Hundreds of decisions and actions are to be taken during flight operations of an aircraft, ranging from pre-flight processes like weather interpretation, fueling, route selection and checklists, to flight operations such as taxing, take-off, cruise and landing. Proper procedures must be correctly executed to ensure safe completion of flight operations and that no risks are taken or hazards are created that may affect the aircraft, aircrew, passengers, cargo and other airplanes. A pilot’s ability to make decision, and or execute tasks that mitigates the possibility of an accident or incident is believably the most important role in an aircraft’s safety, and anything that impairs this judgement increases the potential for accident/incidents to occur. Consumption of alcohol slows down the message travelling between the brain and body, impairing the ability of a person’s mental and manual operations. Alcohol has been linked to a number of aviation incidents involving pilot error.
This case study will analyze the role alcohol may have played in the crash of Aeroflot Flight 821 at Perm International Airport along incidents involving the consumption of alcohol. The report of the subsequent Aviation Accident Database, along with literature relating to alcohol and its effects will form the basis of the analysis. First research findings about alcohol, its effects on a person, and alcohol in aviation specifically, will be examined. A study showing the effects of alcohol on flight operations environment will be examined. An account of an incident and the major finding by the Federal Air Transport Agency (RCAA) will be provided. Next a discussion of the impact of alcohol played in the incident and lessons that can be learnt for the form this. Finally, recommendations will be made on how to avoid such incidents from occurring again.
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More than half the global population drinks alcohol, and it has become a cultural and social phenomenon. Alcohol is a depressant drug, which means it effects the central nervous system slowing the messages travelling from the brain to the rest of the body. When alcohol is consumed, it is absorbed into the blood and tissue of the body thought the detoxification process. The liver breaks down the alcohol and metabolizes it through your body, where it then enters the brain and central nervous system directly interacting with dopamine and serotonin receptors; this is where the ‘feel food’ sensation comes from (addictionblog, 2012). Impairing effects of alcohol are present only minutes after it has been consumed, these impairments include: relaxation, trouble concentrating, slower reflexes, increased confidence and emotional impacts (feeling happier/ sadder). When excess amounts of alcohol are consumed, other factors of impairment take place, including: confusion, blurred vision, short-term memory loss, nausea and the possibility of losing consciousness, entering an alcohol induced coma, and even death (BBC, 2014). These impairments pose a risk to pilots as things such as confusion, blurred vision and slowed reflexes have an impact on the ability of pilots mental and manual operations of aircraft. The majority of adverse effects produced by alcohol on the human body relate to the brain, eyes, and inner ear which are three crucial organs to a pilot. Long-term adverse effects of alcohol include high blood pressure, increased stroke risk, increased risk of heart and liver disease, nerve damage and the increased possibility of mouth and throat cancer. This is why the Federal Aviation administration implemented rules for persons who perform safety-sensitive functions (time from the point a driver begins to work or is required to be ready to work until the time he or she is relieved from work and all responsibilities for performing work) must have a blood alcohol concentration of 0.04 or lower, and pilots are banned from consuming alcohol within eight hours or reporting duty (FAA, 2019). Rules implemented by specific company policies may stricken these rules. These factors have been discussed as the main causes of many incidents over the years leading to tests being conducted to see the adverse effects of alcohol on flight operations. Tests have been undertaken to determine the factors of which alcohol effects the ability of a pilot, tests such as one conducted by the Aerospace Human Factors Research Division and Human Research Facility in March of 1991 (NCBI, 2019).
The study included four volunteer carrier pilots, who were studied during eight simulated flights between San Francisco and Los Angeles. Two flights were conducted at four target blood alcohol concentrations (BAC): 0, 0.025, 0.050 and 0.075%. The simulated flights lasted approximately one hour and were conducted with full crews in a simulated ATC environment. The data received for the study was examined from direct observations and videotapes for discrete errors committed by the pilots (NCBI, 2019). During the study it was found that the total number of errors rose in a linear fashion with blood alcohol concentration. Meaning as the blood alcohol concentration of the subjects increased the number of substantial errors made also increased. Planning and procedural errors increased along with failure of vigilance within the subject groups with the introduction of heightened blood alcohol concentrations. Failures in crew coordination were found not to be associated with BAC during the study. The study found that serious errors increased significantly even at the lowest BAC studied (0.025%), compared with control values (NCBI, 1991). The study clearly showed the correlation between alcohol and pilots mental and physical performance.
Aviation provides an environment where mistakes are unforgiving in nature. Correspondingly, impairment of aircrew performance by alcohol can, and occasionally does, lead to a catastrophic mistake. Such is the Case of Aeroflot Flight 821. Aeroflot Flight 821 was scheduled domestic passenger flight from Moscow (Sheremetyevo International Airport) to Perm (Bolshoye Savino International Airport) on a Boeing 737-505 aircraft. Aboard the plane there was a two-member flight team (captain and first-officer), four flight attendants and 82 passengers. The flight crashed on final approach to perm airport killing all aboard on impact with the ground. An investigation into the final moments into the flight was conducted by the Russian Transport Oversight Authority (RTOA) and the Russian CAA (RCAA) after the accident. It was found that the flight was conducted without deviation during take-off and cruise. During the base turn, to heading 210°, approaching landing course at 600m of altitude both autopilot and auto-throttle disengaged. After this the aircraft climbed to 1300m, rolled 360° over the left wing and collided with the ground (Aviation Accident Database, 2008). Eye-witness accounts state the plane struck the ground with an angle of attack approximately 30-40° of attitude. Initial investigations found that the cause of the accident was spatial disorientation of the flight crew: the inability to correctly determine attitude, altitude or airspeed in relation to the earth. Which is why after the autopilot and auto-throttle disengaged the aircraft, the captain (PF) flipped the aircraft to the left and enter a steep descent and crash the aircraft. This was determined due to the night time operation of the flight. Other factors of the crash were determined to be a lack of proficiency in aircraft handling, crew resource management and of skills associated with upset recovery using ‘western’-type attitude indications (Aviation Accident Database, 2008). Later forensic examinations found “an unspecific amount of alcohol in the captains’ bodily tissue”. This was determined by the RTAO and RCAA to be one of the contributing factors in the captains’ total spatial disorientation, that lead to the crash killing 88 people. All contributing factors of the accident as determined by the RTAO and RCAA are listed below:
- Loss of spatial orientation by the crew and chiefly by the captain who was piloting the aircraft during the landing phase.
- Forensic examination found an unspecified amount of alcohol in the captain's tissue. He also did not have adequate rest before the flight.
- Inadequate practices by Aeroflot-Nord in managing and operating the Boeing 737 aircraft.
- The aircraft had been flown for a long time with a throttle problem (Aviation Accident Database, 2008).
The presence of alcohol in the captains’ blood was determined as one of the leading factors Aeroflot’s 821 demise, along with other human factor issues, such as fatigue and inadequate training and other systematic errors, such as the engine throttling issue (Aviation Accident Database, 2008). A study undertaken by the federal aviation administration (FAA) found that 9% aviation incidents that occurred from 2000 to 2007 were alcohol related. 215 out of 2391 pilots of incidents that occurred during this time frame, had a history of alcohol offenses. Further study into toxicity levels found that 11% (23 of 215) of the pilots with previous offenses were found to have ethyl alcohol within their system prior to a fatal incident (FAA, 2008). For example, an investigation was undertaken by the FAA into the case of a 48-year-old male, who died after his Piper PA-24-180 aircraft colliding with the ground. Toxicity tests taken show that alcohol was present in the pilot system at concentrations of 0.054% in the blood, 0.106% in the vitreous, and 0.095% in the muscle (all being over the legal limit in America: 0.04%). “The NTSB determined a contributing factor in the incident to be the pilot’s impairment due to alcohol” (FAA, 2008). Many other cases were studied and found that most cases where the pilot had alcohol in their system, confusion and over-confidence in their piloting abilities lead to the crash.
This case study examined the role alcohol may have played in the crash of Aeroflot 821 at Perm International Airport on September 13, 2008. Studies of human factors in aviation have shown that alcohol influences the perception and behavior of a pilot. If a crew member has the presence of alcohol in their system, it is likely their reaction time performance, and overall physical capability will be adversely affected. This appeared to be the case for Aeroflot 821 where the captain had the presence of alcohol in his system during flight operations. As a result, of the positive BAC, the captain’s judgment appeared to have been impaired, resulting in complete spatial orientation. This case highlights the need for an effective alcohol risk management procedure (FRMS) and a special issuance (SI) program, along with focused training to ensure crew are fully aware of the impact of sleep inertia on performance, particularly decision making.
Based on the main findings of this case study, recommendations are proposed. First, as alcohol impairs alertness and performance, through the use of an effective alcohol risk management procedure (ARMP) and CRM training, aircrew should be trained to identify an UAS (Unsafe Aircraft State) when a flight crew member is intoxicated with alcohol and other drugs. Strict no alcohol parameters have been in-place in airlines for some time, though through ARMP and CRM training, the effective power distance is diminished and flight members can feel free to speak up if they believe someone is intoxicated. Through the use of ARMP and CRM pilots are able to identify the symptoms of heightened BAC both in themselves and others. Furthermore, a special issuance (SI) program should be implemented to monitor pilots suffering from alcohol dependence, to ensure a balance of safety and productivity in the aviation industry.
References
- Aviation Accident Database. (2008). Aeroflot-Nord – Boeing – B737-505 (VP-BKO) flight AFL821. [online] Available at: http://www.aviation-accidents.net/aeroflot-nord-boeing-b737-505-vp-bko-flight-afl821/ [Accessed 18 Sep. 2019]. In text: (Aviation Accident Database, 2008).
- The Science of Alcohol: How Booze Affects Your Body. (2014). Retrieved 18 September 2019, from http://www.bbc.co.uk/newsbeat/article/30350860/the-science-of-alcohol-how-booze-affects-your-body In text: (BBC, 2014).
- Billings CE, Demosthenes T, White TR, O'Hara DB (1991). Effects of Alcohol on Pilot Performance in Simulated Flight. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/2012569 [Accessed 18 Sep. 2019]. In text: (NCBI, 1991).
- How Does Alcohol Work? (2012). Retrieved 18 September 2019, from https://alcohol.addictionblog.org/how-does-alcohol-work/ In text: (addictionblog, 2012).
- Faa.gov. (2008). Alcohol-Related Aviation Accidents Involving Pilots with Previous Alcohol Offenses. [online] Available at: https://www.faa.gov/data_research/research/med_humanfacs/oamtechreports/2000s/media/200822.pdf [Accessed 18 Sep. 2019]. In text: (FAA, 2008).
- Faa.gov. (2017). Alcohol and Flying. [online] Available at: https://www.faa.gov/pilots/safety/pilotsafetybrochures/media/alcohol.pdf [Accessed 18 Sep. 2019]. In text: (FAA, 2017).
- Skybrary.aero. (2018). The Effects of Alcohol and Drugs on Pilot Performance - SKYbrary Aviation Safety. [online] Available at: https://www.skybrary.aero/index.php/The_Effects_of_Alcohol_and_Drugs_on_Pilot_Performance [Accessed 18 Sep. 2019]. In text: (Skybrary, 2018).
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