Case Study: Aloha Airlines Flight 243 - Human Factors and Maintenance

This case study analyzes the Aloha Airlines Flight 243 incident, which occurred in 1988, focusing on the factors that led to the fuselage separation and subsequent emergency landing. The report examines the human factors involved, particularly concerning maintenance practices and staff attitudes, highlighting issues such as inadequate communication, insufficient training, and time constraints. It investigates the role of Service Bulletins and Airworthiness Directives in addressing structural integrity, specifically regarding lap joint corrosion and fatigue cracking. The study identifies the primary cause of the incident as shortcomings in the maintenance program, including a lack of supervision and inspection deficiencies, and discusses the implications of aging aircraft on aviation safety, including metallic corrosion and high cycle to flight hour ratios. The conclusion emphasizes the critical importance of robust maintenance protocols and thorough inspections to prevent similar accidents.

Case Study 1
Case Study Analysis of Aloha Airlines

Table of Contents
Table of Contents.......................................................................................................................2
Introduction and Summary.........................................................................................................3
Identify the human factors issues in terms of maintenance and general staff............................4
Discuss AA action to Service Bulletin and Airworthiness directive.........................................6
Determine the reasons due to which AA faced incident............................................................8
Conclusion................................................................................................................................10
References................................................................................................................................11

Introduction and Summary
The report summarizes the case study of Aloha Airlines about the incident that occurred in
the year 1988 to the flight 243. Aloha Airline is an airline of America that began its
operations in the year 1946. Its headquarters is situated in Honolulu, Oahu, Hawaii. On April
28, 1988, its flight 243 met with an accident. On that day airline was scheduled for inter-
island flight. On that day as per the daily routine, officer walk around for the flight inspection
but he does not found anything unusual. The same crew flew three round trip flights but there
was no mishappened. When at 13:25 flight departed from Hilo for Honolulu then
decompression occurred as the airplane leveled at 24000 feet (Yoma, 2017). The flight
captain took permission from the first officer and due to the emergency the flight was landed
at Maui. Thus, due to this airplane incident several damages that includes total separation as
well as major portion loss of upper crown skin and other fuselage structure. Due to this
accident, eight injuries occurred that include one flight attendant, one fatality, and seven
passengers.
The aim of this report was to investigate on the Aloha Airline Flight 243 incident. In this
report, it has been analyzed that the human factor issues in terms of maintenance and attitude

of the staff to the incident. It also determines lacking part due to which incident occurred. It
also focuses on several issues that At last conclusion and findings are evaluated in terms of
this incident of Airline flight 243.

Identify the human factors issues in terms of maintenance and general staff
Human factor issues are the issues that occurred due to the lack of maintenance in terms of
designing in an appropriate manner. For Airplane maintenance plays an important role in
order to avoid any kind of accidents or incidents of flight. If there is any lack in the part of
maintenance can omit to the human error. Moreover, maintenance force is confronted in
terms of a set of human factor issues in the aviation. There are certain issues such as airplane
maintenance, technicians work is very risky as they had to work at heights. The maintenance
technicians of airplane spend their time in planning how they will process maintenance rather
than practically implementing it. Another issue maintenance technician also faces a unique
source of stress (Le and Lappas, 2015). On the other hand, there are various other issues like
lack in communication that can also be the human factor issue. This communication gap at
AA can also be the part of accident. Lack of training provided due to which there is lack of
maintenance done by the technicians at AA. Other issue is the limited time due to which
maintenance is not appropriately done and it causes accidents of the flight (Concetti and
Fedele, 2011).

Furthermore, various actions can be taken by AA to minimize the incidents that are faced due
to the reason of lack of maintenance. It is necessary to keep maintenance of the flights to
avoid any kind of human error. For minimizing the issues safety conscious actions can be
taken by the AA thus it do not eliminate overall human error but the processes can be
employed that include training, as well as maintaining safety conscious culture for
eliminating human errors that may lead to accidents. The communication must be appropriate
among the maintenance technicians in terms of all the details about the system in the airplane.
This would be helpful in minimizing the accidents and overcoming human error (Cavalcante
and Cavalcante, 2013). It has also been determined that Federal Aviation Administration is
helpful in overcoming the problem so there should be meeting conducted in order to solve
this problem. It will be helpful in providing right direction to enhance the situation at AA.
The information of maintenance should be easily understandable by the technician so that he
can easily access that information to practical work. It can also be recommended for AA to
implement new information transfer technology in terms of maintaining the airplane. It can
also be suggested that recent technologies are quite helpful for technicians to do maintenance
work in an appropriate manner. Thus before implementing new technologies, the training
should be provided to the workers so that they can easily access the technology to keep

maintenance of the Airplane (Yazgan and Kavsaoğlu, 2017). In terms of FAA after
maintenance, proper inspection should be done if any problem they sees then it can be solved
and it would avoid any kind of accidents.
Discuss AA action to Service Bulletin and Airworthiness directive
Service Bulletin is the notice to the aircraft operator from the manufacturer in which he is
telling about the enhancement in the products or services. In terms of Airworthiness it
impacts the flight safety conditions. Therefore, compliance is necessary to lower any kind of
damage to the airplane. The main reason of failure was the maintenance as it was not
supervised properly in Aloha Airlines. So it is important to evaluate appropriately the Aloha
Airlines maintenance program. FAA failure needs Airworthiness directives 87-21-08
inspection done for all the lap joints introduced by Boeing Alert Service Bulletin SB 737-
53A1039. Thus several safety issues raised that include quality of air carrier maintenance
program as well as surveillance of FAA to certain programs. Moreover, at the time of B-737
service history Service Bulletins was issued by Boeing to repair on fuselage skin panels. Lap
joint corrosion as well as lap joint fatigue cracking inspection. Service Bulletin program
needed less to maintain the structural integrity of lap joints (Aloha Airlines, 2007). Thus there
was again revision of airplanes as one of the operators reported that there are fatigue cracks

on three airplanes that had an impact on flight cycle. It must have compliance in terms of
accident as well as in the context of Service Bulletins communication is eligible to B-737
fuselage structure such as structure item interim advisories, service letters, in-service activity
reports, and significant service items. In terms of AA the guidance is provided by SB in terms
of maintenance records (Wanhill, Molent et al., 2015).
In addition Airworthiness Directive was issued by FAA on November 2, 1987. Airworthiness
Directive made inspection for fatigue cracking SB-737-53A1039. This inspection was
necessary before buildup of 30,000 landings. The cracks found in the airplane should be
recovered according to the instructions that are included in Boeing SB. Along with this, there
was skin bonding problem dealt with SB 737-53A1039 (Warren, 2011). This compliance AD
87-21-08 was taken into consideration to improve fuselage lag splices in airplane. Moreover,
inspector of AA testified that whenever there is problem of crack then it would be inspected
by AD. So to overcome the failure it is necessary to compliance certain things. It would be
helpful in occurring of fewer accidents in the airplane.

Determine the reasons due to which AA faced incident
Aloha Airlines the main cause of the failure was the maintenance program that lacked in
detecting the presence of significant disbanding and damage of fatigue. It leads to the failure
of lap joint at S-10L as well as fuselage separation upper lobe. Moreover, the main reason of
major shortcomings i.e. lacking of supervision to AA maintenance program. It also lacks in
access to the airline’s inspection as well as quality control deficiencies (Shadare, 2016).
There was lack of terminating action after the discovery of difficulties of production in B-737
cold bond lap joint. There was an improper inspection of the airplane before taking off the
flight. This caused an incident in the airplane. The main problem was of maintenance that
caused an issue for the Aloha Airlines flight 243.
Furthermore, Ageing Aircraft can be defined as aircraft that starts soon when at the first time
it flies and effects occur as soon as possible. This term is applied to the issues that can be
raised by Ageing Aircraft. The issues emerged in terms of the maintenance program. It also
raised airworthiness issues in different ageing aircraft that impacts directly on the current and
former practices that are needed for the Aircraft type certificate issue as well as maintenance
program approval (Skybar, 2017). The safety issue is also another issue of Aircraft ageing.
Metallic corrosion is also the third issue that is caused due to the chemical action causes

deterioration of metal surface. In contrast to this, in terms of these issues, there are various
current requirements and practices that need to take into consideration. It should apply
damage and tolerance safe life design philosophies as well as inspection method in an
appropriate manner. For eliminating the metallic corrosion issue, it can be overcome by the
better design. Moreover, fourth issue includes high cycle to flight hour ratio where it is
recorded that how many times door is closed and pressure on fuselage. The timing of the
flight is recorded in airframe log book. So it created a issue as if the time is not recorded in
the log book then at the time of maintenance the problem is occurred.

Conclusion
On the basis of the above discussion, it can be concluded that the major reason for failure was
the maintenance issue due to which incident occurred for AA flight 243. It has also been
analyzed that the maintenance issue can be resolved by following proper instructions, proper
inspection of the flight before it takes off. The report also analyzed human factor issues such
as stress on technicians for maintenance of airplane at a limited time period.

References
Aloha Airlines (2007) Service Bulletins and Airworthiness. [Online]. Available at:
https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/media/
human_factors_maintenance/aloha_airlines.pdf (Accessed: 12 March 2019)
Cavalcante, D. and Cavalcante, D. (2013) Management Matters: How to Prevent Avoidable
Accidents. [Online]. Available at:
https://www.aviationpros.com/education-training/article/10886889/management-matters-
how-to-prevent-avoidable-accidents (Accessed: 12 March 2019)
Concetti, M. and Fedele, L. (2011) Safety in maintenance: errors and human factors. Healthy
Workplaces, p.11.
Le, H. and Lappas, I. (2015) Continuing airworthiness: major drivers and challenges in civil
and military aviation. Aviation, 19(4), pp.165-170.
Shadare, W. (2016) The impact of ageing aircraft on aviation safety. [Online]. Available at:
http://www.woleshadare.net/573-2/ (Accessed: 13th March 2019)
Skybar (2017) Ageing Aircraft - Structural Failure. [Online]. Available
at:https://www.skybrary.aero/index.php/Ageing_Aircraft_-_Structural_Failure