9.1 General - Incidents Flashcards
BA Flight 5390 in 1990, what was the incident?
left windscreen replaced prior to flight and blown out under cabin pressure at 17300 feet. commander sucked half way out of the windscreen, restrained by cabin crew
BA Flight 5390 in 1990, why did the windscreen become detached from the aeroplane?
it was found that 84 out of 90 bolts were smaller than the required diameter
BA Flight 5390 in 1990, what human factors were involved? (5)
night shift
short staffed
failed to follow manuals,
failed to use the approved spare parts list
additional checks are not required (dupe/cabin pressure check)
in excalibur airways incident, what was the incident?
undemanded right roll after takeoff following flap change, loss of spoiler control
in excalibur airways incident, what were the findings of this incident? (6)
didn’t fully follow the maintenance manual
spoilers are still in maintenance mode
procedures not enforced
purpose of CB collars not understood
inadequate functioning of flight controls
operator did not specify procedure for checking flight controls
British midland B737 in 1995, what was the incident?
emergency landing after losing all oil from both engines during climb
British midland B737 in 1995, what was the cause of the incident?
borescope of both engines leading to HP rotor drive covers not being refitted and drain of oil.
British midland B737 in 1995, what were the findings? (3)
covers not refitted although signed off
ground idle engine runs not carried out
quality assurance department had not identified the non-procedural conduct of borescope inspections amongst engineers over a period of time.
in the 3 UK incidents, what were all the incidents characterised by? (9)
staff shortages
time pressures
errors occurred during the night shift or at handover
involved supervisors
element of a “can-do” attitude
interruptions occurred
failure to use data or company procedures
manuals were confusing
inadequate planning, equipment or spares
aloha airlines flight 243 in 1988, what occurred?
suffered extensive damage due to explosive decompression in flight but landed safely
aloha airlines flight 243 in 1988, what is the importance of this aircraft landing after the incident?
a significant event in aviation history with far-reaching effects on aviation safety policies and procedures
aloha airlines flight 243 in 1988, what was noted by a passenger and what did they do about it?
longitudinal fuselage crack
didn’t report it
aloha airlines flight 243 in 1988, what were the findings?
failure by aloha airlines maintenance programme to detect the pressure of significant dis-bonding and fatigue damage
aloha airlines flight 243 in 1988, how come the metal fatigue went missing within their maintenance program?
due to short, regular flight cycles increased compression/decompression of fuselage, shortening the lifespan, despite have an inspection shorter than recommended by boeing
aloha airlines flight 243 in 1988, what was noted in the investigation?
that almost all other 737’s in their fleet had signs of decreased integrity in and around the lap joints
failed to have any severe operating environment corrosion detection and control programme in place
