Evaluating Organizational Failures of US Airways Flight 4560 Maintenance Procedures

Applying the Swiss Cheese model to analyze the gaps in the system and provides recommendations for future risk mitigation and safety measures.

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Introduction Of Human Engineering Assignment – Accident Case Of US Airways, N934HA Flight 4560, De Havilland Dash 8- 100, May 2013

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Air accident is a serious issue and this assignment is related to evaluating an accident case of US Airways, N934HA Flight 4560. In this portion, it is the task to discuss some omissions or failures by the organization as well as involved staff personnel. It is also required to consider cultural and behavioral aspects for understanding the way it contributed to this accident. The purpose of this assignment is to apply the swiss cheese model for evaluating this case and to make effective recommendations so that it can be avoided any future omission.

Discussing the Organisational and individual omissions or failures

Because when airline staff tried and failed to lower this same tail section while making an aspect of the design towards the airport, people received dangerous evidence that left the main undercarriage (MLG). They flew over the airport command center as well as the control system confirmed that now the left MLG has only been least in part stretched. This same flight crew used the alternate undercarriage extension process and collaborated with corporation upkeep to diagnose the problem of this same failure, but still, the left MLG just wouldn't extend despite repeated attempts (Adams et al. 2018). While the initial officer reported becoming confused after the seventh stage of the alternate undercarriage extension process, comment testing revealed that this had no impact on the result. Because left MLG just wouldn't extend, this same captain decided to land including all gear rescinded to reduce the possibility of losing directional movement after a field goal attempt. After commercial airliners came to a standstill mostly on the runway, only those passengers and personnel were successfully expelled. Comment program" that neither the regular nor alternate equipment extension processes would implement this same left MLG. This same left MLG unlock wheel has been seized, and indeed the rhythm mostly on left techniques e.g. door handle was beyond tolerance, according to an investigation of the undercarriage components.

Discussing cultural and behavioral aspects that contributed to the accident

Due to the confiscation uplock roller as well as worn glom, the forces exceeded the crew's capacity to release this same landing gear using the substitute gear infrastructure. In this same accident, planes had been thoroughly checked 11 times throughout the year preceding the accident (Chow et al. 2018). This same inspection documentation indicated that now the wheel was repositioned freely as well as did not need lube in all cases. Furthermore, every 440 hours of flight time, the uplock latches were supposed to be graphically inspected. These same latches just weren't measured and then were supplanted based solely on their condition. The very last quantification of something like left MLG door handle on the disaster plane was taken ten years before the crash. Following the accident, the controller changed the periodic maintenance to have included regular roller lubrication and measuring this same wear of something like the uplock latch.

Based on this aspect, it can be understood regarding the culture and the behavioral aspect that there was a communication gap in the operation process and there was a lack of effective coordination among the members involved. There were some technical faults but it can be understood that due to inefficiency in the monitoring and reporting process, this big accident happened (Khelifi et al. 2018). Therefore, the application of improper monitoring and risk assessment approach by the operational staff is the biggest failure in this case of an accident.

Outlining accident reasons for the selected accident

Evaluating Organizational Failures of US Airways Flight

In this context the factual information is "a Piedmont Airlines Bombardier DHC-8-102, N934HA", flying as "US Airways Express flight 4560", landed including every "gear retracted on runway 4L at Newark Liberty International Airport (EWR), Newark, New Jersey", on "May 18, 2013, about 0104 eastern daylight time". "The left main landing gear (MLG)" did not drop as well as lock during the "initial approach". When the left MLG could not be lowered, the flight crew purposefully made a landing including all "landing gear retracted". The two pilots, one flight attendant, as well as the 31 customers all, remained unharmed, however, the airplane incurred significant damage while landing (Larouzee and Le Coze, 2020). This flight took off from "Philadelphia International Airport (PHL), Philadelphia, Pennsylvania", as well as was operating in compliance with "Title 14 Code of Federal Regulations Part 121". "The first officer (FO)" was the pilot, and the aircraft departed "PHL at 22:52. (PF)". This flight was permitted to use an "instrument landing system (ILS) approach to runway 4R at EWR" at about 2325. Its left MLG displayed a red hazardous indicator there in the cockpit as soon as the crew tried to lower its landing gear. "An EWR air traffic control tower controller" gave the captain permission to conduct a "fly-by" and confirmed that its left MLG looked to still be fully extended. To investigate the problem, the flight also was given vectors as well as given the all-clear to maintain 3,000 feet above mean sea level. That captain began the "alternate landing gear extension checklist", but he then assumed control as PF while allowing the FO handle.

As the FO completed each item here on the "checklist", the captain studied as well as verify it. The FO claimed that the "main gear" didn't extend while he pulled its main "gear release handle". Its FO responded in the affirmative whenever the captain inquired if the checklist has been finished (Sareh, 2018). It has never, though, read the remarks there at the "bottom of the checklist", which talked about using a "hydraulic pump handle" as well as the potential requirement for strong force mostly on backup "gear extension handle". The captain informed business operations after returning the FO's PF responsibilities to a "maintenance control supervisor", who suggested utilizing its hand pump to lengthen the MLG. The FO exited his seat to acquire "better leverage on the pump handle and repeatedly" tried to pump such gear down without effect. Both "captain and FO again" switched roles so that the captain became PF. These pilots changed the controls once more, as well as the captain got up to try to handle the pump but was unsuccessful. This captain said that although its "gear doors" were opened as well as the left MLG wasn't extended when he "left the cockpit" to check the MLG again from the cabin. Its tower once more confirmed that such left MLG wasn't down during a second fly-by.


On the recommendation of such a "maintenance control supervisor" who's been on the "radio", the crew set the alternative gear system to standard, raised every piece of landing gear, but then extended it again using the standard system. This red hazardous alert was once again observed on the "left MLG". Its crew once more used the standard mechanism to "retract the landing gear" (Xie et al. 2020). When the captain requested the "maintenance supervisor" to get in touch with the "flight duty officer", the supervisor replied that a "management conference call" for the company had been currently taking place, which was talking about the optimum landing configuration. Its crew made another attempt to lower the gear while exerting positive G forces on the aircraft at the recommendation of the corporate "maintenance control supervisor".

Using either swiss cheese and Plugging the holes with a safety system

Based on the application of the swiss cheese model, it can be identified that there were several gaps in the system. It can be found that due to ineffective application of the risk assessment matrix and application of the checklist regarding the condition of different technical aspects were the big omissions by the operation and controlling staff personnel (Larouzee and Le Coze, 2020). Apart from that. Organizational omissions were related to the setting of ineffective culture and binding of communication process for prompt reporting process regarding different dimensions.

In the context of mitigating the holes identified based on the swiss cheese model, it is needed to consider the emergency shutdown aspect, active as well as passive protection layer, and the emergency response layer so that it can be taken for any emerging risk factor. In addition, setting such strong layers is also required to make a strong process control system as a preventive measure for future omission or risk control.


In his context, it can be concluded that their flight crew was unable to extend its left "main landing gear (MLG)" using the "alternate extension" method because of the "frozen left main landing gear (MLG)" uplock roller because of a "lack of lubrication" as well as the uplock latch that would have worn past allowable tolerances. This operator's poor maintenance procedures, which failed to notice the roller's lack of lubrication as well as the latch's wear, contributed to such an accident.


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Khelifi, H., Luo, S., Nour, B. and Shah, S.C., 2018. Security and privacy issues in vehicular named data networks: An overview. Mobile Information Systems.

Larouzee, J. and Le Coze, J.C., 2020. Good and bad reasons: The Swiss cheese model and its critics. Safety science, 126, p.104660.

Sareh, P., Chermprayong, P., Emmanuelli, M., Nadeem, H. and Kovac, M., 2018. Rotorigami: A rotary origami protective system for robotic rotorcraft. Science Robotics, 3(22), p.eaah5228.

Xie, W., Kathuria, H., Galiatsatos, P., Blaha, M.J., Hamburg, N.M., Robertson, R.M., Bhatnagar, A., Benjamin, E.J. and Stokes, A.C., 2020. Association of electronic cigarette use with incident respiratory conditions among US adults from 2013 to 2018. JAMA network open, 3(11), pp.e2020816-e2020816.


Semanticscholar.org, 2021, Why do we care about safety Available at: https://www.semanticscholar.org/paper/Why-do-we-care-about-safety-(-and-security-)/01e61786b834fe811bff56f9dfcb9d159aa4d1f8 [Accessed on: 04.11.2022]


Swiss Cheese Model

This model has indeed resulted in communication because it presents organizational accidents in some kind of a sense that anybody who, irrespective of their field of study or amount inside this organization, can easily visualize and understand. Whereas the specific details of risk management and safety procedures are intricate and might be hard to comprehend for many, one such model can indeed be introduced simply, providing many people with an understanding among these complex subjects. It is conceivable that rigid implementation of the whole model will lead organizations to look for dormant conditions that contributed to the incident when the primary cause might have been anything other than user mistakes.

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