Air Accident Investigation Branch - Case Study Example

Air Accident Investigation Branch Table of Contents Contents Page …………………………………………………………….. 3 Introduction………..…………………………………………………. 4 Case Study Summary…………………………………………………..5 Case Study……………………………………………………………..5 Conclusion and Recommendations…………………………………….8 References………………………..…………………………………….11 Abstract On June 10, 1990, a BAC 1-11 aircraft “British Airways Flight 5390” left the Birmingham International Airport and headed for Malaga with eighty-one passengers on board, as well as two flight crew and four cabin crew members. On reaching 17,300 feet, the windscreen was blown off, leading to the pilot almost being sucked out of the plane. The officers carrying out the investigation identified the immediate cause of the accident to be the fastening of the replacement windscreen with wrong-sized bolts. Engineering factors were most to blame for the accident of BA flight 5390. First, the wrong bolts were used for the securing of the windscreen, with most of the bolts being of the incorrect diameter. The technical engineers failed to uphold various moral-ethical issues as defined in the IPENZ code of conduct, as will be discussed further in the paper. The paper also makes several recommendations after coming to the conclusion that engineering factors were most to blame for the accident. These recommendations should help in avoiding any further accidents. AIR ACCIDENT INVESTIGATION BRANCH Introduction Maintenance of aircraft is an essential part of the aviation system that lends its support to the global aviation industry. With the increasing growth of air traffic, coupled with the stringent needs of commercial schedules, and the increased demands it imposes on utilization of aircraft, the pressure on maintenance operations regarding on-time performance will go on escalating. This is forecasted to create more windows of opportunity for occurrence of human error and eventual breakdown of the system’s safety net. Human error in the maintenance of aircraft has become a common causal factor in various air carrier accidents. Unless the industry takes these accidents seriously and learns from them, breakdowns at the maintenance level will occur on a regular basis. Important facts, from a human factors perspective, have been discovered during investigations into these occurrences. This paper seeks to perform a case study of the accident that occurred with aircraft BAC1-11 “British Airways Flight 5390.” The paper advocates the vitality of information exchange and sharing of experience among operators. The need to follow established procedures of maintenance by all is emphasized. The paper will attempt to determine who was at fault for the accident. Additionally, the paper will come up with recommendations as to how to avoid this sort of accident occurring in the future. Case Study Summary On June 10, 1990, a BAC 1-11 aircraft “British Airways Flight 5390” left the Birmingham International Airport and headed for Malaga with eighty-one passengers on board, as well as two flight crew and four cabin crew members. During takeoff, the co-pilot was the one flying the aircraft, and on, establishing the climb, the pilot-in-command took over the handling of the aircraft as per the normal operating procedures. Both pilots at this stage undid their shoulder harnesses, with the commanding pilot loosening his lap strap. There was a loud bang as the aircraft was climbing to seventeen thousand three hundred feet pressure altitude. There was rapid decompression as was indicated by the filling of the fuselage with mist of condensation. A windscreen in the cockpit had blown out, with the pilot-in-command partially being sucked out through the aperture of his windscreen. Additionally, the flight deck door was blown onto the deck, where it rested across the navigation console and the radio. The co-pilot regained control of the plane immediately and was quick on initiating a descent to FL 110. As this was happening, the cabin crew attempted to pull the pilot-in-command into the aircraft, but these efforts were dampened by the slipstream, which stopped them from succeeding. However, the crew held him by his ankles until the point where the aircraft landed. Discussion of Case Study The officers carrying out the investigation identified the immediate cause of the accident as the fastening of replacement windscreen with wrong-sized bolts (Haphaestus Books, 2011). The committee consequently identified the factors that caused it. An individual who carried total responsibility for the achievement of quality undertook a safety critical task, and the installation was not being tested until the craft was in the air on a flight carrying passengers. The Shift Maintenance Manager’s ability to achieve quality in the process of fixing the windscreen was also eroded by failure to utilize suitable equipment, which was found to be asymptomatic of long-term failure. The quality audits and local management of British Airways had not detected the inadequate standards, which the Shift Maintenance Manager had used since they did not directly assess the Shift Maintenance Manager’s working practices. The windscreen change had also occurred some twenty-seven hours prior to the accident, with statistics showing twelve number 1 windscreens had been replaced on BAC 1-11s during the last year, with a similar figure in the previous year. The manager had overseen six windscreen changes prior to the accident while under the employment of the operator. Technical factors were most to blame for the accident of BA flight 5390. First, the wrong bolts were used for the securing of the windscreen, with most of the bolts being of the incorrect diameter (Haphaestus Books, 2011). Various poor work practices, perceptual errors, and poor judgment characterized the process of fixing the windscreen. Each of these eroded safety factors that BA put in place to avoid this sort of accident. During the windscreen fitting process, various problems confronted the shift manager. The previous installation had utilized incorrect bolts as an insufficient stock of A211-7D bolts that, though incorrect, were adequate to an extent available in stock, in the Eastern Apron’s carousel. While this problem was major, it cannot explain the following events of loosening and freeing of the windscreen in mid-air. The technical engineers ignored various procedures and took on some poor trade practices. The IPC that is usually utilized to confirm the size of the bolts to be used was present but not used. Additionally, the TIME system at the store was not used to identify the stock and location of bolts required for the replacement, despite its availability. Attempted use of sight and touch to match physically the bolts, new and old ones, led to a mismatch with bolts retrieved from the carousel at the international pier (Parthalan, 2012). The choice to use A211-9Ds arbitrarily to fit the corners perfectly was attempted. On top of that, an increase in the torque on the bolt was used above that stated in the manual. The technical engineers also showed non-conformity with the standards set at British Airways. They set up an uncontrolled screwdriver meant for torque limiting outside the calibration. They also used unsuitable equipment such as a bi-hexagonal bit holder, which leads to occasional bit loss, and covered the bolt while the torquing process was on going. The safety razor they used gave them limited work-point access. They also ignored various cues, although these could also have been missed. Despite the storekeepers warning that there was a need to use A211-8D bolts, these warnings went unheeded. The technical engineers did not deem the unfilled countersink that the small bolt-heads left were excessive (Haphaestus Books, 2011). The new bolts left a noticeable amount of countersink unfilled, which, when compared to the adjacent screen’s countersink, was noticeable. Torque difference and amount of unfilled countersink of the new bolts compared to the old bolts that had been used on the corner fairing were not noticed. The technicians also missed the difference between the torque limiting screwdriver and the bolt thread stripping through the nut, even though the screwdriver bit and the bi-hexagonal socket in the engineer’s left hand were still in rotation (Parthalan, 2012). IPEZ Code of Ethics The technical engineers failed to uphold various moral-ethical issues as defined in the IPENZ code of conduct. First, with their apparent negligence during the replacement of the windscreen, they failed to protect life and safeguard passengers. This was in direct contravention of clause 1.2 of the IPENZ Code of Ethics. The code requires members to recognize the need for life protection and safeguarding of passengers’ life, and act in observance of this need in their activities as engineers. Moreover, the engineers failed to be professional, competent, and work with integrity. Engineers are required to undertake their activities with integrity and professionalism and work at their competence levels. The technical engineers, as set out in clause 2.1, failed to exercise their skill, initiative, and judgment to the best of their ability for the client’s and employer’s benefit. As discussed in their failings above, they failed to respect this value by failing to check diligently on the size of the bolts. This put the passengers in danger and exposed BA to litigation and government investigations, which hurt the company’s reputation. They also failed to adhere to the value of community commitment since their failure to ensure that the passengers on board were safe from any accidents was their doing. The engineers working on earlier windscreen replacements, as well as those monitoring their work, failed to sustain engineering knowledge, as required in clause 5.1 of the IPENZ Code of Ethics, by failing to mention the effect of using under-sized bolts on other aircraft. Engineers are expected to give priority to the well-being and safety of the community, and on top of that, give regard to the principle in the assessment of their obligations to colleagues, employers, and clients. This is laid down in clauses 3.2 and 3.3 of the Code of Ethics. The engineers, maybe unknowingly, did not do this. They also failed to follow logical steps to minimize the risk of life loss, suffering, or injury that may have resulted from their activities as engineers, either indirectly or directly. The engineers also failed to draw the attention of British Airways’ local management, as required by clause 1.3 of the code, to the significance and level of the risk associated with using undersized bolts. Finally, they failed to assess and take steps to minimize dangers that were involved in their replacement of the windscreen. The windscreen is a major part of the plane’s fuselage, being vital to the compressed atmosphere inside the plane. This is the area in which they should have taken the utmost care when gauging the outcome of their engineering activities. Conclusion and Recommendations The nearly fatal accident of BA flight 5390 could have been prevented if the technical engineers could have followed the values as set forth in the Code of Ethics. A consistently strong commitment to ethical values is the currency that earns the engineering profession respect and trust from the society. These commitments are in addition to obeying the law and professional responsibility. In order to do this, IPENZ maintains a code of ethics that it releases for the public and enforces impartially. Through the above, the code becomes responsive to changes in both societal and professional expectations as well as global engineering standards. The code consists of five essential ethical values, which include safeguarding people and protecting life, sustainable care and management of the environment, commitment to the wellbeing of the society, sustenance of engineering knowledge, competence, integrity, and professionalism. The code is made up of three parts, the first being the ethical values discussed. Part 2 expands on these guidelines in order to help the reader understand it and its intentions. The third part sets out the minimum behavioral standards against which its members will be judged to have complied with ethical behavior. The institution, at any time, could issue definitions of terminologies and other relevant information to aid in interpreting the code. Most of the situations that engineers will come up against professionally, including the situation with BA flight 5390, are covered in the code. If the ethical standards set out in the code were followed diligently, accidents such as flight 5390 would have been avoided. The code can be used in the final analysis of the accident report to decide what a reasonable professional would have done if faced with a similar situation. In future, British Airways should take various steps to avoid this sort of accident in the future. These include: The CAA needs to examine self-certification applicability to critical tasks concerning aircraft engineering safety, following which systems or components are cleared sans functional checks. British Airways needs to review the introduction of reference terms for engineering grades from SMMs and above. The CAA needs to consider the need for periodic testing and training in the world. British Airways needs to review their system of quality assurance and continue to educate their engineers to give them feedback. British Airways need to review the procedure on product samples to achieve an independent standard assessment and conduct an in-depth audit of Birmingham’s work practices. References Haphaestus Books. (2011). Articles on British Airways, including: British Airways Flight 5390, British Airways Flight 9, British Airways Flight 149, British Airways Flight 38, Concorde, David Burnside, Speedbird, British Airways Ethnic Liveries, Rod Eddington. London: Hephaestus Books. Parthalan, O. (2012). British Airways Flight 5390. Morgan City: Vadpress. Read More