Occurrence of the Preventable Flight Accident - Case Study Example

Table of Contents Abstract ii Introduction 1 Case Study Summary 2 This is a case where the technical team together with the management were implicated in an aviation accident that took place in the United Kingdom. A commercial flight lost control with the chief pilot stuck outside the cockpit following a preventable blow out of a window in the cockpit. This incident happened on flight 13A5390 which was from Birmingham heading to Malaga, Spain. At the time of the accident, the plane had 87 passengers onboard, including 6 crew members and a load of 45 tons. The accident took place two minutes after take–off from the airport. Although the chief pilot was handling the aircraft in accordance with the operator’s normal operating procedures, at 0733hrs, an explosion occurred in front of the plane because the windscreen frame had blown out. The chief pilot’s feet immediately contacted the control column, while the co-pilot attempted to control the plane. The crew members held the pilot’s body to prevent him from flying out of the plane. 2 Therefore, it was found that the wrong bolts, which had been used to refit the windscreen frame, were smaller than the older bolts. The decisions made by the SMM were made due to time pressure and an ill fitted maintenance situation. Correct bolts were not located in their proper place and incorrect bolts had been selected without following specific procedures. 2 Discussion of Case Study 3 This case presents a scenario whereby correct procedures were circumvented, hence leading to fitting of wrong bolts which caused the accident. As such, it is clear that this accident could have been prevented if the correct procedures were followed despite the urgency of the situation. Also, the lack of carefulness exhibited in this case is a contravention of engineering code of ethics as defined in the ‘IPENZ’ code of conduct. In essence, all parties including the technical experts on the ground in the hangar, the aviation centre management as well as the British Airways Company shared the blame for the incorrect procedures that resulted in the accident. 3 Conclusion and Recommendations 4 Students Declaration 5 Abstract This case presents a scenario whereby a plane accident occurred after the maintenance manager had fitted bolts of wrong size which caused problems when the plane took off. The analysis of this case shows that both the management of the airport and the technical team were to blame for the accident because they had failed to discharge their responsibilities appropriately. It is realised that the maintenance manager had grossly violated the code of conduct as stipulated in ‘IPENZI’ by carelessly fitting a wrong bold. The management is also blamed for failing to discharge its supervision role accordingly. Some of the key recommendations made to avoid recurrence of a similar accident include strict following of IPENZI code of conduct, careful supervision by the management, and careful mechanical check up before a plane takes a flight. Introduction This report has been written to examine the party to blame for the occurrence of the preventable flight accident. The report has also examined the IPENZ code of ethics provisions that could have been flouted by the technical experts that were involved in the whole process. The report goes further to explain how the fortuity could have been averted. This report does not determine the real cause of the accident, but rather provides general provisions that could have resulted in mayhem of the ill-fated Aircraft. Case Study Summary This is a case where the technical team together with the management were implicated in an aviation accident that took place in the United Kingdom. A commercial flight lost control with the chief pilot stuck outside the cockpit following a preventable blow out of a window in the cockpit. This incident happened on flight 13A5390 which was from Birmingham heading to Malaga, Spain. At the time of the accident, the plane had 87 passengers onboard, including 6 crew members and a load of 45 tons. The accident took place two minutes after take–off from the airport. Although the chief pilot was handling the aircraft in accordance with the operator’s normal operating procedures, at 0733hrs, an explosion occurred in front of the plane because the windscreen frame had blown out. The chief pilot’s feet immediately contacted the control column, while the co-pilot attempted to control the plane. The crew members held the pilot’s body to prevent him from flying out of the plane. The co-pilot eventually managed to land the plane safely with no loss of life. Thereafter, the pilot was taken to Southampton hospital. Investigations into what had caused the accident begun immediately, with questions arising on whether it was the management or the technical team that was responsible for the accident. All in all, it was revealed that there were problems in personnel’s maintenance practice at the British Aircraft Maintenance Centre. It was also disclosed that the windscreen frame had been refitted by senior maintenance manager (SMM) just before the plane took off. The senior maintenance manager (SMM) was the engineer in charge, and had carried out the refit himself as the hangar was short staffed. He went to the store, but he did not find the appropriate bolts, yet the store man did not care about this issue. Therefore, it was found that the wrong bolts, which had been used to refit the windscreen frame, were smaller than the older bolts. The decisions made by the SMM were made due to time pressure and an ill fitted maintenance situation. Correct bolts were not located in their proper place and incorrect bolts had been selected without following specific procedures. Discussion of Case Study This case presents a scenario whereby correct procedures were circumvented, hence leading to fitting of wrong bolts which caused the accident. As such, it is clear that this accident could have been prevented if the correct procedures were followed despite the urgency of the situation. Also, the lack of carefulness exhibited in this case is a contravention of engineering code of ethics as defined in the ‘IPENZ’ code of conduct. In essence, all parties including the technical experts on the ground in the hangar, the aviation centre management as well as the British Airways Company shared the blame for the incorrect procedures that resulted in the accident. First, during the fitting of the windscreen on the aircraft G-BJRT, the technical expert used incorrect bolts which had been used in a previous installation. It was a clear lack of professionalism that led the technical team to apply physical matching of old and new bolts by touch and eye. Furthermore, the bolts were neither installed using the correct torque nor was the work done following fail-safe checks. Therefore, the maintenance manager did not care for the safety of community and did not do his work properly. From this case, the technical manager broke some parts of “IPENZ code" such as Part 2/1-1 which touches on issues of giving priority to the safety and well-being of the community and having regard to this principle in assessing obligations to clients, employers and colleagues. In addition, it was a gross violation of safety standards since there was insufficient stock of A211-7D bolts, yet the rest of the technical experts had not played their supervision role, before the plane run out of maintenance. Furthermore, they had not provided an appropriate place and lighting for the necessary repair. Conclusion and Recommendations From the discussion of this case, there is no doubt that the management together with the technical team had played part in the occurrence of this accident which could have otherwise been avoided if due safety and maintenance procedures had been followed. It was a big blander for the shift maintenance manager to use bolts of the wrong size without caring about the outcome of such an error, and it was surprising to realise that all these mistakes were committed without the management of the airport noticing it; they must have been sitting on their job, as well. If the management had carried out their supervision role properly, it is most likely that the technical team could not have committed errors due to fear of such errors being detected. In view of the scenario that surrounded this accident, the following precautions are recommended to avoid recurrence of such an accident in the future: The management should ensure continuous supervision of the work of the technical team. This includes undertaking random checks, when perpetrators are unaware to ensure they are always careful with their work. Before any plane takes a flight, a through mechanical check should be performed to avoid detecting errors when on air. The pilots should adhere to the standard operating procedures and ensure that they are versed with good working practices. The engineers should adhere to IPENZ code of ethics which requires them to demonstrate strong and consistent commitment to ethical values. This way, they will carry out their duties carefully and professionally, and avoid any commission or omission that can cause accidents. Students Declaration I have not copied any part of this report from any other person’s work, except as correctly referenced. Collaboration: No other person has written any part of this report for me. Student Name: ______________________________________________________ Student Declaration of the above: ______________________________________________ (Signature) Date: _________ / _________ / ________ Read More