s panopticon, another symbol for the modern day authority. In the figure, each prisoner was placed in a room that could be watched from a centralized tower. Each room had two windows, one directed towards the tower and another in the opposite direction and open to light. The light would then illuminate prisoners and allow an observer at the tower to see whatever happened in the rooms. No communication is however possible bet ween prisoners or between prisoners and the observers. Unlike the previous approach to isolation, the panopticism model offered access to light and visibility and improved efficiency of discipline. It allowed for use of lesser personnel and effectiveness of administration (Foucault 200- 204). The author’s discussion of the two imageries, the plague and Bentham’s panopticon, are ways of seeing history and developed bases for the author’s exploration of history. Based on the images, the author explores many questions that form major themes of the article. The first question can be framed as follows, how is power attained and managed in ensuring discipline? The author uses both imageries to answer this question. From the plague imagery, the author reports that power is attained through mobilization of authority for extensive influence and through isolation of subjects. The panopticon approach is a replica of the approaches but

Breyer Meat Packing Case Study Essay Example | Topics and Well Written Essays - 500 words

Breyer Meat Packing Case Study - Essay Example 14). Awareness of the details surrounding the cumulative trauma disorder would assist in informing the employees and the employer that â€Å"carpal tunnel syndrome is the disorder most commonly reported for this industry and is caused by repeated bending of the wrist combined with gripping, squeezing, and twisting motions. A swelling in the wrist joint causes pressure on a nerve in the wrist. Early symptoms of the disease are tingling sensations in the thumbs and in the index and middle fingers. Experience has shown that if workers ignore these symptoms, sometimes misdiagnosed as arthritis, they could experience permanent weakness and numbness in the hand coupled with severe pain in the hands, elbows, and shoulders† (Occupational Safety and Health Administration, N.D., par. 15). Question #2:  Ã‚  Assume  OSHA is  applicable.   Provide two (2) specific  recommendations to address the issue.

Essay on Utopia - Disneys Utopian Community -- Exploratory Essays Res

Disney's Utopian Community      Ã‚  Ã‚  Ã‚   The concept of utopian communities is a hot new commodity among major enterprises. The Walt Disney Corporation is currently marketing its own community called Celebration. Disney, known for creating worlds of fantasy through theme parks and movies tackles reality. According to architect Robert A.M. Stern, the idea behind Celebration is to "recapture the idea of a traditional American town, traditional in spirit, but modern in terms of what we know about how people live"(Oilande 1). Also, the town is "structured around the five cornerstones of life in Celebration: community, education, health, technology, and place"(Oilande 2). Celebration uses this concept to create a special utopian vision. Despite contradictions of artificiality, regulation, and price, Celebration is a good utopian vision because it has a sense of community, an outstanding educational system, and a credible health care system.    The notion of a artificial or theme park feel has come up as a possible concern. "The town resembles a movie set with the neat-and-pretty homes like facades"(Oilande 5). Disney is taking a community and making it a fantasy of the lost traditional suburb one would see on "Leave it to Beaver" or "Pleasantville". As one visitor of the new community stated, "the minute you drive into Celebration's property, Disney's visual magic takes hold. White fences reminiscent of Kentucky's Bluegrass Country, surround the property. Upon a closer inspection they prove to be plastic. And from a distance, the preview center looks like a classical mansion. It's not. It's a faà §ade. Behind the mansion door is a pre-fab"(Wilson3). This ideal is created in a conference room at a corporate office somewhere and it i... ...able: http://www.detnews.com/EDITPAGE/SAT1028/CANTOR.html. Cottrell, Kenny. Celebration: Frequently Asked Questions. Tuldp. Avaliable: http://www.tudlp.org/celebfaq.html. Disney. General Celebrations Facts and Figures. Available: http://www.primenet.com/~dbrady/oliande/celebfacts.html. February 1997. Hoffman, Derek. Review of Disney's Celebration. Avaliable: http://mason.gmu.edu/~dhoffman/week4.htm. 12 February1997. Lease, Daryl. Village theme for Disney: Wonderful World of Wal-Mart. The Free Lance-Star. Avaliable: http://.starweb.infi.net/columns/lease/dl032396.htm. 23 March1996. Oliande, Sylvia. A Visit to Celebration. Avaliable: http://www.primenet.com/~dbrady/oliande/celebration.html. 9&10 March 1997. Wilson, Craig. Celebration puts Disney in reality's realm. USA Today. Avaliable: http://www.sjsu.edu/faculty/wooda/usacelebration.html.

How Far Was World War One Responsible for the Overthrow of Nicholas II, 1917 Essay

The First World War was indeed a major cause of the Tsar’s overthrow in the February Revolution. However, it was not the sole factor – rather, it was a catalyst and a focus that allowed all the other preexisting factors to boil over into revolution. The First World War caused a multitude of problems for the peasants of Russia, both at home and on the front. The vast majority of conscripts were from farming villages, meaning that less men were at home to till the soil and produce food – it also meant a general slump in food production as a whole, resulting in a shortage of grain to feed the hungry industrial workers in the cities. As the death toll of the backwards, ill-equipped Russian Army was devastatingly high, this meant that virtually everyone in Russia would lose someone they knew, regardless of social status. The lack of reliable supplies of food and basic commodities such as coal (most of it was going to the front) further crippled the economy, especially during the harsh Russian winter. This caused riots and protests to break out, ones that the once-Royalist troops were now unwilling to curb. Economic problems aside, the Tsar also made several extremely misguided decisions that further damaged his reign. While he intended to use the Great War to secure his status as Father of the People, Nicholas failed utterly in two respects. Firstly, he left directly to command the front – this meant that all the blame for every military defeat fell on his shoulders and not some scapegoat commander. He would no longer be able to divert the illwill of the people should defeats occur, and they did indeed. Secondly, he left the Tsarina in charge of running the Empire while he was away, and this was a disasterous choice on many levels. Tsarina Alexandra was a German-born princess, which naturally aroused severe animosity on the part of the people who were actually fighting the Germans. Even worse, she listened to Rasputin in everything, sacking many loyal ministers and replacing them with his incompetent cronies. This threw the already-disorganised Russia into even greater disarray, preventing supplies from getting through to the hungry workers and wrecking the economy even further. The Russians called her a spy and accused her of conducting an affair with Rasputin, whom they loathed. They could not fathom why an uncouth, dirty peasant would find so much favor in the eyes of their monarch. The status of the Royal Family was at an all-time low in the eyes of the people, and everyone began to talk about how they should be disposed of – in every class of society, no less. Further compounding the problem was the fact that the vast majority of the Russian Army was at the front. Unlike the 1905 Revolution, where the Tsar could quickly sign a peace treaty with Japan and get his soldiers’ loyalty with generous payments to crush the revolution, the First World War showed no signs of ending. The army’s morale was incredibly low. With mass desertions almost every day due to the obsolete nature of both Russian millitary tactics and equipment, many soldiers had gone back to the cities of Petrograd and Moscow to live with their families. This meant that when the tide of public sentiment finally broke out against the Tsar in another revolution, these soldiers turned in support of the revolutionary cause. Because of the poverty and chaos caused to civilians by the war, the loss of millitary support and disasterous handling of the army, and finally the Tsar’s own mistakes, the Romanov Dynasty was at an end. That being said, there were other factors that stemmed from before the Great War. After the 1905 Revolution, the Tsar had promised to make his rule more constitutional. These token promises were shown in the October Manifesto, his abolition of redemption payments and the creation of the Duma, an elected parliament who in theory would help him run the empire. However, these were merely halfhearted, hollow words. The Tsar practically ignored the Duma, dashing the hopes of the middle class and destroying their trust in him. In addition, he released the 1906 Fundamental Laws, which shrewdly reestablished his sovereign authority by stating that everything in the October Manifesto was permissible – but only in the limits of the law, which naturally the Tsar still controlled. Additionally, the Tsar had his new Chief Minister Stolypin carry out land reforms. He allowed the more capable peasants to accumulate the holdings of their neighbours, creating a prosperous class of ‘kulaks’ or wealthy peasants. It was hoped that this would both stabilise food prices and create a ‘barrier to revolution’, a lower-middle class that would be loyal to the Tsar and unwilling to upset the favorable status quo. It mostly worked. However, what Stolypin had overlooked was the fact that many peasants would be displaced by this new mini-elite. Evicted from their homes and encouraged by the government to settle on the Trans-Siberian Railway, they traveled many miles in cramped and cold conditions only to find that all the prime land had already been bought up by wealthy capitalists. Feeling cheated and betrayed by their Tsar, these peasants drifted into the city and found meager work in the factories. When the time came for a second revolution, they were ready. Stolypin himself was assassinated in 1911, leaving Russia a disorganised mess. No other statesman of his caliber would ever step up again in the Tsarist regime. The First World War was a major cause of the 1917 Revolution, but not the sole one. Rather, it was a climax that focused and pushed all previous elements over the edge.

Life of Alexander Calder, Sculptor of Massive Mobiles

Louisiana High School Athletic Association - 1574 Words

Louisiana High School Athletic Association Coty Kibodeaux February 8, 2015 Introduction The Louisiana High School Athletic Association (LHSAA) was formed in order to better regulate and develop the high school athletics of the state. It currently governs all high school sports for Louisiana, for both males and females and will soon celebrate its centennial in 2020. The LHSAA finally got its permanent home in Baton Rouge in 2010 and currently governs 16 different sports with various classifications based on school enrollment. History The inception of the idea for the formation of the LHSAA occurred in October of 1920: a group of high school principals met in Baton Rouge after deciding that high school athletics did not have a proper amount of development and regulation. C. A. Ives initially appointed a committee to draft a constitution for the association and those members were P.H. Griffith, S. M. Brame, P.C. Rogers, and Grover C. Koffman. This committee decided that membership within the LHSAA included approved high schools within the state. Originally, there was only one type of school classification: Schools with 110 boys or more (Class 1A) and schools with 110 boys or less (Class B). The original schools had to give up the large sum of $2.00 to be a member of the LHSAA. In about 1930, Class 2A (more than 300 boys) was added. Class C (45 boys or less) was created later in 1949. Three more classifications were added in 1954, 1971, and 1991 to give a total of sevenShow MoreRelatedMedicine Physical Therapy Essay1481 Words   |  6 Pagesconsidering becoming a Sports Medicine Physical Therapist, one should prepare for the amount of education and training required to fulfill the job. It is crucial that anyone going into the medical field earns a high school diploma. College admissions directors will be looking for exceptional high school education backgrounds. 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