Analysis of Human Factors in Aloha Airlines Flight 243 Case Study

This case study examines the Aloha Airlines Flight 243 incident, where a Boeing 737 suffered explosive decompression. The report analyzes the incident's root causes, focusing on the ineffectiveness of AA's maintenance program. Key issues include the neglect of manufacturer service bulletins, ina...Read More

AA CASE STUDY
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2020
STUDENT DETAILS
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Contents
1. Introduction............................................................................................................................2
2. Human Factors involved in incident at AA:..........................................................................2
3. AA compliance with Airworthiness Directives and Service Bulletins..................................3
4. Maintenance Program at AA..................................................................................................5
5. Conclusion..............................................................................................................................6
6. References..............................................................................................................................7

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1. Introduction
Aloha Airlines Flight 243, the 152nd Boeing 737 airframe, suffered extensive damage after
explosive decompression at a height of 24,000 when it was flying from Hilo to Honolulu in
Hawaii on 28 April 1988. The aircraft was safely landed at the nearby airport at Kahului
Airport on Maui island. The incident resulted in loss of a flight attendant who slipped off
from the plane during the incident, and more than 60 passengers and other crew members
suffered injuries. The decompression has resulted in the separation of a large part of the roof,
which consist of the entire half of approximate 18 feet from the cabin skin and to the fore-
wing area (HNN, 2018). The incident occurred was the result of the ineffectiveness of the
maintenance programs at AA. The report is focused on analysing the issues at the Aloha
Airlines (AA) due to which the incident occurred.
2. Human Factors involved in incident at AA:
The incident at AA was the result of its faulty maintenance system, as the AA neglected the
requirement to conduct maintenance periodically as specified in manuals by the
manufacturer, and due to which the cracks longer than 100mm were overlooked by the
operator, and the cracks on the body of the aircraft and the damage in the fuselage lap joints
that were not effectively identified by the operators resulted in separation of the roof of the
aeroplane during its flight (Kobayashi & Terada, 1988).
Another aspect which links the human factor with the incident is that the maintenance
activities were conducted out at night or during the early morning hours, due to which it is
identified that the human effectiveness lowers at night also visualising the physical defects
become difficult to recognize in the night. Dr Colin Drury, a professor at New York State
University specialised in Industrial Engineering indicates that performing a visual search for

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any defects at the physical structure of the aircraft is not easy for a human being as they
require to focus on a large area and identifying such cracks is a tough job (Drury, 1996).
The training and guidance quality provided to the maintenance and inspection personnel also
influence the effectiveness of the maintenance activity conducted. As the inspector staff who
was entitled to inspection of the aircraft has received only a two-hours session from the
Boeing executive, also the inspector does not have the exact information about the key areas
of an aircraft that are required to be checked when the aeroplane is being inspected for the
corrosion signs.
The incident at AA was the result of the ineffective planning of the maintenance program at
AA. The Maintenance errors at AA could be minimized if they have focused on
implementing the maintenance program as per the SBs provided by the manufacturer and the
ADs issued by FAA. Also, the training and development programs for the inspection
personnel were required to be improved, by proving formal guidance while conducting the
maintenance activities of the aircraft. AA were required to effectively focus on the
accumulation of the aircraft within its fleet and decide upon developing effective inspection
programs that would provide its inspectors with adequate resources and time-period to
inspect any defect within the aircraft that would impact the performance (NTSB, 1988).
3. AA compliance with Airworthiness Directives and
Service Bulletins
Boeing has issued certain service bulletins (SBs) for the identification of the corrosion and
the fuselage skin panels repair requirements, lap joint corrosion, repair and disband and the
inspection of the lap joint fatigue cracking. Boeing has provided nine SBs that provided the
guidance for the aircraft maintenance and for detecting the issues within the aircraft. Among

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the nine SBs, five SBs were found within the maintenance records of AA, which included
sealing of cold bonded Splices, skin lap joint inspection, cargo compartment body frames,
lower lobe skins and frame stations 351 and 360, and the rest four were not included in the
maintenance records including the SB 737-53-1076, 1078, 1085 and 1089 (McEvily &
Kasivitamnuay, 2013).
Airworthiness Directive a notification that is issued by the FAA to the operators or the
owners of the certified aircraft, that highlights the safety deficiency within the aircraft and
provides a time limit within which it is required to be corrected. FAA issued an AD on 2
November 1987 for repairing of the defect in the fuselage lap slices so that the rapid
depressurisation can be prevented. The AD also required that the operators or the investors
perform a close inspection for any cracks or any defect on the skin of the aircraft and if found
it is required to be repaired immediately or before the completion of the 30,000 hours of the
aircraft or 250 landings from the date when the AD becomes effective (Busey , 1989).
The SB 737-53A1039 Skin Lap Joint Inspection, as mentioned in the Boeing service
guidelines, required the inspection of the lap joint at S-10, 14, 19, 20 and 24the inspection of
the lap joint at S-10, 14, 19, 20 and 24 but were not included in the AD provided to the AA,
and were not accomplished during the visual inspection of the aircraft. The maintenance
personnel reported that after the AD released on 2 November, an inspection was conducted
and cracks were visually detected on the S-4L, which were immediately repaired, the
inspection team performing an eddy current inspection of the upper rivet joints in the lap joint
along the length of the panel and they reported no cracks at the outer surface. The aircraft has
completed 87,056 hours when the inspection was conducted and the incident occurred at
89,680 hours. But we're not able to provide any physical evidence related to the inspection of
the aircraft (NTSB, 1988).

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4. Maintenance Program at AA
The maintenance of aircraft at AA was approved under the FAA continuous Airworthiness
Maintenance Program. The program recommends that the aircraft inspection should be divide
into four series for conducting an effective inspection of the aircraft. The series includes
primary inspection and the intermediate check to analyse the general condition of the aircraft
and after that the system and component check and the structural inspection of the aircraft to
determine the airworthiness. The maintenance program at AA included three factors which
were the areas for concern as per the Safety board; the factors included, high utilisation of the
flight cycles between the inspection cycles, the maintenance program at AA as per designed
by the management of the organisation extended the inspection to one and half times of the
flight cycle, due to which the corrosion, lap joint disbond and fatigue resulted in impacting
the aircraft quality and the way the maintenance program at AA was implemented was also
an area of concern (Meyers, 1989).
The incident occurred at the AA was due to the ineffectiveness of the maintenance program
at AA. As the maintenance program at AA were not able to effectively recognize the issues
within the aircraft and the inspectors at the airlines were not adequately trained as per the
guidelines of the FAA. As the maintenance activity at the AA were mostly conducted during
the night hours and due to high flight hour to cycle ratio the aircraft was required to be ready
for the morning flight. Therefore, a limited area of the aircraft was inspected during each
inspection cycle and was not able to identify the major issues within the aircraft. Also, the
aircraft at AA were utilising the flight cycles at twice the rate the Boeing has prescribed in
MPD. The aircraft is required to inspect in short intervals so that any defect can be identified
at the early stage and the required repair activities can be conducted. But, the Maintenance
cycle at AA includes an interval of 8-years due to which early identification of the defect

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within the aircraft and permitting the repair function for the defect related to corrosion or any
other reason was not permittable (Meyers, 1989).
5. Conclusion
The incident at AA that happened on 28 April 1988 when the aircraft was on its round-trip
from Hilo to Honolulu. The incident happened due to the cracks on the outer skin of the
aircraft and the defect the fuselage, which resulted in an explosive decompression which
damaged the cabin door and nearly half of the top roof of the aircraft separated from the
aircraft. The issue occurred due to the ineffective maintenance program of AA. The
maintenance program at the AA neglects the major aspects of the service bulletins as
provided by the Boeing, which indicated the necessary repair activities that are required to be
conducted. The maintenance program was required to be developed and some changes were
required to be implemented within the program at the AA, including the development of the
training programs and the flight cycles to ensure that the maintenance personnel can identify
the defects within the time and can implement the repair works.

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6. References
Busey , J. B., 1989. In reply refer to: A-89-53 through 69. [Online]
Available at: https://www.ntsb.gov/safety/safety-recs/recletters/A89_53_69.pdf
[Accessed 24 January 2020].
Drury, C. G., 1996. Design For Inspectability. In: G. Q. Huang, ed. Design for X. UK:
Springer-Science+Business Media, pp. 216-229.
HNN, 2018. It's been 30 years since the AA flight 243 tragedy in the skies. [Online]
Available at: https://www.hawaiinewsnow.com/story/38061083/its-been-30-years-since-the-
notorious-aloha-airlines-flight-243-tragedy-in-the-skies/
[Accessed 24 January 2020].
Kobayashi, H. & Terada, H., 1988. Decompression of B-737 of AA by Separation of Upper
Fuselage. [Online]
Available at: http://www.shippai.org/fkd/en/hfen/HB1071009.pdf
[Accessed 24 January 2020].
McEvily, A. J. & Kasivitamnuay, J., 2013. Metal Failures: Mechanisms, Analysis,
Prevention. 2nd ed. USA: John Wiley & Sons.
Meyers, A. M., 1989. In reply refer to: A-89-70 through 72. [Online]
Available at: https://www.ntsb.gov/safety/safety-recs/recletters/A89_70_72.pdf
[Accessed 24 January 2020].
Meyers, A. M., 1989. National Transportation Safety Board. [Online]
Available at: https://www.ntsb.gov/safety/safety-recs/recletters/A89_70_72.pdf
[Accessed 24 January 2020].

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National Transportation Safety Board, 1988. Aircraft Accident Report, Washington D.C:
National Transportation Safety Board.