This paper examines the January 13, 1982, crash of Air Florida Flight 90 (Palm 90), a Boeing 737 that went down seconds after takeoff from Washington National Airport during a blizzard. The paper identifies the primary causes of the disaster, including pilot error, failure to de-ice the aircraft, inadequate safety training, and broader organizational failures within Air Florida as a new carrier. It then applies the Loss Causation Model developed by Bird and Germain to the accident, tracing the five sequential stages from lack of management control and basic causal factors through substandard acts and conditions to the ultimate loss of life and property.
On January 13, 1982, an Air Florida-operated Boeing 737 crashed shortly after takeoff. Flight 90, with the call sign Palm 90, was scheduled to fly from Washington, D.C., to Fort Lauderdale via Tampa. The flight crashed seconds after takeoff, just a mile from Washington National Airport (Kaye, 2009). The Palm 90 disaster was "the first major airline accident attributed to organizational factors" (Ciavarelli, 2007, p. 1). Some of the potential causes of the disaster are attributed to organizational factors such as Air Florida being an "upstart airline" that was willing to "cut corners" (cited by Kaye, 2009). A "poor decision chain" that included inadequate staff training, errors in judgment, "inappropriate procedures," and communication breakdowns were the primary factors in the accident (Ciavarelli, 2007, p. 2).
Weather was an intervening factor, but it was human error that caused the crash itself. At the time of the scheduled departure, there was a blizzard in the area severe enough to shut down local schools. In fact, "the airport was closed for most of the day due to the severe weather, but was re-opened just prior to the accident" (Ciavarelli, 2007, p. 1). If robust safety procedures had been followed, the Palm 90 disaster could have been averted.
Pilot error was a major reason for the Palm 90 disaster. "Instead of leaving the cockpit to make a visual inspection, Capt. Larry Wheaton relied on an employee stationed inside the terminal to glance at the plane" to check for potential weather-related problems such as ice on the wings (Kaye, 2009). Furthermore, the pilot and co-pilot both neglected to turn on the anti-ice mechanism "that would have thawed the engines and ensured proper power readings on their cockpit instruments" (Kaye, 2009).
Boeing had also published air safety bulletins that specifically warned pilots about snow and ice on the wings; either the pilots never received the bulletins or chose to ignore them (Ciavarelli, 2007). The National Air Disaster Alliance also claimed that the pilot was inexperienced (Kaye, 2009).
The Loss Causation Model was developed by Bird and Germain (cited by OHS Body of Knowledge, 2012). It is a relatively simple linear model that identifies five main stages in the sequence leading to an accident. The Loss Causation Model places accidents within an organizational culture and social context, and it can be readily applied to the Air Florida Palm 90 disaster.
"Mapping each model stage to the Flight 90 accident"
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