You are required to conduct a review of the Human Factors analysis in the investigation report with the objective to propose solutions to prevent a similar accident in the air force. Using this accident as a case study, examine human capabilities and limitations in operating military transport planes in a high-stress situation.

Identify the possible safety and risk management issues in defence and security operations, and examine design principles to reduce human errors both in operations and maintenance of military/combat equipment. You may refer to other reliable news reports or commentaries in your review.

Question 1a

Review the investigation report and identify the human errors presented. Describe how these errors relate to physical and cognitive human capabilities and limitations.

Question 1b

Explain how human limitations contributed to the cause of the plane accident.

Question 1c

Mission planning, pre-flight preparation, take-off and landing phases, situation awareness and decision making, detection and communication of errors are very critical parts of a flight. Given this situation, examine how stress impacts performance and what can be done to manage stress in such circumstances.

Question 1d

Using Crew Resource Management (CRM) principles, evaluate the team performance of the transport plane flight crew comprising the three pilots, loadmaster and other aircrew.

Question 2a

Based on the findings from the report (case study), analyse the safety climate of the 37th Airlift Squadron, 86th Airlift Wing, Ramstein Airbase (AB), Germany, in particular, the attitude towards safety displayed among the airmen. Support your analysis with the evidences reported.

Question 2b

The pilots failed to identify the aircraft sink rate and broke down in visual scan as a result of focusing on maintaining threshold airspeed and failure to identify the Climb Dive Marker (CDM) / aim point shift associated with the rapid sink rate. The lack of discipline to perform adequate risk assessment of critical information, and failure to identify / correct risky or unsafe practices displayed by the aircrew in deviating from established procedures were evident. Illustrate how this discipline issue relates to a unit’s attitude towards safety and risks.

Question 2c

Present how a safety management system, with the implementation of education, intervention and monitoring programmes can possibly avert safety discipline issues.

Question 3a

All the pilots were reported to be good senior pilots.

MP1 was a current and qualified C-130J pilot (Note: there is no qualification differentiation between the C-130J and C-130J-30) (Tab T-17 to T-281). MP1 had 399.1 total flying hours in the actual C-130J, 259.5 primary hours, 113.4 secondary hours, and 26.2 other hours. In the simulator, MP1 had a total of 174.3 hours, 95.3 primary hours, and 79.0 secondary hours.

MP2 was a current and qualified instructor pilot and USAF Weapons School graduate in the C-130J. MP 2 had 1,591.0 total hours in the C-130J, 445.6 primary hours, 282.9 secondary hours, 561.3 instructor hours, and 301.2 other hours.

MP3 was a current and qualified evaluator pilot in the C-130J (Tabs G-82 and K-6). MP3 had 1,586.6 total hours in the C-130J, 1,824.3 in Remotely Piloted Aircraft (RPA), 2,250.3 total primary hours, 239.3 secondary hours, 607.6 total instructor hours, and 130.2 evaluator hours (Tab T-4 to T-6). Of the 2,250.3 total hours flown, 418.1 flying hours were combat hours and 1827.2 were combat support hours (Tab T-4 to T-5).

MP3 flight time for the 90 days prior to the mishap is as follows (Tab T-4 to T-6): Hours Sorties

Given the human errors discussed in this case study, propose design solutions that could have assisted the aircrew in handling the emergency during the mission flight.

Question 3b

Assuming the role of the incident’s unit commander, recommend the actions your unit/squadron need for improvement and to prevent future incidents. Your recommendations should be based on the findings of the investigation report and should include training or re-training options.