Aviation Safety - Accident Investigation & Incident Reporting

This document discusses various aviation safety incidents and accidents, including the Space Shuttle Columbia accident, British Airways Flight 268, ValuJet's rapid growth, and Alaska Airlines 261. It analyzes the culture at NASA during the Columbia accident, the crew's decisions in Flight 268, the impact of rapid growth on safety in ValuJet, and the CVR data and FAA's oversight of Alaska Airlines in the 261 accident. The document provides insights into accident investigation and incident reporting in the aviation industry.

Aviation Safety - Accident Investigation & Incident reporting
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Question 1 Space Shuttle Columbia Report
It has been argued by many experts that the “culture” at NASA was to blame for the accident.
Please analyse the culture at the time of the accident
The success of moon landing in 1969 showed that introduction of system engineering
was a correct tactic. NASA had developed centres which were limited in their freedom to run
many design test cycles but had enough freedom to design a spacecraft which would prove a
success. The rules involved in these centres promoted an informal culture. The reusable shuttle
idea could be projected to make an expected 50 flights a year and the scientists were needed to
justify the idea. The technology which was being used was experimental but were under pressure
to make the idea look normal as possible to attract funding from expected customers.
Based on former missions, NASA carried out, the new shuttle project was estimated to
have a tight budget, have high reliability and efficiency of 100 missions. In 1986, the space
shuttle was to make its 25th mission and prior to launch, officials from NASA and SRB met
through a teleconference. The weather forecasters had predicted low temperatures would affect
the take-off as they had an effect on O-rings.O-rings’ function is prevention of a leak of hot
gases.
Boisjoly argued that this would cause a failure but due to data presented at the
teleconference would not justify the argument. The culture was grounded on proofing a concept
was right or prove that there is something done in the incorrect way in which Boisjoly lacked. In
conclusion of the teleconference, the launch was approved and net morning the space shuttle
after a minute of launch exploded.

The investigation set up by Rogers’s commission identified the cause-low temperatures
at launch caused o-rings to be rigid and didn’t perform as required. Nevertheless, it also unveiled
other problems with the O-rings dating back to 1977 which were caused by culture at NASA
which made the problems to be overlooked.
Why was this not listed as the official “cause” of the accident
The report further noted that over the years NASA had developed a habit in which the
shuttle would launch with O-ring problems and proved a success. Further it said that the risk
involved was no longer high with the next launch. NASA had lowered its standards to a level
because each and every launch they got away with it.
Question 2- British Airways Flight 268
• Analyze the crew’s decisions from the time of the fire to the eventual fire (10 Marks)
The British Airways flight 268 was on its scheduled flight from the LAX airport, Los Angeles to
Heathrow airport, London on 20th February 2005. The flight is a Boeing 747- 436 with 4
engines. Barely a few minutes after take-off the 2nd engine burst into flames. The pilot and the
crew aboard the cockpit completed the appropriate checklist resulting in the engine being shut
down. This was a result of an engine surge. Engine surge is an abnormal condition where the
airflow through a gas turbine engine becomes unstable and momentarily reverses. Its cause is
due to repaid spread of a rotor blade stall condition in part of the engine’s compressors. s engine
surge in this plane was caused due to excessive wear to the high-pressure compressor casing and,
with the standard of fuel controller software installed, this resulted in turbine over-temperature
damage.
As standard procedure, the captain of the plane should shut down the troublesome engine.
This is a recommendation especially after localization of the malfunction. The Boeing aircraft is

designed and certified to operate on 3 engines. The captain together with the crew of the plane
assessed the situation of the plane in accordance with the approved policy and recommendations
and they decided to continue with the flight rather than dumping the fuel and returning to Los
Angeles. The captain assessed that an immediate, overweight landing was not required since
there was no indication of damage.
In an emergency situation like this, it is necessary for the pilots to land the plane and
cancel the flight plan, the British Airways pilots acted in contrary and decided to continue with
the journey using the 3 engines. This was after consultation with the airline dispatcher. The pilots
set out on “get as far as we can” plan rather than dumping 70 tons of fuel and landing. This was a
risky decision in case they encountered another engine malfunction that would require them to
shut again another engine. The decision to continue to the final destination was in accordance
with the operator’s policy. The policy provided that in case there was continuous absence of
abnormalities and the aircraft is in safe conditions, the plane can continues for the extended
onward flight. The United States Federal Aviation Administration (FAA) regulations do not
allow a plane in such conditions to cross over the Atlantic Ocean. They termed the carrier
“unairworthy”
At the East Coast of USA, the crew accessed that there was no indications of further
abnormality and they still had adequate predicted arrival fuel. The cockpit crew decided to divert
the plane to Manchester so that they could maintain the required fuel reserve as per the company
regulations.
Once the plane was in the United Kingdom, the captain declared an emergency believing
that usable fuel available would be insufficient to reach Heathrow airport. The plane then landed
safely at Manchester airport.

An investigation recommended that the British Airways should revise training of crews in
three engine operation fuel management procedures.
The standard procedures in case of engine fire are:
1. The captain should declare emergency
2. Plan for immediate descent and landing
3. Fight the fire. It involves isolating and controlling the fire using the available equipment.
The crew should follow company procedures in the process.
The abnormal engine behavior indicated to the crew shortly after takeoff and reported by
ATC and passengers was symptomatic of an engine surge. The crew dealt with the situation by
prioritizing control of the aircraft, declaring an emergency and remaining close to the airfield
while evaluating the situation. The crew acted in accordance with the laid procedures in checking
the engine behavior.
• Based on the discussion in class do you think the captain should have been charged by the
FAA, explain? (5 Marks)
No
Even though the captain contravened the regulations stated by the Federal Aviation
Authority, the British Airways captain acted according to the regulations and procedures of the
United Kingdom Civil Aviation Authority. Further the British Airways came to its defense
stating that its rules were derived from the international civil aviation organization.

Question 3 ValuJet 592
Assume you are part of a multi-disciplinary investigation team, the IIC (Investigator in
Charge) has asked you to analyse the rapid growth of ValuJet as it may have played a role in
the accident;
Prepare a high-level analysis of ValuJet’s growth, and how rapid growth affects safety in
general (do not make any recommendations/decisions only analyse the growth) for the IIC to
decide if this is an area worth exploring
Table 1 ValuJet score table based, based on the ValuJet growth analysis- decision analysis
1.1 1.2 1.3
1.
4 1.5 1.6 1.7 2.1 2.2 2.3 3.1 3.2 3.3 3.4 4.1 5.1
1 2 0 0 0 0 2 0 0 0 0 0 0 0 0 3
3 0 0 0 0 3 0 3 3 6 3 0 0 2 0 0
0 0 0 4 0 1.5 0 0 0 3 0 3 0 0 5 0
0 2 0 0 0 0 1 0 0 0 2 0 0 0
0 0 0 1 0 0.5 0 0 0 0 0 2 0
0 0.8 0 0 0.6 0 1 0 0.4 0 2
0 0 0.5 0 0
1.166
7 0
0.5714 2 0 0
0 0.25 1
0 0
0.6 0
0
0
0.4615

Table 2 ValuJet SMS readiness analysis graph based on the score table above
Safety Policy
Non Punitive Policy
Roles & Resp
Communication
Safety Planning
Perf Measurement
Managemnet Review
App Regulations
SMS Documentation
Records Management
Reactive Processes
Pro-Active Processes
Investigation & Analysis
Risk Management
Training
QA
Emerg Response
0
0.5
1
1.5
2
2.5
3
3.5
Valujet SMS Readiness analysis
Table 3 ValuJet score table, based on ValuJet performance decision
Safety Policy 0.57
Non-Punitive Policy 0.8
Roles & Resp 0
Communication 1
Safety Planning 0
Perf Measurement 1.5
Management
Review 0.5
App Regulations 1
SMS Documentation 0.6
Records
Management 3
Reactive Processes 0.5
Pro-Active
Processes 0.6
Investigation &
Analysis 0.25
Risk Management 0.4
Training 1.17
QA 0.46
Emerge Response 0.6
Average 0.76

ValuJet had several strategies which would drive its growth by using low fares. The
strategies used would maintain a low-cost structure were: provide cheap services which were
easy to use, employ productive personnel with low wages but with bonuses aimed at profiting the
company, develop a corporate culture which is productivity oriented and superiors compared to
competitors, automate its system to cut overhead costs and eliminate middlemen from the firm-
client relationship.
The above strategies were implemented by other innovations which were electronic
ticketing and use of second-hand airplanes. This reduced cost of tickets and a lot more of its
customers adopted the new method and travel agent commissions were reduced. Further the high
costs of purchasing new aircrafts were reduced as the second hand didn’t cost a lot. ValuJet
coupled with the strategies and innovations experienced rapid growth in which the airworthiness
failed to keep pace.
The rapid growth caused the firm to have problems maintaining records of aircrafts
which meant the maintenance was not done according with the industrial standards. Further,
ValuJet was under pressure to add aircraft to its fleet to keep up with growth. This strained the
company’s ability to find new airplanes into its services and it was easy to buy underperforming
aircrafts under the give situations.
FSDO had requested ValuJet to add staff to keep pace with growth, and it keep its
airworthiness. ValuJet responded that its entire staffing concept used to make its
additional personnel didn’t accommodate rapid growths. Also, ValuJet being a non-
traditional carrier meant it was difficult for it to be surveyed. The FSDO was contracted

by ValuJet’s to make examination and it was spread all over US making it difficult to
inspect the carrier. Hence,
ValuJet’s did not have the ability to handle the fast growth and embraced an
organisational culture which disputed its services and operations carry great risks of safety.
Assume there is pressure from the highest office to not explore growth any further. Based on
your analysis the IIC asks you if you’re ok dropping this and moving onto another part of the
investigation. How would you respond to that?
The growth of ValuJet brought in a lot of problems which had not been projected. Based
on it, I could drop growth of the carrier new aircraft and develop the current services to the
optimal best. Ticketing would be automated and hire adequate staff to do maintenance
operations. Unlike ValuJet, there could be an onsite office for the industry regulatory authorities
to make easy inspections and ensure the airline complies with regulations.
Question 4 Alaska Airlines 261
Analyse the CVR data and the crew’s actions
The CVR data shows that the plane recorded a horizontal stabilising move until two
hours later when the plane was gaining altitude and the autopilot was disengaged. It was flown
manually and the speed was increased and the pulling force was decreased. This happened for
next one hour and twenty-two minutes when the autopilot was re-engaged. After on the

horizontal stabilizer failed which caused loss of pitch control and a diversion was taken to Los
Angeles airport which didn’t materialize.
Analyse the FAA’s oversight of Alaska Airlines
FAA which is top of aviation industry has the power to oversee every operation being
carried out by airlines and the related airline industries. It makes manuals for services delivery
and performance, inspections and maintenance operations and other measures which need to be
observed. Although the FAA has an oversight it lacks ability to implement the decisions. This
gave an opportunity for Alaska airlines to incorporate the FAA rules into its own and change
them over the course of its operations.
Alaska airlines approved long inspection periods/intervals, use of unstandardized
equipment for inspection and measurement of jackscrew assembly, and endplay check, and
approving maintenance work when none was done. This was done without the consent of FAA.
Before the crash took place, Alaska airline started to use its own maintenance procedure which
was approved by FAA. It had time intervals in which the routine check-up and maintenance
operation would be carried out. Over the years, Alaska airlines changed the procedure in order to
improve service delivery and cut down costs (Chen and Chen 2012)
Why would the NTSB allow the board member statements to be included towards the end
of the report?
Board member gave exact mistakes which caused the accident. For example, John J.
Goglia stated that maintenance operations and inspection periods were made longer than normal
with no technical backing. And in the event that rationale and standard practice manage that as

risks increases so should observing, Alaska’s program was something else. Also, he faults the
associated crew of not performing their tasks diligently. Further on he argues that the jackscrew
equipment is hard to wear quickly and even strong to carry its functions at the wear limit. Alaska
airline had expanded too quickly with pressures to keep airlines on operation which yielded more
profits overlooking maintenance. Nevertheless, he also states the recommendations suggested by
NTSB which partly followed. Hence the board member gave the exact sentiments of what had
transpired prior to the accident and the cause of it.
What recommendation would you make to the FAA?
I recommend FAA should be given interim powers to oversee and ensure the regulations
are strictly followed. The incorporating of FAA’s regulations into individual airlines manual
should cease and it should make periodic check up to ensure the regulations are followed. The
maintenance operations should be done with the required tools which are regulated by FAA to
ensure standards are followed and also the spare parts and other airline related products (jet fuel)
supply be done by FAA to ensure quality. It should train the airline crew to ensure same quality
standards are followed by each airline and introduce fines for the crew who perform dismal.
Question 5
1. Critically analyze the role of the manufacturing process for the 787? (15 marks)
Boeing 787’s assembling process takes place at Everett in Washington DC. The staff in the
factory are responsible for the completion of assembly of the aircraft. Boeing 787 Dreamliner
has its components sourced from manufacturers found in different places around the globe. The
tail of the aircraft is manufactured at its plant in Frederickson, Washington. The flaps and
ailerons are manufactured in Australia and fairings in Canada.

The techniques by Boeing have been guarded entirely. These techniques entail the design
and mass production of the jetliner wings. Wings are being manufactured by Japanese companies
such as the Mitsubishi Heavy Industries. The specifications of precision that come with the
Boeing 787 Dreamliner have imposed conformity that has not been witnessed by the United
Nations. Boeing quality control engineers have scrutinized and the plane and found errors that
threatened the structural integrity of the aircraft.
The major challenges that faced Boeing were as a result of materials being sourced from
outside and some faulty components such as the battery. The composite structure was used in its
body in order to reduce weight of the aircraft and therefore minimize fuel usage. One aircraft,
United Airlines experienced a problem with its Lithium-ion battery which failed just before it
landed at Charles de Gaulle Airport. That was not the first plane to develop issues with the
battery since the launch of the Boeing 787 Dreamliner.
The Dreamliner was sent back to design and servicing of the battery before it resumed
service in April 2013. In January 2014, a Japanese airline Boeing 787 was forced to touch the
ground at Narita airport due to battery malfunction. A similar plane, Qatar Airways, Boeing 787
Dreamliner got its was forcefully diverted due to battery failure. The battery failures in the 600
planes that have encountered malfunction is best known to Boeing because it was recently stated
by the FAA that they do not require any notification concerning failures, either from Boeing
itself or the operators of the Dreamliner. They claim that the steel housing in the aircraft
eliminates the threat to safety during thermal runaways. Battery experts claim that battery failure
is due to problems that occur within the cells. Their argument was that batteries would not
malfunction unless mishandles or tampered with mechanically or electrically. The fact that they

are properly housed in a box means that they were not being abused mechanically and thus the
reason to have an underlying problem (Negroni 2017).
Boeing manufacturers have a duty of coming up with the best that the company deserves in
order to produce the best planes. Production of planes with mechanical or electrical problems
damages the reputation of Boeing as a company. The few failures due to battery that have been
seen before have reduced trust in the airline stability and hence the market.
2. What recommendation would you make to the FAA, explain? (5 marks)
The FAA and Boeing experts checked the aircraft and found that it was designed soundly.
They claimed that both the manufacturer and the FAA had to carry out some effective processes
to ascertain that the aircraft was safe and sound for use, that is before and after it had been
certified. The first Boeing 787 battery failure called for better and comprehensive review of the
entire design and manufacture of the aircraft and the critical review of the oversight job of the
Federal Aviation Administration (FAA). FAA should ensure make a point of checking the
various critical components of the aircrafts in their specific places of manufacture before they are
assembled in the planes. This will ensure that no problems are realized in the near future
concerning various components such as the battery (Brown 2014).
Conclusion
While placing the cause of accidents on technical faults, the real and major cause can be
directly linked to human failures. Regulatory authorities had stated they had several mitigations
set in place to prevent the accidents, but due to human errors and organisational culture spanning
the airlines have led to accidents. The airlines pressure to profit at the expense of compromised
safety measures have led to catastrophic accidents

Reference list
Airways, B., 2017. British Airways. Where we fly.[online] Available from: https://www.
britishairways. com/travel/where-we-fly/public/en_gb/map [Accessed 13 february 2019].
Brown, L. J., 2014. Press Release - Review Team Finds Boeing 787 Design Safe. [Online]
Available from: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=15974
Chen, C. and Chen, S. (2012). Scale development of safety management system evaluation for
the airline industry. Accident Analysis & Prevention, 47, pp.177-181.
Fishman, D.A., 2009. ValuJet Flight 592: Crisis communication theory blended and
extended. Communication Quarterly, 47(4), pp.345-375.
Faa.gov. (2019). Press Release – Review Team Finds Boeing 787 Design Safe. [online]
Available at: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=15974
[Accessed 14 Feb. 2019].
Grundy, M. and Moxon, R., 2013. The effectiveness of airline crisis management on brand
protection: A case study of British Airways. Journal of Air Transport Management, 28, pp.55-
61.
Gehman, H.W., 2003. Columbia Accident Investigation Board, Report Vol. 1, August 2003.
Columbia Accident Investigation Board.
Gero, D., 2009. Aviation disasters: the world's major civil airliner crashes since 1950. The
History Press.
Kanamori, H., Mori, J., Anderson, D.L. and Heaton, T.H., 2008. Seismic excitation by the space
shuttle Columbia. Nature, 349(6312), p.781.
Langewiesche, W., 2008. The lessons of ValuJet 592. Atlantic Monthly, 281(3), pp.81-97.
Williard, N., He, W., Hendricks, C. and Pecht, M. (2013). Lessons Learned from the 787
Dreamliner Issue on Lithium-Ion Battery Reliability. Energies, 6(9), pp.4682-4695.
Starbuck, W. and Farjoun, M. eds., 2009. Organization at the limit: Lessons from the Columbia
disaster. John Wiley & Sons.
Schnedler, C., Murphy, D., Stumpp, S. and Phar, F. (2007). Alaska Airlines Flight 261:
Understanding the Systemic Contributors to Organizational Accidents. Systems Research Forum,
02(01), pp.42-51.
Zhu, J. (2011). Airlines Performance via Two-Stage Network DEA Approach. Journal of
CENTRUM Cathedra: The Business and Economics Research Journal, 4(2), pp.260-269.