AVIATION ACCIDENT CASE STUDY

AVIATION ACCIDENT
STUDENT DETAILS
STUDENT DETAILS

AVIATION ACCIDENT CASE STUDY 1
Table of Contents
Introduction................................................................................................................................2
An identified gap of General Electric GE90-115B:...............................................................4
Maintenance gap:...................................................................................................................4
SA fails the manufacturer guidelines.....................................................................................5
Fault in the maintenance team’s guidelines with minor issues..............................................5
Loss of control in-flight (LOC-I):..........................................................................................6
Mechanical issues:.................................................................................................................6
Analysis and recommendations..................................................................................................8
Conclusion................................................................................................................................10
References................................................................................................................................11

AVIATION ACCIDENT CASE STUDY 2
Introduction
Aviation safety management is a systematic approach that is designed for implementing the
safety parameters in the aviation management. The aviation safety management system
(SMS) also incorporates a set of tools and procedures that are necessary for organizational
structure for creating an effective safety management plan in order to prevent accidents. Even
after lots of efforts of an aviation company, mishappening occurs and put adverse effect. For
this report, the incident of the Singapore Airlines Flight 368 is selected. In this accident, the
operator was Singapore Airlines (SA). Singapore Airlines was founded on 1st May, 1947 and
its hub is situated at the Singapore Changi Airport (Mendonca and Carney, 2017). SA also
has various subsidiaries such as Scoot, SilkAir, Singapore Airlines Cargo, NokScoot, etc. In
this report, there will be a discussion about the accident of Singapore Airlines Flight 368, key
gaps, legislation changes made by the legal administration of the country, etc.

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Summary of the accident
On 27th June 2016, Singapore Airlines Flight 368 was scheduled for the international flight
from the company’s hub (Singapore Changi Airport) to Milan-Malpensa Airport which is
situated in Italy. At this time, Boeing 777-300ER was in the operations and it was carrying
around 222 passengers with crew members. According to the sources, it is noted that this
flight was late by 10mins at that time. The IATIA flight number was SQ368. When this
aircraft took the successful take-off then at that time red alerts start beeping in the aircraft’s
indicator. This indicator was indicating about the faulty measure in the airline’s engine. After
getting the red signal, pilot and ground-level technical staff immediately decide for taking a
emergency landing. While landing the aircraft, the right engine caught fire (Jackman and
Millam, 2017). All the teams gather for taken out 222 passengers with all the crew members.
SA confirms that Boeing 777-300ER was utilizing the General Electric GE90-115B engine.
However, after the incident, SA was in the shock that GE90-115B fails because in the year
2016 Boeing 777 had completed 9 years of successful operations (Mendonca and Carney,
2017).
After the investigation conducted by the Air Accident Investigation Bureau of Singapore
(AAIB) it was founded that the right engine's oil system was contaminated due to a crack in
the engine’s oil system through the heat exchanger. According to the sources it was founded
that manufacturer of the general electric engines already conveys to their buyers that after
9years, they may face a certain crack in the engine due to oil heat exchanger. After this
statement of the engine manufacturer, all the Singapore journalists and other agencies starting
putting blame on the maintenance department of Singapore Airlines. Here, the good and
positive news is that all the passengers were safely taken. After the incident, the share price
of Singapore Airlines was declined to $11.77. However, the department of the SA arranges
flight for all the 222 passengers with their other aircraft (Aviation-accidents.net, 2017). In

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Singapore, social media and news reporters were starting posting about this issue and starting
blaming the company because according to the mob the management fails to effectively
maintain their crafts in their workshops. As, when the engineer was sent to the Aircraft
Communication and reporting system then also management can conduct the process for
checking the engine crack but they failed to identify and if this mishappening has happened
in the mid of the air then it could lead towards the major damage including the life of 242
people, passengers and crew members (Aviation-accidents.net, 2017).
Key gaps and weakness in the safety management system that led to the accident
occurring
An identified gap of General Electric GE90-115B:
In this incident, the fundamental weakness is that Singapore Airlines fails to conduct a
routine check on the crack of the General Electric GE90-115B. As engine manufacturers
already convey to the airlines that after 8-9years of age General Electric GE90-115B require
the crack maintenance (Kaur, 2016). In this incident, the major issue was that while
successful take off the engine was indicating the red alert. However, the pilot and ground-
level team immediately took the decision for landing so that it can fix this damage. At that
time, the primary goal of the airlines was the safety of the 242 people including passenger
and crew members (Baugh and Stolzer, 2018).
Maintenance gap:
Singapore Airlines conduct a mandatory check-up for their airplane in the fixed span of time.
Boeing 777-300ER was also going with the successful mandatory check-up but the
maintenance team was failed to note that internal cracks in the engine that resultant in
causing a fire. If the maintenance team of the SA analysed properly then they might identify

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these cracks and they could fix these engine cracks with effective and efficient efforts (Chen
and Li, 2016).
SA fails the manufacturer guidelines
It is noted that SA failed to follow the guidelines issued by the manufacturer of General
Electric GE90-115B. The manufacturer told the SA that these engines face crack after a life
span of more than 9 years. In 2016, it was confirmed by the SA that Boeing 777-300ER had
completed the 9 years of age with successful operations but as time passes engine cracks
started getting emerged (Kaur, 2016). In general, aviation accidents mainly cause losses to
human life and physical properties. The incident of the Singapore Airlines Flight 368 had
causes loss only to the physical property and it was great to know that no humans were
injured or died in this accident. However, the loss of physical property could also be saved if
the management has paid attention while conducting routine check-ups (Devlin, 2016).
Fault in the maintenance team’s guidelines with minor issues
According to the sources, not only in Singapore Airlines but in the complete aviation
industry, the maintenance team followed a fixed framework under which they conduct the
internal check of the engine in the span of 365 days. Boeing 777-300ER was planned to go
for an internal engine check-up in August 2016 (Insua, et. al., 2018). Here, not all the blame
can be put on the maintenance team because for many decades SMS department of the
aviation industry was following the same routine and this is the first time in the world when
an accident happens due to the internal engine cracks because of the heat transmitters
(Hulínská, Němec and Szabo, 2016). At that time Singapore Airlines CEO. Goh Choon
Phong expressed his deep sorrow for this action and he promised that he will take immediate
measures to prevent such errors. In this interview, he also appalled other airlines company to
make necessary adjustments in their engine maintenance system so that in future such
measures can be prevented with effective and immediate efforts (Hulínská, Němec and

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Szabo, 2016). As, in this case if management had paid attention to the maintenance
guidelines then they could save the loss of damage.
Legislation changes made by the country in the aviation industry’s regulation and
changes in the safety parameters of the company
Civil Aviation Authority of Singapore (CAAS) make guidelines and framework for the
aviation safety management under the various legal actions in the country such as Air
Navigation Act, Carriage by Air Act, Carriage by Air (Montreal Convention, 1999) Act,
Energy conservation Act 2012, etc. After the incident of Singapore Airlines Flight 368
happens the government changes the legislation policies and implement that internal check-
up of the fire engine should be conducted once in the 8months. However, many journalists
indicate that the legislation should take more effective change than just changing the
mandatory time schedule because this change does not implement a high probability that in
future such kind of aviation incidents can be avoided. On this statement, CEO. Goh Choon
Pong stated that it is the duty of the government and aviation sector to implement a strong
framework but no one can guarantee that even the strong framework can completely prevent
any mishappening but it is the aviation industry’s duty to always look for measures that can
prevent the mishappening (Kaur, 2016).
Key safety issues and risks
Loss of control in-flight (LOC-I):
The ASN database incorporates the detailed of 27 fatal LOC-I accidents from 2014 to 2019.
Through the study of these fatal LOC-I accidents, the management of Singapore Airlines can
gain the design framework for preventing and incorporating an effective safety management
system (Panagopoulos, Atkin and Sikora, 2016).

AVIATION ACCIDENT CASE STUDY 7
Mechanical issues:
According to the ASN database, in the last 5 five years, there are 13 fatal accidents that are
originated due to mechanical and engine issues. Thus, the fundamental safety measures for
the aviation industry should be starts with solving the mechanical and engine issues in an
effective and efficient way (Robertson, Harrison and Ruiz, 2018).
Measures should be followed by the aviation industry in order to prevent aviation
accidents
 Improving the air traffic environment: The government should take the measure to
improve the air traffic control and safety through the Air Navigation System with the
improvement in the airspace and air routes system (Mendonca and Carney, 2017).
 Need to increase the framework for the disaster measures of airports with aviation
safety facilities: Authorities of the country should take effective measures for
strengthening the disaster measures of airports such as earthquake resistance
requirements, control towers, landing spots, etc. Apart from this, the legislation
should also make a measure for emergency transport and other alternative vehicles at
the time of the mishappening. Moreover, currently, there is the provision for
emergency transports in the airport itself but it is suggested that the setup for
emergency transport should be established in another place because it is possible that
at the time of the disaster at the airport, the emergency vehicle setup can also
adversely impact (Robertson, Romero and Goetz, 2018).
 Improve aviation accident investigations: The legislative authority of the country
should take measures to improve the aviation accident investigations so that an
organization can effectively monitor the critical issues (So, Kim and Lee, 2019).
Moreover, SA conduct the detailed analysis of this accident and they made effective
changes in their framework of maintenance department. Although this incident

AVIATION ACCIDENT CASE STUDY 8
adversely impacted the share prices of the company, thus it put more pressure on the
management to made effective changes in their process in order to re-gain their
market reputation.
 Securing aircraft operational safety: The government needs to set up the strengthening
supervision system for air transport companies in the country. As, many people take
participants in aerial leisure activities such as skydiving, flying gliders, hot air
ballooning, etc. Thus, it is important to improve the safety measures in these activities
also in an effective and efficient way (Baugh and Stolzer, 2018).
Measures to prevent aviation accident rate provides effective guidelines and operators are the
primary people who develop these guidelines. However, as time passes, these guidelines are
modify by the operators in order to make these measures framework more strengthen for
preventing further errors. Apart from this, these tools or measures should be in the perfect
sound position in terms of the technical analysis and these measures should be innovative
with the time for ensuring better safety management. Moreover, it is the fact that the above
measures or any other measure for aviation safety management in the world can only act as
the high probability measures to prevent accidents but none of the measures can ensure
complete guarantee that after following this measure mishappening will never occur (Chen
and Li, 2016).
Analysis and recommendations
 Utilization of AI and ML in the aviation accident investigation: It is recommended
that aviation management should utilize the applications of Artificial Intelligence(AI)
and Machine Learning (ML) in the investigation of air accidents. This will help them
to conduct more detailed investigation operations and the utilization of AI will deliver
more quick results with a high level of accuracy (Aviation-accidents.net, 2017).

AVIATION ACCIDENT CASE STUDY 9
 Insurance of the passengers while air travels: As it is the fact that mishappening can
happen even after taking strict measures. Thus, the aviation industry around the world
should make it mandatory that passengers need to purchase insurance while traveling
(one-time travel insurance). In countries like Australia, India, China, etc. passengers
have the opt for one time travel insurance or not. Generally, people do not opt the
travel insurance in order to lower their ticket prices. However, it is suggested that it
should be mandatory to take travel insurance (Jackman and Millam, 2017).
 Maintaining effective R&D department: Aviation industry should effectively
contribute to its R&D department and empower its R&D department with the latest
technology so that they can conduct effective research on the noticeable outcomes in
order to prevent mishappening in future (Mendonca and Carney, 2017).

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Conclusion
In this report, the incident of the Singapore Airlines 368 is selected. In this incident, on 16th
June 2016, the engine of the Boeing 777-300ER was indulged in the fire due to heat
transmission in the right engine while taking off. However, the pilot took the emergency
landing and all the 242 passengers including crew members were safely taken out. In this
report, it is concluded that the General Electric GE90-115B engine incorporates the engine
fire cracks in the span of 9 years. Apart from this, it is recommended in this report that the
aviation industry should utilize the Artificial Intelligence (AI) and Machine Learning (ML) in
their aviation investigation process in order to conduct a detailed critical analysis for
preventing future mishappenings.

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References
Aviation-accidents.net. (2017) Aviation Accidents. [Online]. Available at:
http://www.aviation-accidents.net/singapore-airlines-boeing-b777-300er-9v-swb-flight-
sq368/ [Accessed on: 7th February, 2020]
Baugh, B.S. and Stolzer, A.J. (2018) Language-Related Communications Challenges in
General Aviation Operations and Pilot Training. International Journal of Aviation,
Aeronautics, and Aerospace, 5(4), p.8.
Chen, W. and Li, J. (2016) Safety performance monitoring and measurement of civil aviation
unit. Journal of Air Transport Management, 57, pp.228-233.
Devlin, P. (2016) Terrified passengers film their Boeing 777 bursting into flames on the
runway after emergency landing and watch from INSIDE the plane for five minutes as
firefighters battle to put out the flames. Available at:
https://www.dailymail.co.uk/news/article-3661493/Singapore-Airlines-flight-SQ368-plane-
bound-Milan-catches-fire-Changi-Airport-emergency-landing.html [Accessed on: 7th
February, 2020].
Hulínská, Š., Němec, V. and Szabo, S. (2016) Regulation for aviation
safety. Interdisciplinarity in Theory and Practice, pp.38-41.
Insua, D.R., Alfaro, C., Gómez, J., Hernandez-Coronado, P. and Bernal, F. (2018) A
framework for risk management decisions in aviation safety at state level. Reliability
Engineering & System Safety, 179, pp.74-82.
Jackman, F. and Millam, M. (2017) Top global safety issues. [Online]. Available at:
https://flightsafety.org/asw-article/top-global-safety-issues/ [Accessed on: 7th February,
2020].

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Kaur, K. (2016) SQ368 fire: Emergency landing raises concerns over safety. [Online].
Available at: https://www.straitstimes.com/singapore/emergency-landing-raises-concerns-
over-safety [Accessed on: 7th February, 2020].
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Mendonca, F.A. and Carney, T.Q. (2017) A safety management model for FAR 141
approved flight schools. Journal of Aviation Technology and Engineering, 6(2), p.3.
Panagopoulos, I., Atkin, C.J. and Sikora, I. (2016) Lean Six-Sigma in Aviation Safety: An
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Robertson, M., Harrison, B. and Ruiz, J. (2018) The Status of Safety Management Systems at
FAR Part 139 Airports. The Collegiate Aviation Review International, 32(2), 89-90.
Robertson, M., Romero, M. and Goetz, S. (2018) The Status of Safety Management Systems
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So, D., Kim, S. and Lee, G. (2019) A Study on the Improvement of Enforcement Procedures
for Strengthening Aviation Safety Management and Enhancing Aviation Reporting
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