Synopsis

The crash occurred at Kansas City, Missouri the 16 February 1995 (NTSB, 1995^[1]). The Air Transport International flight was scheduled to fly from Kansas City to Chicopee for engine maintenance (NSTB, 1995^[1]). With one inoperative engine of the Douglas DC-8 aircraft, the crews had aborted the initial takeoff attempt after losing control of the aircraft (Wiegmann, 2003^[4]). In the second attempt, the crews once again lost control of the aircraft (Wiegmann, 2003^[4]). However, the captain decided to continue and rotated the aircraft early rather than abort the takeoff as they had before (Wiegmann, 2003^[4]). Finally, the aircraft roll to the left and crashed into the ground (Wiegmann, 2003^[4]). Tragically, all three crews on board were killed (NTSB, 1995^[1]).

Main Cause

Wrong Decision Made
The captain made a wrong decision to continue the takeoff in the second takeoff attempt without sufficient considerations (NTSB, 1995^[1]). The loss of control of the aircraft in both the first and second attempts was because of the increase of the thrust too quickly, thus causing the left-drifting of the aircraft (Wiegmann, 2003^[4]). Repeating the same mistake shows the crews did not analyze the causes for the loss of control in the first takeoff attempt thoroughly (Wiegmann, 2003^[4]). Without the identification of the true cause, the captain decided to continue the uncontrolled takeoff in the second attempt instead of adopting the takeoff, leading to the accident (Wiegmann, 2003^[4]).

Remedial Actions

1. The decision-making process should be improved by outcome evaluation, error catching, as well as the increase of realistic training (Orasanu, 2009^[2] and Wiegmann, 2003^[4]). To evaluate the outcome, crews should consider constraints on options thoroughly prior to acting (Orasanu, 2009^[2]).
2. Instead of relying on the captain only, error catching should be performed among all crews to monitor the performance of each other and solve the problems encountered together (Orasanu, 2009^[2]).
3. Realistic training should be increased using the flight simulators (Wiegmann, 2003^[4]). If crews had accumulated enough experience of three-engine takeoff from this type of training, they would have recognized the stimulus more quickly and made a more appropriate decision (Robson, 2008^[3]).

References

1. National Transportation Safety Board. (1995). Aircraft Accident Report: Uncontrolled Collision with Terrain: Air Transport International Douglas DC-8-63, N782AL, Kansas City International Airport, Kansas City, Missouri, February 16, 1995. Washington DC: The Board.

2. Orasanu, J., Martin, L., and Davison, J. (2009). “Cognitive and Contextual Factors in Aviation Accidents: Decision Error.” In Salas, Eduardo and Gary Klein. Linking Expertise and Naturalistic Decision Making. New York: Lawrence Erlbaum Associates Inc.

3. Robson, D. (2008). Human Being Pilot: Human Factors for Aviation Professionals. Australia: Aviation Theory Centre.

4. Wiegmann, D. A. and Shappell, S. A. (2003). A Human Error Approach to Aviation Accident Analysis: The Human Factors Analysis and Classification System. England: Ashgate Publishing Limited.