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INTRODUCTION:
Aviation accidents are one of the present-day hazards. This hazard can be observed due
to a number of reasons such as technical faults, human error, bad weather conditions, signal
disconnection, failure to read handling instrumentation, bird collisions etc. But above all the pilot
endures the biggest blame for a plane crash. The commercial aircraft crash to be considered in
this paper happened back in July 2013.Flight 214 of Asiana Airlines was a scheduled transpacific
passenger flight that took off from South Korea, Incheon International Airport in Seoul. The
flight's Boeing 777-200ER stopped and met an accident on its final landing on July 6, 2013,
when it descended into San Francisco International Airport in the United States (Wikipedia,
2022). Three of the 307 persons on board perished, whilst the other 187 people were hurt, 49 of
them were severely injured. Four members of the aircrew were critically wounded when they
were pushed onto the airport runway while still buckled into their seats by the tail section came
off after hitting the seawall just short of the runway. It was the first fatal Boeing 777 disaster
since the aircraft's market entrance and first flight in 1995.

The NTSB determined that some of the likely causes of this accident were the flight
crew's mishandling of height control of the aircraft, insufficient surveillance of flying equipment,
and futile planning and decision making. Other contributing reasons included the sophisticated
but insufficient documentation auto complex explanation of throttle procedures, the flight crew's
deviation from regular devised protocols for communication, insufficient pilot training for visual
approaches, insufficient captain supervision, and crew exhaustion. Each of these reasons may be
linked back to various levels throughout the organization, indicating that this was not an isolated
occurrence caused only by pilot mistake. Instead, it was the unavoidable outcome of several
risky practices being permitted across Asiana Airlines, which stemmed from issues within the
organization's highest management (Chow, 2014).
 The pilot in command had insufficient instruction on how to use the autopilot and auto
throttle systems He first mis programmed the autopilot during the landing approach, causing the
aircraft to climb rather than descend near the runway. In reaction, he deactivated the autopilot
and lowered the throttle to relax. Because all of the systems in this aircraft are linked, when the
pilot lowered the throttle to idle, he unintentionally shut off the automated airspeed control
(Campion EM, 2016). The aircraft gradually decreased to dangerously low airspeeds throughout
the whole approach, but this was disregarded and left unaddressed until the tragedy. These errors
were brought on by a lack of training in approach procedures and aircraft systems, highlighting
the importance of higher-level training alternatives.
Inadequate supervision, improperly designed activities, inability to fix a known problem,
and supervisory infractions are all examples of violations. Inadequate supervision is defined as a
scarcity of standardized instruction or oversight, which was a major issue for Asiana Airlines
because the pilots had no authoritative officer to report to. Because the flight's pilot, commonly
known as the pilot monitoring, was guiding him because he was inexperienced with the aircraft.

Correctly outlining an approach or operating outside of restrictions The NTSB

determined that Flight 214's pilots failed to provide an adequate, detailed, and authentic approach
briefing. (NTSB, 2013). Why is approach briefing necessary? to ensure that pilots in the cockpit
verbally communicate their understanding of the order in which events must occur within the
strategy as well as the corrective action to be taken if something goes wrong. Because everything
was examined confirming all the details before the approach enables for a faster reaction time
and better decision-making during a less stressful part of the flight. The pilots would have
identified possible risks and chosen when to start the go-around if they had been adequately
briefed on their approach. Asiana Airlines had briefing SOPs, but due to the negligence of the
pilots and shear human error, the SOPs were overlooked.
 During the go-around approach, the flight crew must determine if the approach is stable
at 500 feet above ground level (AGL), which means that all components of the landing are
establish and sustained as necessary. Despite the considerable instability of their approach, the
operators of Flight 214 did not do a go-around (Foundation, 2007). The plane's velocity was
extremely low, and the drop-off rate was irregular and excessively steep. The pilots did not seek
a go-around until the aero plane had plummeted under 100 feet above ground level, at which
point recuperation became impossible. The pilots were blatantly violating Asiana's SOPs by
refusing to do a go-around at the 500-foot AGL threshold. SOP violation is a significant safety
risk. However, it pushed pilots to take needless risks during the trip.

Environmental considerations include both the physical and technological environments.

Minimal winds, clear skies was reported, moreover during the time of the accident there were a
little clouds, therefore bad weather was not a role. The greater concern was the technological
environment. Technology plays a significant part in the cabin. When utilized effectively,
technology dramatically decreases the difficulty for crews, allowing for stress depletion and
improved job administration; yet, when used badly, technology has the opposite effect,
increasing the crew's stress levels and producing more work to be done, as was the case on Flight
214 (Maryam Tabibzadeh, 2019). Automation, if not employed effectively, can have a
profoundly detrimental effect on the operator's mental health, raising the chance of a dangerous
behavior.
The stressful conditions caused by technological challenges resulted in inadequate
operating conditions, leading in undesirable mental and physiological states for the pilots. The
pilots in the cockpit reported a full lack of insight, furthermore channeled concentration and
work overload. These three factors combined to generate severe mental tiredness, this ultimately
led to the undesirable physical exhaustion and stress-related physiological states (Scott Shappell,
2006).
The figure depicts the link between output and amount of stress. The pilots' stress level
was significantly over the optimal level throughout this approach (Flavio A. C. Mendonca,
2020). This is essentially what caused the situation's negative reactions—a massive informational
overload coupled with a stress-related degradation of performance capacities.

SHELL MODEL:
The SHELL model is a conceptual framework for human factors that aids in
understanding the interplay between the human component of the aviation system and the
resources and environment of the flying subsystem (the human subsystem). The SHELL model
adopts a systems perspective and suggests that humans are seldom, if ever, the accident's major
cause. The systems approach takes into account a various environmental and task-related
components that communicate with the human operator within the aviation system to affect the
performance of the operator. Correspondingly, the SHELL model takes latent and active defects
in the flying services into account. Each component of the SHELL model (software, hardware,
environment, and liveware) serves as a foundation for human factors research in aviation
(International Civil Aviation Organization, 1993). The human element or worker of interest is
central to the SHELL model, which reflects the current air transportation system. The second L
in the SHELL model is quite significant in the domain as it implies the relationship of human in
charge with other humans on board. In the prospects of the specific case being discussed here,
the interaction of captains and air crew with the passengers at the time of accident and even
before that signify the liveware-to-liveware relationship. If developed responsibly it can help to
manage a disaster. As air hostess Haely of flight 214 carried people double her size out of the
crashed plane, to rescue them. Such events lead to the fact that the survivor percentage of this
crash was 99%.
The liveware contained within the model serves as a link among humans and the
controllers featured in the plane. It comprises of the flying crews, as well as the engineers and
maintenance specialists. It also comprises administrative and managerial personnel who aid in
the smooth running of the flight. Liveware is utilised for people to engage with others in the
aviation business, which aids in the development of leadership, teamwork, and collaboration. It
aids in the management of resources within the crew individuals as well as the management of
resources within the teams. It aids in the functioning of the programme so that things are done in
an ordered manner and the operation is efficient. It aids in the creation of places that need to be
developed, as well as the protection of equipment.

Situational awareness:
It is described as the awareness of components present in the environment within a
certain location and time, which aids in forecasting the status in the near future. It is therefore the
key aspects in the environment that may be observed and understood more effectively when they
are connected with the aims of the aviation crew. It enables pilots to operate in an efficient and
timely manner. The pilots must use their sensory organs to assist them develop a better
environment, which will aid in the process of taking care of the flight and averting any type of
perilous circumstance. The pilots of Asiana Journey 214 had to understand the components that
would be of some assistance throughout the jet's flight, which may have spared the plane from
crashing. The pilots needed to have a good grasp of the controls' surroundings by communicating
effectively with the control room so that the fear that led to the disaster might have been
prevented as soon as possible.
The pilots of Asiana Journey 214 had to understand the components that would be of
some assistance throughout the jet's flight, which may have spared the plane from crashing. The
pilots needed to have a good grasp of the controls' surroundings by communicating effectively
with the control room so that the fear that led to the disaster might have been prevented as soon
as possible. The pilots must communicate properly with the control rooms so that they may be
led in flying the aeroplane properly by integrating and understanding the information supplied to
them through the control rooms. They needed to properly examine the issue by utilising the
choices available to them rather than losing connection with the control room. The risk of the jet
crashing may have been avoided with appropriate communication between the two pilots and the
control centres.
The pilots had to pay close attention to the minute details conveyed to them by the air
traffic control rooms so that the vast amount of information supplied during the flight may have
assisted them in avoiding the dangerous scenario. The attention of the aircrew that is new in the
company is one of the elements that will impact situational awareness among aviation crew
members (Shappell S, 2007). The Asiana flight crew members had a lot of flying hours, but they
lacked a means of seeing and processing the external world, which resulted in delayed responses
when the aeroplane was in the air, which led to the disaster The third stage of emergency
situations would have assisted the pilots in playing a significant role while the decision-making
process, which would have been based on their understanding of the current situation by
gathering information in a better manner so that an accurate decision could have been made.

Information Processing:
The information that arrives from various sources to the aviation crew members must be
properly appraised so that the choice made after processing the information is effective in nature.
The capacity to digest information varies across individuals based on health, age, stress, and the
degree of experience that the pilots have operating in diverse cultures. The ability to process
information aids in assigning and structuring jobs so that needs may be given to employees based
on their talents. The pilots in command of the Asiana flight failed to comprehend the information
that was communicated to them. They even misused the information, resulting in the deaths of
ordinary passengers. The pilots failed to respond appropriately, resulting in the plane's disaster
(Knudson, 2016).

SUGGESTIONS AND RECOMMENDATIONS:

After every crash or accident one of the major reasons of doing research and investigation is
find out the issues, malfunctions and faults which lead to such an incident. Such finding help
companies, organizations, airlines, developers, engineers and designers to learn from the
mistakes of others and come forward with a final product which is human friendly even at the
time of a crisis. Some of the recommendations after the investigation from NTSB are mentioned
as follows.
- Cockpit culture should be developed, Korean culture itself is hierarchal. It means that the
respect of seniors is the fore most aspect. Due to the similar reasons junior officers shy
away from mentioning and communicating at the advent of a danger or crisis. In this
regard specific formal language should only be used as a mode of communication in such
serious place.
- Technical advancements and sophistications are liked by everyone. People always want
to be indulged with the latest technology in the market. Similarly, the Boeing 777 was a
technically advanced model, where the captain despite being a veteran had little
experience with it.
- Pilots especially captains should be given the aircrafts which match their skill set. If a
technically advanced aircraft is to be deployed, then thorough training and practice of the
aircrew officers should be ensured.
- Compatibility is a vital aspect of any relationship. May it be humans or computers. The
aircraft was to be operate on autopilot and it was compatible to the environment in way
that autopilot can be turned off with a measured movement of the throttle. When the
captain did that, the aircraft should have mentioned or notified the pilot about such a
change (Law, 2016).
- The advanced landing technology at the San Francisco airport was suspended due to
certain reasons. If the aircraft was built in accordance with a certain backend technology,
it was an essential task for the airlines to ensure the availability of that technology at the
landing terminal.
- Human Factor Analysis and Corresponding Systems should be used, this system explains
the whole working environment of the airlines, from the executive to the janitor, and how
every official is designated with a specific list of tasks. The impact of all these tasks on
the airline, aircraft and most important the passenger (Towles, 2010).
- The number of problems, hazards and disasters which can be avoided from deploying
HFACS are huge.
CONCLUSION:
Flight 214 of Asiana Airlines should not have crashed. As this accident investigation
demonstrates, there were several contributory organizational elements that may have been
avoided prior to the tragedy. In the view of the fact, commercial aviation mishaps are seldom
yielding to isolated incidences, most may be avoided by deploying HFACS. Throughout history,
sector reform has only occurred in the aftermath of crisis or the loss of life. The HFACS
approach provides a chance to modify this thinking proactively. By using this scientific approach
to hazard identification, safety risk data may be gathered and reviewed without the need for an
accident. This study also highlights the need of adopting a proactive safety approach, reducing
risks inside an organization before they result in a disaster. The results of this analysis show that
the HFACS working methodology, which was initially devised for and tested in the army base,
can be utilized to repeatedly identify the underlying human factors problems linked with
commercial aircraft accidents. Furthermore, the findings of this study identify crucial areas of
human considerations necessitating more safety studies and serve as the cornerstone for a wider
civil aviation security programmed.
Finally, data analyses like this one will provide important information to reduce aircraft
accidents through data-driven investment strategies and objective evaluation of intervention
activities. The HFACS framework might potentially be used as a tool for directing future field
safety inspection and improving accident statistics and records, in addition to this would raise the
overall standard and accessibility of Data on human elements in accidents.

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