Disastrous Airbus A400M Clash Findings Focuses on Impacts of Accident

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This paper investigates the Airbus A400 M, serial number MSN0123 that crashed in Seville on 9th may 2015; the aircraft crashed just five kilometers from the Seville Airport, with four crew members on board being killed and two surviving. The crash is important because it led to a significant pile up in the aircraft model orders as the problem had to be identified and corrective action taken in the aircraft design and tests done again before deliveries are made.

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Disastrous Airbus A400M Clash Findings Focuses on Impacts of Accident
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University
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Table of Contents
Introduction..........................................................................................................................................3
Critical Literature Review....................................................................................................................3
Methodology.........................................................................................................................................8
Findings................................................................................................................................................8
Discussions...........................................................................................................................................9
Conclusion..........................................................................................................................................10
References...........................................................................................................................................11
Introduction
The convention on International Civil Aviation under Annex 13 defines an accident in
aviation as an occurrence that is associated with the operation of aircraft that occurs from the
instance a person boards that aircraft with the aim of flight until all people that boarded have
disembarked and where a person is seriously or fatally injured, there is significant structural failure
or damage sustained by the aircraft, or the aircraft becomes inaccessible or goes missing
completely. Under the ICAO Annex 13, an incident in aviation is defined as an occurrence that is
anything other than an accident that is associated with aircraft operation that affects or can affect the
safe operation of the aircraft. When an aircraft is destroyed, lost, damaged beyond being capable of
being repaired, or is completely inaccessible, a hull loss is defined as having occurred. When such
accidents occur, thorough investigations usually follow, recording the events leading to the accident
and using the black box, a device that records all communication and operation of the aircraft
before the accident occurred to give clues and help identify the cause of the accident. Usually,
accidents in civil aviation are seldom sudden or caused by just a single issue; they are usually
systemic and these events and issues all add up to cause the accident as defined by the Annex 13 of

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the ICAO. This paper investigates the Airbus A400 M, serial number MSN0123 that crashed in
Seville on 9th may 2015; the aircraft crashed just five kilometers from the Seville Airport, with four
crew members on board being killed and two surviving. The crash is important because it led to a
significant pile up in the aircraft model orders as the problem had to be identified and corrective
action taken in the aircraft design and tests done again before deliveries are made. This paper will
commence with a a detailed review of relevant literature before describing how the research was
done under the research methodology heading. The findings from the research will be described and
then a detailed discussion of the event undertaken before conclusions are drawn.
Critical Literature Review
Usually, any news of an aircraft accident usually raises several questions, the foremost being
what was the cause of the accident as well as concerns on air transport safety and in modern times,
the ever present threat of terrorism. Safety is one of the most impoortant concerns in aviation and it
is driven by the basic principle of totally eliminating human errors and mechanical breakdowns.
The solutions geared towards improving safety are largely dependent upon the systems’ global
safety level. However, when there is an improvement in safety, the systems used to improve safety
need not be optimized further; instead, they should be implemented at current standards and levels
in order to maintain the safety that has been obtained. However, new solutions can be implemented
to supplement it. Linear optimization and the maintenance of solutions whose effectiveness is
dwindling can lead to several paradoxes that eventually jeopardized the safety already realized in
the first place. Human error has been criticized and its definition has remained ambiguous,
according to Martinussen & Hunter, (2010); who argues that human error is essential as the basis
for developing greater safety standards.
According to Plant & Stanton (2012), human error continues to be a dominant item in
research in aviation; however, methods for predicting human error continue to be criticized for not
being able to offer sufficient explanations on causal factors for accidents and instead, they have
focused on classification. Schemata has remained common and prevalent in in the discourse of
discussing human error and their contextual causes in aviation. The schema theory provides a
systems view in the context of human activity to explain why actions that are considered erroneous
occurred even though these actions may have looked like being appropriate at the time the error was
committed. Air accidents can have huge and devastating social, economic, and technical impacts;
Sobieralski (2013) investigated the general costs of aviation accidents in the United States of
America, justified by the statistic that very few studies relating to general aviation accidents have
been conducted. The level of general aviation operations in the US is large, and a significant
number of injuries and fatalities that are caused by general aviation accidents in the USA. Tye
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researcher realized that understanding the costs of general aviation accidents to the society in
general is important.
Using estimation models for direct and indirect costs, the author established that average
annual general aviation accident costs to be $1.64 billion using the human capital approach, and $
4.64 billion using the willingness to pay model. These show how huge the impacts of general
aviation accidents are to the USA. According to Lee (2009), human error can be categorized in
several different ways , form Swain and Guttman;s error probabilities to Meisters’ Types failures .
However, it is impossible to eliminate human error because all humans are prone to making
mistakes. Focus should be placed on determining why an operator made an error rather than on the
error itself. In aviation, errors are an inevitable aspect and was documented as far back as the First
World War and since then, it has been determined that no matter how well a pilot or operator is
trained, mistakes are inevitable. Situational errors is one of the most common errors pilots make and
while mistakes cannot be eliminated, they can be decreased by best personnel selection, systems
design, and training.
According to Schijve (2009), a lot has been done to reach the present standards in state of
the art aspects of aircraft structures and materials and their fatigue. Aircraft incidents as well as
accidents were used as the milestones for developing the standards and after each accident or
incident, new concepts were developed. Extensive research has been undertaken to determine better
ways of dealing with aircraft fatigue, as mechanical failures are a major cause of aircraft accidents.
While aircraft fatigue and mechanical issues are undesired, the author shows that in some cases they
are tolerated, to devastating effects. Failures of equipment are still responsible for about 20% of
aircraft accidents; 20% is a significant number and this happens despite the vast improvements that
have been made in aircraft design. While engine design has improved to have much more reliable
engines than was possible fifty years ago, these engines still suffer failures that can be catastrophic
(Lipsey, 2015).
An example is the British Midland crash of a Boeing 747-400 that lost power in one engine
after a disintegrated fan blade was sucked into it. The plane lost power and the pilots made a
mistake in reading which engine was losing power due to difficult to read instrumentation resulting
in the pilots shutting off the working engine, leading to the crash short of reaching the runaway,
killing 47 people and resulting in many getting injured (Truslove, 2015). Chen, Chen & Lin (2009)
investigated the the significant threats to aviation safety in the Taiwan aviation industry using a
questionnaire to obtain views from experts. The research established that the most important threat
to aviation safety is crew errors. Human errors do not just affect aircraft safety as regards the
aircraft crew; those charged with maintenance also impact aircraft safety just as much. Liang, Lin,
Hwang, Wang & Patterson (2010) undertook research on how human errors can be prevented or
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reduced during the maintenance phase of aircraft. The researchers developed an on line MAP
(maintenance assistance platform) to aid technicians in performing maintenance work.
The MAP platform defined human error risks at each stage of the maintenance processes and
tasks and an experimental system was employed with a JT8D engine. The researchers established
that the maintenance teams’ situational awareness, risk recognition, job satisfaction, as well as their
performance increased significantly when the proposed online MAP was used to aid the technicians;
this was in comparison to the present work card instruction system. Incidents also lead to aircraft
accidents; the past few years have seen enormous advances in attempts to standardize the tools as
well as methods for managing risks, especially in determining the tolerable level of safety (TLS) in
transport in general, including in aviation. Skorupski (2012) undertook research on methods for
analyzing the relation between air traffic serious incidents and accidents using the TLS framework.
The author established that for serious air traffic incidents, just a single additional factor is
sufficient to result in an air accident and using the TLS modeling technique can help reduce
incidents and subsequently, air accidents.
Weather and environmental factors are responsible for about a tenth of aircraft accidents
resulting in aircraft losses, according to Jenamani & Kumar (2013). this is despite the availability of
a myriad of technical aids and navigational systems as well as weather monitoring and early waring
systems for adverse weather. Organizational factors can also result in aircraft accidents; Debrincat,
Bil & Clark (2013) studied the effect of organizational factors in aircraft accidents. The authors aver
that despite there being high level safety standards in the design and operation of aircraft, accidents
still do occur and propose a continuous improvement process model as a way of reducing accidents.
The authors conclude that often, aircraft accidents are usually the outcomes of sequence of
seemingly minor events that are often unrelated. A major challenge, according to the authors, is that
it is difficult to identify, with certainty, the major causes of organizational deficiencies and problems
in organizational processes well before te accident is experienced. Recent scientific and
technological developments have led to high tech aircraft systems that make use of software with
algorithms to control an aircraft automatically almost as well as, and in some case, better than
humans can.
According to Favarò, Jackson, Saleh & Mavris (2013), software is today central to the
operation of an aircraft and in the same breadth, is playing an increasing role in incidents and/ or
accidents in the aviation industry. Errors related to software have failure mechanisms that is
distinctive and how the contribute to aviation accidents is not yet well understood. The authors
sought to help improve understanding in the filed through the analysis of five aircraft accidents in
the recent past where software was involved. The researchers identified the role software played in
the particular aircraft accident and adopted a visualization tool that is based upon STEP (Sequential

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Timed Event Plotting) method to show how the various software interacted with the sensors in the
aircraft and how the software contributed to aircraft incidents/ accidents. Te authors undertook an
in-depth analysis of failure mechanism that were recurrent and they were able to identify the causal
patters and the causal chains for the accidents. The researchers established, for instance, that failures
related to software can be situation or context dependent and such situations are easily overlooked
when the aircraft software is being tested or validated.
Further, the research identified the crucial role that sensor inputs with flaws can be triggers
for software defects that are dormant. They authors established that in certain cases, the software
features implemented in order to address and resolve some risks in nominal conditions of operation
are the ones that either contribute or cause accidents under operating conditions that are off-
nominal. Further, the research unearthed that while aircraft software may be operating according to
its intended operation and functioning, it can put the aircraft in jeopardy or hazardous state of result
in an adverse event. The results from the findings challenge the widely held notion that software
failure happens when it fails to comply with requirements and this needs to be critically re-
evaluated. This is because software can malfunction or set off a chain of incidents that lead to an
accident, even when meeting requirements in nominal conditions of aircraft operation. The three
aspects of software failure, software fault, and software error must be evaluated afresh in the
context of aircraft software control systems because even the most robustly designed software can
experience errors even when operating at optimal conditions.
Atak & Kingma (2011) investigated the safety culture in an organization involved in aircraft
maintenance using a case study based on the observation of participants, document analysis, and
interviews. The research established that the culture of safety is particularly identified with the
improvement and development period of the association and expressly relates security culture to
generation interests. The examination centers around the different jobs and the pressures between
the quality affirmation and upkeep administration offices, and the way flying machine support
specialists (AMTs) practically speaking manage strains among wellbeing and generation interests.
Hypothetically this article focuses on the estimation of a procedure see on authoritative
advancement for the examination of security culture and the incomprehensible connection among
wellbeing and monetary interests. Particularly in the development period of the association the
security culture may move toward becoming subordinated to creation interests. Contrasts in power,
security esteems and time weight account for this situation for deviations from wellbeing measures.
The most conspicuous methodology of obstruction by AMT's is attempt to-run and pursue the strict
method for working. Support administration and quality administration not simply perform
distinctive undertakings but rather likewise serve, and consult about, various and opposing
organization interests
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Methodology
The research was undertaken using the secondary research methodology entailing a
descriptive qualitative research design. The secondary research method was chosen as being the
most suitable for this research because it entails an evaluation of a past event in which various in
depth studies have been done and a descriptive analysis method based on secondary research and
data. Secondary research is research is employed differently in relation to essential research in that
essential research includes the age of information, while optional research utilizes essential research
sources as a wellspring of information for investigation. Qualitative research is a systematic and
subjective approach that is utilized in describing life experiences and to give them some meaning
and its goal is to gain insights into events and issues. Qualitative research approach aims at
exploring the richness, complexity, and depth inherent in the phenomenon being investigated. The
specific qualitative research methodology to be employed in this research is phenomenology, in
which the experiences and events will be described as they happened. The research was conducted
by first setting objectives and a research aim, after which a detailed literature search was done using
Google Scholar database to identify relevant articles and material to use for research. These were
then evaluated, as well as data from the ICAO on the Airbus A400M accident and reviewed, using a
systematic approach to identify and discuss the causes and impacts of the aircraft accident. The
literature review and evaluation of the accident reports and its impacts were essential in creating the
material used for this research discussion and conclusions.
Findings
A technical error mediated by human action was responsible for the Airbus A400M accident;
the human error entailed the failure to properly configure the aircraft engine software, eventually
leading to the accident. Aircraft are nowadays controlled through elaborate computer software
(Osborne, 2015). This led to the aircraft losing power in three engines out of the four engines it uses
resulting in the accident just five kilometers short of the airport. The aircraft was using four TP400-
D6 engines manufactured by Europrop International; engines one, two and three failed after
experiencing a power freeze after taking off and failed to respond to any attempts by the crew
testing the aircraft to control power setting using the normal protocols, although engine four
responded to the power demands for throttle. The three engines that failed were operating at take off
settings and the test pilots decided to move power levers to the ‘flight idle’ position to reduce their
power. This led to a reduction in power but the engine powers then remained at the reduced ‘idle
flight’ power mode for the remainder of the test flight despite the crew’s attempts to regain power
needed for landing or other maneuvers. Due to this, the test crew made attempts to land the aircraft
at the Seville airport 15 minutes after take off but the aircraft crashed after reportedly crashing into
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power lines; the aircraft crashed despite all other systems performing normally as required (‘Flight
Global,’ 2015). the faulty software affected engine operation and it is believed the European and
Airbus safety specialists were aware of the software glitch that is responsible for the crash
(‘Computing,’ 2017).
Discussions
After take off, the flight pilots reported a problem with engine power after attempting to
restore engine power fro idle and made an attempt to land at the Seville San Pablo Airport, for
which they got clearance to land. However, according to information from Flight radar 24, the
aircraft veered to its left before coming down after having reached an altitude of 526 meters; the
aircraft then descended at a steady speed of 160 Knots before hitting an electricity pylon and
crashing. The vulnerability of the engine control software for the aircraft led to a the computer files
being wiped off accidentally; this led to the engine control system failing, resulting in the engines
power freezing and failing to respond to controls, leading to the crash. Anomalies were discovered
by investigators and Airbus team in the aircraft’s data logs that suggested a software fault. The files
required for interpreting engine readings were accidentally deleted causing the engine propelers
affected by this to spin slowly, leading to drastic engine power loss (Kelion, 2015). the accident
resulted in massive effects to the Airbus supply chain; the A400M was intended to provide the
NATO partners in Europe independent access to heavy aircraft for the transport of large weaponry
and troops, with the aircraft being grounded. After the accident, the airport (San Pablo) was closed
and there was a temporary pause in the use of the aircraft while other customers that had purchased
the aircraft, including the Turkish, German, and Malaysian air forces suspended their A400M fleet
operations; this action was replicated by the British air force and other customers using the aircraft.
Further, the permit granted by the Spanish authorities was suspended pending the investigations
results.
He findings from the preliminary survey and study is consistent with findings from a
research conducted by Favarò, Jackson, Saleh & Mavris (2013) which established that software can
be functioning according to requirements in nominal conditions but cause errors when the
conditions of aircraft operation are non nominal. The findings are also consistent with the work
done by Debrincat, Bil & Clark (2013) which established that organizational factors can set off a
series of events and incidents that ultimately lead to aircraft accident. In the Airbus A400M case, it
is suspected the company and the authorities knew of the vulnerability of the critical engine control
configuration file systems but either chose to do nothing or thought it could not cause a problem,
yet the accident points to the failure of software to properly enable the engine respond to pilot
controls; the config files may have been accidentally deleted. A solution can come in the form of

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algorithms based on multiple kernel learning has been proposed for heterogeneous anomalies
detection to improve aviation safety as proposed by Das, Matthews, Srivastava & Oza (2010)
Despite the accident, the tests for the aircraft resumed just a day after the accident, with the
Head of Airbus Military, Fernando Alonso acting as a flight engineer and going aboard in one of the
tests in order to prove that the company can make safe aircraft for military uses. Failure in safety
protocols were responsible for the eventual accident; it is believed the defect was known, but it was
not foxed as required by safety standards or even tested in a simulator before undertaking the main
test flights. a technical hitch and human error during design and security protocols in which the
error in the configuration files of the engine control software in the engine control unit led to the
accident as the test pilots were unable to restore power. The accident cause was systemic,
confirming research findings from previous research that systemic factors and technical hitches as
well as human error are the most common causes of aircraft accidents (Leveson, 2011), (Tiffany,
Gallagher, and Babish, 2010), (Nazeri, Donohue and Sherry, 2008). as per Knemeyer, Zinn &
Eroglu, (2009); proactive planning could have helped avert the disaster, as well as human
intervention and maintenance of safety standards if there was even the remotest suspicion that the
software to control the engines was faulty.
Conclusion
Aircraft accidents occur for a variety of reasons, and usually raise serious questions on
safety. While air transport is considered the safest mode, with chances of dying from an accident
being one in 9821 which is far safer than for cars whose chances of dying are one in 114. There is
a correlation between incidents and aircraft accidents; in evaluating the Airbus A400M accident in
2015, a series of incidents led to the fatal crash; the configuration files for the engine control system
unit had a vulnerability and despite Airbus knowing this, nothing was done as part of safety
standards to solve it. The config files were deleted accidentally (it is believed), leaning to the engine
power failing to respond to commands. An attempted emergency landing led to the crash five
kilometers before the San Pablo airport in Seville. The impact was canceled orders, delays in
deliveries, and grounding or limiting use of the aircraft by Air Forces that had taken delivery until
the investigation is complete.
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