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Potential Human Factors Involved in the Crash of AF 4590 The Concorde
Potential
Human Factors Involved in the
Crash of AF 4590
The Concorde
People
Air France First Officer
Failure to adhere to policies regarding takeoff weights
Assessment of knowledge (Worksafe BC 2018)
Complacency to act on weather information received prior to departure
Assess Job Requirements (Worksafe BC 2018)
Air France Captain
Failure to control others during emergency (Flight Engineer)
Assessment of Information Transfer (under pressure) (Worksafe BC 2018)
Complacency to act on weather information received prior to departure
Assess Job Requirements (Worksafe BC 2018)
Failure to adhere to policies regarding takeoff weights
Assessment of knowledge (Worksafe BC 2018)
Decision made to attempt take-off prior to achieving minimum take-off speed. Possibly due to obstruction (President's plane) ahead.
Assessment of Critical Decision Making (RSSB 2008)
Airport Runway Technicians
Failure to perform scheduled runway visual observations
Assessment of Management Decisions (Worksafe BC 2018)
Assessment of Policies (Worksafe BC 2018)
Assessment of expectations (Worksafe BC 2018)
Air France Flight Engineer
Failure to adhere to policies regarding takeoff weights
Assessment of knowledge (Worksafe BC 2018)
Complacency to act on weather information received prior to departure
Assess Job Requirements (Worksafe BC 2018)
Shutting down of engine against stated protocols
Assessment of Critical Decision Making (RSSB 2008)
Assessment of workload (during critical incidents) (Worksafe BC 2018)
Air France Baggage Handlers
Loading of 500 kgs of Extra Baggage into rear hold just prior to flight without informing flight crew
Assess Workload Analysis (RSSB 2008)
Assess Information Transfer (Worksafe BC 2018)
Air France Engineers
Maintenance System
Failure to replace metal spacer during routine service of Concorde's landing gear
Assess Procedural Compliance and Documentation (FAA 2014)
Continental Engineer
Maintenance System
Failure to follow set maintenance protocols regarding metal strip
Assess Procedural Compliance and Documentation (FAA 2014)
Management
AF Management failure to ensure all crew are competent in the tasks they are assigned
Assess task and training requirements (RSSB 2008)
Airport failure to carry out schedule visual inspections of runways for debris
Management delay inspection due to exercise being conducted on runways
Assess the job design, specifically work schedule and job requirements (Worksafe BC 2018)
Failure of baggage handlers to inform flight crew of excess baggage that was added prior to flight
Assess information transfer between all stakeholders of the organisation (RSSB 2008)
AF Management fail to ensure policies are adhered to regarding takeoff weights
Assess procedural compliance and documentation (FAA 2014)
AF Management failure to ensure maintenance systems are adequate and functional
Observational Analysis (RSSB 2008)
Workplace
Stress of attempting to control the plane with multiple failures
Assess ease of use in emergency situations (Worksafe BC 2018)
Concorde's onboard warning lights and emergency control systems
Assess ease of use in emergency situations (Worksafe BC 2018)
Stress of ensuring charter flight passengers arrive at New York in time to catch their departing cruise ship.
Assess feedback from stakeholders regarding delays and act accordingly (Worksafe BC 2018)
DC-10 Replacement strip
Ensure correct replacement procedures are followed
Assess maintenance instructions for usability and ability to be understood (FAA 2014)
Assess procedural compliance (FAA 2014)
Concorde Landing Gear Design
Ability to leave out vital components when replacing after service
Assess maintenance instructions for usability and ability to be understood (FAA 2014)
Ensure compliance with safety directives
Assess management decisions (Worksafe BC 2018)