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Human Machine Systems 2011

Air crash & Human Machine System

Abhishek Khokle

Auckland University of Technology


This research paper is about the human machine interaction & the ambiguity & confusion that
results from this interplay. This is explained with the help of an air crash accident that
occurred near Cali, South America. Its investigation report clearly blamed the pilot for the
accident. The role of Human machine factor & how it affects human beings is explained in
detail in this report.

Some types of Human Machine interactions are explained as below:

• Direct Control: It deals with physical contact between Human & tools (machines) to
operate certain equipment. And the dynamics of human action is required to get the
desired overall performance. For example, driving bicycle, cars, etc

• Intermittent control: Here, the actions are not physically controlled by humans but
they are visualized by humans’ n controlled by the mechanical systems operated by
human beings. For Example, Lifting or moving of containers, mud etc done using

• Supervisory control: This includes human supervising an automated system. Human

needs to just to start/stop operations, change co-ordinates, or monitor the system
functioning. For example, CNC machines, Flying airplanes etc.

There are behavioural models developed for easing the Human machine interactions which
are as follows:

• Skill Based behaviour: This is the behaviour one normally doesn’t think about. He
learns it by time. And gets so used to its performing that the mind is become used to it
& doesn’t require any response for performing the task.

Human Machine Systems 2011

• Rule Based Behaviour: This behaviour requires one to follow a certain standard
operating procedure to carry out a task. One can learn it or is complete information
about the task operation by an expert.

• Knowledge Based Behaviour: this behaviour is developed by individuals based upon

their knowledge. This occurs when one is not aware of the work he has to perform.

These are few tools which we would be using in this report to discuss an air crash

How do the air crash accidents occur? There are several answers for this question like engine
malfunctioning, pilot error while flying, incorrect area co-ordinates used, Miscommunication
between the air traffic controller & the flying crew, errors caused by the ATC while directing
the aeroplanes or while navigating, or aeroplane being hit by a bird & many more can be
listed. But considering the investigation reports of many air crashes, it can be said that
Human factor or human error has been the most striking feature for these accidents. Humans
tend to panic in emergency situations, & same thing happens with the air craft pilots too
leading to fatal crash of the air craft.

Miscommunication or language barrier seems to be one of the key factors for accidents.
Especially in countries where English is not spoken so commonly.

Engine Malfunctioning errors are pretty rare but have occurred in many cases.

Talking about panic during sudden or instant situations, pilots or the flying crew do get
confused thinking the best way out possible. So such decisions can either get them wrong or
can get them through. If it gets them wrong then the result can lead to fatal crash. So the
blame for such accidents gets entirely on the Pilot. This is the classic case of Human-machine
interaction. As the pilot fails to control the machines appropriately, leading to accident.


Human Machine Systems 2011

This Air crash accident occurred on 20th December1995 at 21:42 Eastern Standard
Time(EST).It was an American Airlines Flight 965 (AA965), a Boeing 757-223, N651AA, a
regular scheduled passenger flight from Miami international Airport (MIA), Florida to
Alphonso Bonilla Aragon International Airport (SKCL) in Cali, Columbia. It crashed into a
mountainous terrain during a descent from high altitude around 33miles northeast of Cali.The
impact was about 8900feet mean sea level near the summit of El-Deluvio.Just 4 passengers
survived out of 155 passengers, 2 flight crew members & 6 cabin crew members on board.

No operational or maintenance discrepancies were found out on the previous flight which
could have resulted in this accident. The Cali airport was not equipped with the functional
radar due to which the controller had to note down their position frequently. After getting
cleared to proceed after passing BUTAL, the last of the regional airport ATC centres by the
BOGOTA air traffic control center, the flight crew requested descent clearance to Cali
control centre. The ATC cleared the request to descent & asked to lower their altitude. It
instructed flight crew to reach height 15000 feets.Also the flight was delayed at the Miami
airport by approximately by two & half hours which might be the reason why the ATC of
Cali airport asked them if they can take straight runway 19 rather than runway 1 which would
make them take another route. The flight crew agreed to this request & applied speed brakes
to lower the speed & expedite descent.

This could have resulted in deleting all the remaining data to reach assigned destination using
provided co-ordinates from the Flight Management System (FMS). This could have been
done by the flight crew manually. After descent, the flight crew decided to report ATC after
reaching ROZO which was ahead of Tulua geographically. So this time, they were of the
opinion that they have already passed Tulua.

After contacting ROZO 1 for clearance, it controller asked them to report to Tulua at 21miles
& 5000 feet. After passing ULQ, during the descent, the airplane started turning left for about
a minute & flew on an easterly heading & then turned left again. The flight crew weren’t sure
about their position as the controller asked them to report Tulua whereas according to them
they had already crossed it.

In the next minute conversations from the CVR recorded panic in the cockpit. As in they
were now aware of the danger ahead as they could probably see Tulua & the airplane was

Human Machine Systems 2011

heading straight towards it. They tried increasing the altitude but could take it where they
wanted it to be. And ultimately the airplane crashed on the trees at the east side of the peak.


There are many sequences here that have effective relation to human machine systems.

1) The speed brakes applied for speed reduction were not relieved at the time of
emergency. The accident could have been averted had they retracted the speed brakes
as that would have enabled the nose to rise up to its 100 percent efficiency which was
not the case as the speed brakes were intact at the time of pull up.

This can be graded in the ‘Rule Based Behaviour’ as these behaviours are set on the
basis on standard practices which one needs to follow. These rules can be learnt with
experience or with some other expert guidance.

Although it is not 100% sure if the airplane could have missed the peak had they
retracted the speed brakes as the brakes could not be back driven during the testing
analysis during investigation. But it could certainly could have made some difference.

2) From the investigation report, it can be figured out that the flight crew was of the
opinion that they had already cross passed Tulua & were on the way to ROZO at the
time they reported to ROZO.But it was the mistake on the part of flight crew that they
could not understand the codes of the areas on the way. As given in the report it is
clear that the crew failed to make note of those codes & ultimately misjudged the
areas resulting into collision with the peak.

This could graded in ‘Over Attention’ error which led to such a big mistake on the
pilot’s part thereby leading the airplane in the wrong direction. Over Attention occurs
when one intends to perform action too fast or too eagerly.

It can also be a ‘Knowledge Based Mistake’ by the flight crew. They probably
misinterpreted the information displayed by the FMS.

There was a slip/lapse in the action performed by the pilot at that time. As he intended
to do the right thing but his reactions went wrong. This is a ‘Skill based error’

Human Machine Systems 2011

3) From the investigation report, it can be stated that the conversation between the ATC
& the pilot were not upto a level to where it should have been. This occurred, due to
limitations of English language use for the ATC & he agreed that the conversations
could have been in more detail had the pilot spoken in Spanish.

The controller added that the request from the pilot to fly from their position to the
arrival transition sounded quite annoying to him as they were quite near (37miles)
from the Cali airport. He stated that the pilot perhaps forgot to report Tulua which
according to him is 38miles from Cali VOR.

This is a clear case of ‘Language Barrier error’. Had the controller alerted them
about their position or could have alerted them about their missed reporting about
passing Tulua, the flight crew could have got realized then n their about their missed
assigned path, they could diverted their path & could have averted the accident.

4) One of the errors the flight crew did was to accept the request from the controller of
landing on runway 19 than the assigned runway 1 to which the flight was basically
programmed. This was requested by the controller expecting the experience of the
pilots of the flight. Even the pilots discussed this request for a mere 4 seconds before
accepting it. The CVR recordings indicate the first officer seemed to be in hurry to
land just to decrease the level of delay.

This can be graded in ‘Rule Based Behavior’, in which the request from controller
can be assigned as an event & the flight crew failed to follow the basic rules to prefer
safety first than to reduce delay. They were experienced enough to understand the
changes in route coordinates if they decide to change the assigned route. The airplane
got deflected from the assigned route & also the first officer maintained the speed up
position during descent.

May be the first officer put incorrect coordinate data in the flight management system
(FMS) for the new approach, which resulted in change in direction of route by 3o for
approximately for 1 minute before it turned right again.

5) After accepting the request of landing on runway 19, there was a CVR recording in
which the pilot asked the first officer whether he has time to verify the approach chart.

Human Machine Systems 2011

But there was no response to this question but just the sound of rustling pages may be
of approach chart was recorded in CVR.

Once they got prepared to land on runway 19, they were short of time to review &
brief the approach; unable to get even oral approval from other pilot before executing
a flight path change through FMS.Also they found it difficult to locate the VLQ &
ROZO arrivals. Had they put a thought on these considerations, they could have
averted landing on runway 19 for safety reasons. But none of them even rethink on
their decision & continued with the landing.

This clearly indicates the pilots were not experienced enough to fly under such sudden
conditions. And they couldn’t follow the regular standard of procedure after the route
change which resulted in the fatal accident. (Rule bases error)

6) After getting cleared to proceed directly to Cali VOR & agreeing to report to Tulua,
the captain made changes in the flight management system programmed flightpath.In
doing so, he deleted all fixes (programmed data) between the airplane’s present
position & Cali VOR including Tulua, the fix they were to proceed towards.

This is clear ‘negligence’ on the captain’s part. He should have verified the location
with the approach chart.

It can be also graded under ‘Rule Based Behavior’, as it is necessary for every flying
crew to cross check the new data to be entered in the FMS to reach the assigned
destination. Such errors can lead to fatalities.

7) The airplane B-757 was one of its kind aircraft, with automated "glass cockpit" types
of transport aircraft. The new FMS computers were installed in these automated
flights of A-757. And it was evident that both the pilots were proficient in flying this
machine along with the use of FMS computers. The flight crew committed a critical
error by executing change of course through the FMS computers & not verifying its
effect on the flightpath.They mistakenly executed ‘R’ which they thought was ROZO
but instead it denoted Rome Beacon which was 132miles Northeast of Cali. Both had
same radio frequency. At the same time the flight was on its decent path as well. The
flight continued to fly on that path for approximately 1 minute before they realized
their position & directed it right again. But by this time they were well 2 miles apart

Human Machine Systems 2011

from the prescribed approach & flight flied towards the mountainous terrain &
impacted shortly a while after.

This was the ‘Supervisory Error’ committed by the flight crew. As being the
proficient in the FMS’s use they could have guided the aircraft well to the approach.

It was again ‘Negligence’ on the flight crew’s part as they failed to locate ROZO with
its denotion as this was not their first trip to Cali airport.Infact both the pilots had flied
to Cali about 13 times before that flight.


1) Retrieved on 27th

2) Human Machine Systems’, Thesis by Peter A.Wieringa & Henk G.Stassen Retrieved on 27th April, 2011
3) Article on Human Machine Systems summary.
4) Paper on “Understanding Human Behaviour and Error” by David Embrey.