1. Systemic and Emotional Analysis of Continental 1404
Logan Abner, Michele Kelley, & Zachary Hutcherson
METHODS
Beginning with regulators, our team of three will analyze what impacts regulations had on the Continental 1404 accident. Our approach is to introduce the concept of regulatory capture, its effects on the industry, and identify examples of harmful regulatory acts in the Continental 1404 accident. Additionally, the systemic environment will be analyzed. This includes the system that airlines operate in, the system Continental Airlines operated in, and the environment in which the pilots operated in. This systemic analysis will include Normal Accident Theory (NAT) and High-Reliability Theory (HRT), identification of Continental Airline’s systemic approach, and conclude with an application systemic theory to Continental Finally, emotional hijacking will round off our analysis through describing the state of emotional hijacking, examining situational awareness models and theories, and then applying each to the CON1404 accident. Ultimately, this team predicts to see a trend that systemic factors and operating environments should play a role in the accident. Through our initial rote analysis of the CON1404 NTSB report, this team also expects to see examples of regulatory malfunction, loss of situational awareness, and a state of emotional hijacking.
ABSTRACT
Continental 1404 crashed December 20, 2008 on runway 34R during takeoff at DEN in Denver in transit to George Bush Intercontinental Airport in Houston. The accident report by the NTSB concluded that the pilot’s cessation of the right rudder during roll off was the cause of the accident, while also issuing 14 recommendations to the FAA to prevent accidents such as this.  While the pilot’s cessation of the right rudder was the final active failure, we recognize that as a tightly coupled system the pilot’s failure to apply enough right rudder could not be the true cause of the accident. We wished to explain the “why” of the accident, where the NTSB reported the “how.” Our methodology began by gathering various accounts and reports of the accident including reports of the major systems involved, such as Continental’s involvement with the LOSA program. We then applied various theories, including regulatory capture, Reason’s High Reliability Theory, Endsley’s Situation Awareness Model, and then assessed their implications. It is our conclusion that, though Continental Airlines was a Highly Reliable Organization as implied by LOSA findings and company reports, it was the failure of the management to recognize the issues of inexistent wind gust programming in the simulators and accurate wind data reporting that ultimately lead to the crash of Continental In our report, we concluded with recommendations to the management level of the airline in how to strengthen its deterrents for situation such as this
INTRODCTION
This analysis of the accident is to determine threats to aviation safety beyond the commonly determined “pilot error”. What is “pilot error”? Why does it occur? This is an analysis of not only what went wrong that day, but what factors propagated the accident into occurring. Our team concludes that this, as with almost all accidents, was simply dismissed for pilot error, when in fact latent systemic, regulatory, and organizational threats existed which allowed an environment that did not adequately mitigate the risk posed during the strong, gusty crosswind takeoff. This culminated with identifying error in the simulation, error in emotional hijacking training, and error in air traffic control procedures for runway selections. It concludes with simple, but crucial recommendations to address the broad range of systemic and behavioral issues which allowed this accident to occur.
RESULTS
As the research team could not physically test the hypothesis proposed, the team relied on gathering relevant data and information, which was then applied to contrasting theories in the field. This was done to match the data the team gathered to a theory that explained the interaction and results of the said data. The team also found that the conventional model of Situational Awareness by Endsley was inept because it did not factor the internal environment of the body. After research into the nervous system the Porges’ model proved to complete the model as seen in figure 1. Additionally, the team used the Reason’s model to study CON1404 in order to understand the interplay of the unsafe acts, workplace, and organizational factors. This is in figure 2.
DISCUSSION
Throughout this extensive overview of one non-fatal accident, it is clear that some serious flaws exist within the current regulatory and systemic safety programs, along with a lack of recognition of emotional based flaws. Unfortunately, this does not accurately represent the seriousness of the situation. It is this team’s opinion that while flaws existed within this accident’s system, there were also many more successes that are not seen with other accidents. This includes the fact that regulatory capture was not a major factor leading up to the accident, Continental Airlines could already be regarded as an HRO with some NAT practices, and that the accident occurred primarily due to one person’s error in judgment, which was concluded to be a strong case of emotional hijacking. Ultimately, our analysis is as follows. The proximate cause of the accident was the failure of the Captain to recognize his control inputs were in fact working correctly, and the subsequent reaction of this failure to recognize was an onset of extreme emotional hijacking that caused the Captain to cease rudder inputs and apply counter-intuitive measures to attempt to recurrent onto the runway. The proximate contributing factor was ATC’s failure to provide relevant wind data from sensors that were within two miles of the departing runway. This additional information would have likely altered the Captain’s decision to depart in a direct crosswind, as the crosswind component would have exceeded company maximums. Additionally, inaccurate wind gust modelling and lack of willingness to proactively simulate realistic wind conditions prevented the pilot from experiencing the possibility of control loss due to crosswind pressures. The only threat that did not exist during our accident was a prominent systemic or environment threat. This was concluded that the operations of Continental allowed adequate crew rest, both pilots were regarded as well trained and skilled amongst their peers, and that the LASA data demonstrated a sharp increase in frontline decision making and risk identification and mitigation.
Figure 1. Endsley’s and Porges’ model combined
Figure 2. Reason’s model.