MAJOR AVIATION ACCIDENTS
AmericanAirlines Flight 191
TheAmerican Airlines Flight 191 crash in 25thMay 1979 was one of the darkest moments in the history of Americanaviation industry. It has been argued that the airplane “fell outof the sky” resulting into death of 258 passengers and 13 membersof the crew aboard. American Airlines Flight 191 was a regularpassage flight from O’Hare International Airport to Los AngelesInternational Airport. The aircraft crashed a few moments afterdeparture killing all persons aboard as well as two people on theground. There is no doubt that the crew responsible for the freightwas highly qualified and experienced. The captain had over 22,000hours flying hours on the same route the first office and the flightengineer had a combined 25,000 flying hours. At takeoff roll, thecockpit and the cabin were normal. However, at six thousand feet, theair traffic controllers in the airport control tower noted some partof the aircraft falling away (Hermes, 2011). This was followed by theaircraft rotating resulting into more parts separating from theaircraft. This was engine number 1, which fell exactly as it wasdesigned in cases of emergency. Unfortunately, the processes had animpact on the hydraulic system connecting the leading edge slats.This resulted into air linkage and retraction of the edge slat.Although the air traffic controller commanded the captain to comeback to the runway, the Captain opted for the ‘American’s engineout procedures”. The aircraft crashed on a field killing all peopleaboard and two people on the ground. Accident investigationsestablished that when the first engine separated, it alsodisconnected the captain’s control panel. Although it was firstspeculated that the design of the McDonnell Douglas DC-10 aircraftwas the main cause of the accident, further investigation establishedthat the accident was cause by faulty maintenance procedure (Hermes,2011).
AlaskaAirlines Flight 261
AlaskaAirlines Flight 261 is another passenger aircraft which has crushedin the recent past due to poor maintenance of the aircraft. Theaircraft crashed into the Pacific Ocean on 30thof January 2000. Alaska Airlines Flight 261 was an internationalflight from Puerto, Mexico to Seattle Washington through SanFrancisco in California. The plane crashed in the ocean, about fourkilometers from Anacapa Island in California killing 83 passengersand five members of the crew. Preliminary investigated establishedthat the aircraft crashed after a loss of pitch control.Surprisingly, in the month of January 2000, two other major accidentsin the aviation industry had occurred. Kenya Airways Flight 431 hadcrashed in Ivory Coast in West Africa and Crossair Flight 498 hadcrashed in Switzerland. Alaska Airlines Flight 261 involved aMcDonnell Douglas MD-83 plane operated by Alaska Airlines. The pilotsof the aircraft were highly experienced individual where the captainhad over 17, 000 flight hours and more than four hundred hours flyingthe same type of aircraft. On the other hand, the first officer hadover eight thousand flying hours mainly in the MD-80 categoryaircrafts (Fitzgerald, 2010). Two hours after departure from PuertoVallarta, the crew contacted the maintenance facility in Washingtoninforming them that they had experienced a jammed horizontalstabilizer. The crew discussed the possibility of diverting theflight to the nearest airport such as Los Angeles. Although thedispatch personnel tried to convince the crew to proceed with thejourney as planned, the crew decided to divert the flight to LosAngeles. Although the crew struggled to control the plane, it hit thewater at high speed killing all the passengers and members if thecrew. Investigations by the national transportation safety boardestablished that the crash was as a result of inadequate maintenanceof the aircraft. This resulted into excessive wear of critical partsthat eventually lead to flight control system failure (Fitzgerald,2010).
JapanAirlines Flight 123
Anothermajor aviation accident as a result of inadequate maintenance was theJapan Airlines Flight 123. The domestic flight from Tokyo to Osaka inJapan crashed on 12thAugust 1985 32 minutes after departure killing 505 passengers and 15members of crew. The aircraft, a Boeing 747SR crashed into themountainous region of Ueno, Gunma Prefecture, about one hundredkilometers from the Tokyo. The crash remains the deadliest aviationaccident in history. However, four passengers survived the accident.The aircraft involved in the accident was in its fifth flight duringthat day, with a six flight remaining to complete the plannedflights. The fifteen members of the crew included 12 flightattendants while the other three were cockpit crew. The captain actedas a trainer and supervisor to the first officer, while handingcommunication. The captain was therefore an experienced pilot withover twelve thousand flying hours and a huge experience on 747aircrafts. The first officer and theflight engineer both had aboutfifteen thousand combined hours of flight. 12 minutes after theaircraft departed from Tokyo international airport, an explosivedecompression resulted into loss of the aircraft tail. This causedthe hydraulic system failure, which disenabled flight control. Investigations established that poor maintenance of the aircraft wasthe main cause of the accident. However, the main concern relating toJapan Airlines Flight 123 accident was the response by the Japanesegovernment. It is believed that more people survived the crash butdied as a result of delayed rescue mission (Hood, 2013)
Counterfeitparts business in aviation industry
Overthe years, the aviation industry has been characterized by majoraccidents. Due to the susceptibility of the air transport, theincreased accidents are an important concern. An investigation byrelevant authorities on the recent major aviation industry indicatesthat majority of them are caused by human errors, mainly poormaintenance and unapproved aircraft parts. Counterfeit goods in themarket have an impact on all sectors of the economy. Almost anythingin the commodity market has its counterfeit fashion. However,counterfeit parts in the aviation industry are a matter of life anddeath. The use counterfeit parts in the maintenance of aircraft putthe lives of millions of people who use this means of transport.Although there are other challenges, such as terrorism, the increaseduse of counterfeit and unapproved parts in the aviation industry isan important concert. Statistics indicates that there is an alarmingincrease in the number of counterfeit, stolen or unapproved partsentering the aviation maintenance workshops. These parts aregenerally referred to as bogus parts, to resonate with the aviationindustry language. The term bogus parts can be traced back to theSecond World War when the counterfeit and unapproved aircraft partsflooded the market. The term refers to aviation parts which areconsidered substandard, counterfeit or have not been approved by theFederal Aviation Administration (Mathews et al, 1994). The unapprovedparts may be from the genuine manufacturer but are stolen beforefinal inspection by the authorities. In some cases, the partmanufacturers can over produce and sell the surplus to brokers andaviation workshops at a discount. Although counterfeit may beinappropriate for these parts, they result into similar risks becausethey are not subjected to strict quality controls required by theapproving authorities. Despite the inherent risks associated withthese bogus parts, once they have been installed, it is difficult todetermine whether they were bogus or genuine parts (Mathews et al,1994). This has posed a huge challenges in the control of bogus partssince this encourage aviation workshops to opt for shortcuts.
Questionshave been raised on why there are an increased number of counterfeitparts in a sensitive industry such as the aerospace workshops.Whether electrical or mechanical, all aircraft parts in theircounterfeit form are available in the market. There are national andinternational initiatives that are aimed at mitigating thesechallenges. The airline management has the overall responsibility ofensuring that the maintenance of their fleets meets the higheststandards, as recommend by the regulating authorities. In recognitionof the problem, measures to curb this vice have been put in place,but it has remains an important challenge. However, irrespective ofhow the parts get into the workshop, whether the management of theworkshops is aware, they have a huge impact on the reliability,performance and consequently the performance of the aircraft. Themaintenance schedules proposed by the regulating authorities ormanufacturers of the parts are based on the performance of theparticular authentic part. The manufacturers are aware of performancehistories of their authentic products based on which maintenanceschedules are suggested. Authentic products also pass through strictquality control systems. Installation of counterfeit parts in anaircraft has an impact on the general performance, including theperformance of other authentic parts. The cost of counterfeit partsin the aviation industry goes beyond the loss of business experiencedby the manufacturers of the authentic products. Perhaps some of themost important problem associated with counterfeit parts includesincreased probability of product failure resulting into accidents(Aerospace Industries Association, 2011).
Despitethe fact that the airspace industry has stringent controls in theaircraft part market, majority of the major mishaps and crashes areassociated with unapproved components. However, the biggest concernsare why there are some many counterfeit parts in the aviationworkshops. Expert’s estimates that up to ten percent of theaircrafts parts in the American supply chain are unapproved. Whilethis does not mean they are defective or counterfeit, they do notmeet the stringent requirements in the airline industry. Majority ofthese parts do not have the required paper work. These parts alwaysfind themselves in the aviation industry and into the airlinesworkshops or distributors stores. Counterfeit parts business isillegal and therefore perpetrated by criminals. However, since it isa billion dollar industry, it will always attract unscrupulousbusinesses. For example, a small nut from the original equipmentmanufacture can cost up to 400 dollars. However, a counterfeit nutmanufacturing cost is a fraction of this figure, and thereforeindividuals are able to make huge profits while selling thecounterfeit at relatively cheaper price (Power-Waters, 2008).Additionally, people are tempted to steal these parts, which reachthe workshop without the necessary paperwork. Additionally, someaerospace parts are not readily available from the original equipmentmanufacturer or the authorized manufacturers. This has alsocontributed to the flourishing of the counterfeit market in aircraftparts industry (Aerospace Industries Association, 2011).
HumanFactors Analysis and Classification Systems (HFACS)
Theaviation industry is the epitome of advanced mechanical andelectronics technology in the 20thcentury. It has had a huge impact on the human society, resultinginto increased dependence of the modern social system on aviationtechnology. However, the archives of aviation industry are litteredwith major accident that resulted into huge loss of life. Theincreased accident risks in the aviation industry have resulted intovarious mitigation measures aimed at elimination some of the risks.This includes stringent national and international regulations of theaviation industry. However, these attempts have yielded littleresults. There is no doubt that there are a number of factors thatare responsible for major accident in the aviation industry. However,safety studies and accident investigation have revealed that thehuman error elements are the major causes of aviation accident. It isestimated that up to 90 percent of all aviation accidents can beattributed to human error and not mechanical accident. Human error,for example, account for over 80 percent of mishaps in the UnitedStates military aviation (O’Connor, 2008). The identification ofhuman factors in the aviation accidents in the military led to thedevelopment of the “Human Factor Analysis and ClassificationSystem” otherwise knows as HFACS. The broad human error frameworkwas developed by Scott Shappell and Doug Wiegmann to investigate andanalyze human factors that affects the operations in the UnitedStates air force. The framework has however been applied in thecivilian aviation in the training of crews and development ofpreventive strategies (Li & Harris, 2006). It is also applied infactories and industries as an occupational health and safetymeasure.
HFACSframework identified four levels of human factors that result intomishaps and accidents in the aviation industry. This includesorganizational influence, unsafe supervision, unsafe acts, andpre-condition unsafe acts. The unsafe acts include skill basederrors, decision errors and perpetual errors. Skill based errors areoperator based and dependent of routine, practice and proficiency ofthe operator. Decision error occurs as result of the operator’saction which is inadequate to achieve the desired results. Perpetualerror on the other hand includes cases where an operator makes aterror based on faulty or wrong information. Unsafe act also includesviolations, which could be routine or exceptional violationsoverlooked by the management. Pre-condition unsafe acts includeenvironmental factors, condition of operators and other personnelrelated factors. Environmental factors include the physical andtechnological factors that have impacts operations, for example,weather or designs. Personnel factors related to crew management andreadiness of the personnel to perform optimally, including when thestaff is off duty. Unsafe supervision level of HFACS includesinadequate supervision of staff, inappropriate operations, ignoringknown problems and violation of supervision rules. Lasting,organizational influence includes how the resources are managed, theworking atmosphere and operation procedures in the airline (Shappell& Wiegmann, 2012). These factors have a direct impact on thesafety of passengers and property in the aviation industry. However,the biggest concern is the effectiveness of HFACS in preventingaviation industry accidents (Woods et al, 2010).
Studiessuggest that HFACS framework is an effective tool in theinvestigation and prevention of major aviation accident in themilitary as well as civilian air traffic. The framework provides alink between theories and practical in the identification andclassification of accidents and mishaps in the aviation industry. Theframework puts into consideration all human errors that can result inaccidents, including organizational as well as operator’s errorsand failures. The most successful application of HFACS ininvestigation of aviation accident has been in the United Statesmilitary (Shappell & Wiegmann, 2000). The framework has been usedin the investigation of over one thousand accidents and mishaps. Overthe years, the repeated use of HFACS in investigation as well asprevention of aviation accident has remained reliable and valid. Theapplicability of the framework has been demonstrated and tested innumerous occasions. The application of HFACS in the military as wellin civilian aviation in identification of human factors in accidenthas been essential in the development of objective and evidence basedstrategies to reduce the likelihood of aviation accidents. PerhapsHFACS has been more effective in the development of techniques andstrategies for investigation of aviation accident. Therefore, HFACShas been an effective framework in the development of safety programsin the aviation industry (Shappell & Wiegmann, 2000). Despitethis, there are several accidents that continue to be reported in theaviation industry. Nonetheless, the application of HFACS ensures thatinvestment in aviation safety are systematic and data driven.
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O’Connor,P. (2008). “HFACS with an additional level of granularity: validity and utility in accident analysis”. Aviation,Space and Environment Medicine,79, p 599-606.
Power-Waters,B. (2008). Isit safe? : Why flying commercial airliners is still a risky business,and what can be done about it: this book may save your life!,New York: iUniverse.
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