A sociotechnical systems analysis of aircraft aerodynamic stall events

Abstract

In 2009, Colgan Air Flight 3407 had a fatal crash in New York due to an aircraft aerodynamic stall. Previous reports had placed the actions of the crew as the cause of the incident; however, this work provides a sociotechnical systems analysis of the events that led up to the fatal accident. An Accimap analysis provides a top-down systemic analysis of Flight 3407, considering the high-level governmental and regulatory agencies involvement. An online survey with 47 airline pilots provides a bottom-up review of pilots’ perceptions and decision-making in response to aerodynamic stall events. Combining the two approaches generates a holistic approach to managing aerodynamic stall events. Analysis of Flight 3407 identified contributory factors within the higher regulatory and company levels. Furthermore, questions of appropriate training were raised by the pilots within the survey results regarding the immediate response to a stall event which commonly affords a startle and/or surprise response. The impact of “startle and surprise” on the pilots’ response to this situation was identified as a key area to focus on, with design and training recommendations provided. We consider these within the context of recent training recommendations in the industry.