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Policy Wording
Examples of Incidents and Accidents
There have been several ‘high profile’ incidents and accidents, which have involved maintenance human factors problems. The Human Factors in Aviation Maintenance and Inspection (HFAMI) web site lists¹ 24 NTSB accident reports where maintenance human factors problems have been the cause or a major contributory factor. In the UK, there have been several major incidents and accidents, details of which can be found on the AAIB web site².
Below are some of the major incidents and accidents:
Accident to Boeing 737, (Aloha flight 243), Maui, Hawaii, April 28 1988
The accident involving Aloha flight 243 in April 1988 involved 18 feet of the upper cabin structure suddenly being ripped away in flight due to structural failure. The Boeing 737 involved in this accident had been examined, as required by US regulations, by two of the engineering inspectors. One inspector had 22 years experience and the other, the chief inspector, had 33 years experience. Neither found any cracks in their inspection. Post accident analysis determined there were over 240 cracks in the skin of this aircraft at the time of the inspection. The ensuing investigation identified many human-factors-related problems leading to the failed inspections.
As a result of the Aloha accident, the US instigated a programme of research looking into the problems associated with human factors and aircraft maintenance, with particular emphasis upon inspection.
Incident involving Airbus A320, G-KMAM at London Gatwick Airport, on 26 August 1993
An incident in the UK in August 1993 involved an Airbus 320 which, during its first flight after a flap change, exhibited an undemanded roll to the right after takeoff. The aircraft returned to Gatwick and landed safely. The investigation discovered that during maintenance, in order to replace the right outboard flap, the spoilers had been placed in maintenance mode and moved using an incomplete procedure; specifically the collars and flags were not fitted. The purpose of the collars and the way in which the spoilers functioned was not fully understood by the engineers. This misunderstanding was due, in part, to familiarity of the engineers with other aircraft (mainly 757) and contributed to a lack of adequate briefing on the status of the spoilers during the shift handover. The locked spoiler was not detected during standard pilot functional checks.
Further Examples
